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,,, Kill
HC MD3E K
Boston
Medical Library
8 THE FENWAY
r
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THE
Pennsylvania Medical Journal
REPRESENTING ■ ', I
THE TRANSACTIONS OF THE MEDICAL SOCIETY
OF THE STATE OF PENNSYLVANIA
AT ITS ANNUAL SESSION HELD AT
PITTSBURGH— OCTOBER, 1920
VOLUME L
(VOLUME XXIV OF THE JOURNAL)
Edited for the Society under the supervision of the Publication
Committee of the Board of Trustees.
BY
FREDERICK L. VAN SICKLE, M. D.
212 North Third Street, Harrisburg, Pa.
The Evanirelical Press
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.it
Nov 7 1922
J-/BRABV .
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The Pennsylvania Medical Journal
Owned, Controlled and Published by the Medical Society of the State of Pennsylvania
Issued monthly under the supervision of the Publication Committee
VotuiiE XXIV
NuuMit t
212 North
PRESIDENT'S ADDRESS*
SuBscmpTioH :
)3.oo Pkk Yia>
SBURC, Pa., October, 1920
Year after year advocates of unique forms of
HENRY D JUMP M d"*^*^ ^^ I9?9 treatment ask for state recognition. It has been
„„„ /„„ „A^ o"*" <J"ty to contend against these, for the public
Mr. President, ladies and gent
ciate most deeply the honor which you gave me
last year when you made me the president of
this Society. I feel profoundly the responsibili-
ties attendant upon the office and the inadequacy
of my qualifications to meet the unsolved prob-
lems present with us and the new which are
bound to arise. There is so much unrest and
desire to change the existing order of things
that we are rushing into chimerical and foolish
experiments of government and other things.
The medical profession is affected by this cos
dition and it will require our best judgment and
intelligence to properly appreciate the value of
the various propositions oflfered. Just as the of-
ficers of this Society have considered the mat-
ter of Compulsory Health Insurance from the
standpoint of the public good and have elimi-
nated the selfish side of the argument, so must
we approach all of these new questions in a
purely unselfish spirit. This is one of the most
important and influential medical societies in the
country. Such is our position that our action
in a given case may become the example which
others follow. It behooves the Society, there-
fore, to set the right example. It has attained
its present position because of the character of
the leaders you have chosen. It has been foi
tunate in having for president Stevens, Van
Sickle, Donaldson, Codman, Heckel, McAlister,
Taylor, Appel, Roberts and others of like ear-
nestness of purpose and energy of execution.
Foremost among these we must place Dr.
Stevens, who is just retiring from the office.
For years he has been the energetic editor and
secretary; two years ago the Society signally
honored itself by making him president. No
labor has been too great, no detail too exacting
for him. He has given all that he has, often at
great expense of his time, domestic pleasures
and even of his health. The Medical Society of
the State of Pennsylvania has had no more
faithful officer ; no officer has held the love and
respect of his colleagues as he has.
•Delivered at the General Meeting of the Medical Societj- of
the State of Pennsylvania, Pittsburgh, Oct. s, 1920.
/ i|_P .Qy must be protected from improperly educated
practitioners. Whatever good may be said of
their methods the fact remains that they have
only a form of treatment of very limited range
and not a system of medicine. It is not surpris-
ing that the osteopath should see the limitations
of his treatment and desire the privilege to use
the established methods of regular medicine.
But it is astounding that he should expect full
privilege to practice medicine when he has had
little or no training in the basic sciences. There
should be uniform requirements of knowledge
in the fundamentals for all who practice the
healing art. There should be no short cuts for
any.
Anti-vaccinationists and anti-vivisectionists
are constantly striving to handicap us in our ef-
forts to prevent illness and advance medical
knowledge. In every session of the legislature
efforts are made to pass other pernicious med-
ical legislation.
Fortunately your committee on Medical Leg-
islation has been able to prevent some of this.
In the Legislative Conference it is prepared to
watch and fight all such. The Conference de-
serves your support and its success will be meas-
ured by the extent of your support.
The newer problems to which I wish to direct
your attention are those which arise from a
growing tendency to place the medical treatment
of the people under state supervision; to de-
velop or extend paternalism in medicine. Some
physicians have said that they foresaw the time
when all medical care of the people would be
controlled by the state ; that practitioners would
be under salary and assigned districts in which
to practice ; would be under orders to go where
a superior officer directed. Such a position ap-
peals to the minds of some and there is perhaps
a certain amount of satisfaction that an income
is assured, that position and income are not de-
pendent upon initiative and energy but upon
keeping up to a general average, high enough to
continue in the good graces of the employing
officer. I am sure that under such a condition,
however, the individualism which is the out-
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THE PENNSYLVANIA MEDICAL JOURNAL
October, 1920
standing feature of success in the learned pro-
fessions, would be largely eliminated. The phy-
sicians would be in the position of the medical
officers of the army and navy. Few who served
in the great war were so favorably impressed
with this system as to wish to continue it in
times of peace.
Prevention of sickness has long been a gov-
ernmental function and has come to be consid-
ered as such. This is right so far as it is re-
sponsible for the protection of the people from
foes within as from foes without. Laws gov-
erning the purity of water, milk and other food,
and the quarantine of persons suffering with
contagious disease are operating to our advan-
tage.
The state has also gone into the matter of
treatment of the sick. Years ago it built hos-
pitals in the mining regions and supplied them
with salaried medical officers. Such service was
needed, for no other was available and this large
body of people had to be looked after. Whether
this was a state function or not is a debatable
question. I have no doubt it would have been
better had the hospitals been built and supported
by private funds, particularly of the mine own-
ers. As it is, the state assumes the expense of
the care of these individuals, who should be
able to pay for such service and not be subjected
to charity. The state has also partly supported
many other hospitals, according to the amount
of care given free to the poor. Institutions for
the care of the tuberculous and insane have been
established and controlled by the state. Efforts
are made to pick out those who can pay and to
care only for the poor. As we have granted the
right of the state to protect itself by preventive
measures, we must also grant it function in
curing the sick who are unable to pay. Few,
however, are willing to concede the wisdom of
fatherly support for those who are well quali-
fied to support themselves.
Workmen's Compensation for Accident in-
curred in pursuit of the occupation, is the most
important recent legislation which affects phy-
sicians. In this the insuring body selects the
medical attendant for the injured man and pre-
sumes to determine for the physician the amount
of his fees. Those offered are usually less than
those prevailing. Fortunately this matter is in
process of adjustment, by the fee bills which our
county societies are establishing. Under these,
which are the usual fees for like work in pri-
vate practice, the physicians of the particular
county are willing to do compensation work.
Our Committee of Society Comity and Policy
recommend that all do this. And I urge that all
county societies do this unless they have already
done so, and bind themselves to refuse such
work at lower fees. I see no other way for you
to properly conserve your rights in this particu-
lar. The insurance companies are entitled to no
more consideration in regard to fees than the
private individual.
We are now confronted with the problem of
the compulsory insurance of certain classes of
workmen. It is claimed by the advocates of
such legislation that it is a natural outgrowth
from and sequel to the compensation for acci-
dents to workers. The analogy is not complete,
however, for accidents are due in most instances
to the occupation and sickness is not. In the
former the matter may naturally be chargeable
to the industry and in the latter not at all. The
chief, or rather the most telling argument which
is presented is that there is an inadequacy of
medical service. If this be true, then measures
must be taken to remedy the condition. It is
our duty to lead the way. So far as the experi-
ence of many observers goes there is no lack of
opportunity to secure medical service in cities
and towns. In some localities there are more
physicians than are needed and many are failing
to make a proper income because of a lack of
patients. If some of these could be induced to
go where the need is greater much of the ap-
parent need of physicians would be met. There
are probably enough now if they were properly
distributed. For those people who cannot af-
ford to pay medical fees, there are free dispen-
saries, hospitals and visiting physicians. Then
too, private physicians are still willing to reduce
their fees or give their services free.
In the country there is a growing scarcity of
physicians. Farm workers, however, are not in-
cluded in the provisions of bills already offered.
Under Compulsory Health Insurance the medical
care of beneficiaries is directed and controlled by
the governing body which in turn is under state
control. Physicians' fees are fixed, regulations
as to medicines used are made, the physician's
actions are trammeled by restrictions and he no
longer can give full scope to his individualism
and initiative. He cannot decide on immediate
operation however sick his patient may be, but
must have the consent of his chief before the
patient is sent to the hospital. The workman
pays only a part of the expenses of his medical
care and becomes a recipient of charity with iti
attendant malign influences. As ali- workmen
are assessed according to the wage and not ac-
cording to age or present condition of health,
the act puts a penalty upon some to the advan-
tage of others. The vicious and immoral, with
their greater incidence of illness, are cared for
at the same rate as the others.
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October, 1920
PRESIDENT'S ADDRESS— JUMP
As Sir Arthur Newshobne says of the act in
Great Britain "it is not. actuarially, financially or
medically sound, and has involved expenditure
in administration entirely incommensurate with
the benefits received." However social insur-
ance has been established in certain countries
and we must judge of its effects from them. In
these it has seemed to be the starting point of
further control of medical practice. The scope
of the Act in Germany has widened until ninety
per cent, of the people are included in its provi-
sions. The physicians there are complaining
much of the small fees ; they have combined to
resist the downward tendency of the fees and to
ask for more liberal regulations. They have
even made a futile effort to strike like their less
educated but better paid fellow citizens, who
wield the hod, trowel or pick. But the matter
has gone so far there, that hope for improve-
ment is faint and may come only with reversal
of the present trend of thought. We are cer-
tainly justified from the standpoint of the peo-
ple and of the good of our own profession in
resisting efforts to establish such a system here.
On account of the scarcity of doctors in coun-
try districts a bill was introduced in the last ses-
sion of the New York Legislature to establish
health centres or hospitals under the control of
the state. These centres are designed to pro-
vide complete laboratory and hospital facilities
for all parts of the state which need them. The
medical staffs of these centres are to be under
salary and within control of the state. As in
Compulsory Health Insurance the physician be-
comes an employee and enters into relations of
master and servant with the state. Freedom of
action and independence of thought will be in-
terfered with, for one is prone to be influenced
by the attitude of the employer. The University
of Michigan is planning to attach to the Uni-
versity Hospital a number of young physicians
who, as a part of their medical training may be
sent out into localities which are in need of phy-
sicians. It is proposed to equip these men with
one or more nurses and a small laboratory. The
costs will be paid by the University and it will
be reimbursed by the community. Those who
are able to pay will do so and the poor will be
provided for without charge. They evidently
propose to do this in connection with the med-
ical society whenever possible. This is a better
solution than the f ojmer, but is this not a matter
which should be handled by physicians for them-
selves ?
Cannot the State Medical Society advise
and cooperate with those of its members who
may make such efforts with a desire to guard
their rights and improve their material inter-
ests? It would seem so, for the purposes of this
Society, among others set forth in its Con-
stitution, are "to extend medical knowledge and
advance medical science;" "to guard and foster
the material interests of its members." The
former of these has been well attended to and
the excellence of the scientific program which is
offered to you at this session bears witness to
that.
The time has now arrived for the greater de-
velopment of the purpose to guard and foster
your material interests. The officers have done
what they could but the members have not ap-
preciated enough the value of such efforts to give
their full cooperation. I should like to see such
a community of interest among us that no phy-
sician could afford to stay out of the Society:
for he would understand that all that is worth
while in material things in medicine originates
in the Society. Here is an opportunity to take
a step forward in medical society affairs. It is
not the function of this body to institute and
support such hospitals but it is distinctly within
its powers to survey the field and make plans in
this matter, which so vitally touches us. When
such plans are formed it should stand ready to
advise any group who wish to organize such a
hospital. I know there are such but they have
not known how to proceed. The staffs should
be limited to our own members, for membership
in the Society carries with it the badge of cor-
rect medical practices. A directory could be
kept by the Society by which any organization
could be helped to find physicians to complete
the staff. Any community will be benefited by
such a hospital, for better medicine will be prac-
ticed and patients in remote districts can be
moved into the hospital and receive more ade-
quate treatment. Support for the institution can
therefore reasonably be asked of the community.
Under the New York proposal the community is
to be assessed a part of the expense. I shall
recommend to the House of Delegates that a
committee be authorized to investigate and re-
port working plans to meet this urgent need.
With the inauguration of such work we will
have done something more of material good for
you and something more to advance medical
service.
As our problems and the difficulties attendant
upon them arise, discouragement will come and
there will be an inclination to cease our efforts
and drift along. This must not be, for the very
life of our profession is at stake and we must
face things with a strong heart. Maeterlinck
says "there is the temptation to grow discour-
aged at the impossible task that seems to be be-
fore him and to abandon it altogether. Our one
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THE PENNSYLVANIA MEDICAL JOURNAL
October, 1920
and only duty is none the less to continue our
effort to know where we are."
ORIGINAL ARTICLES
EPIDEMIC (LETHARGIC)
ENCEPHALITIS*
MAX. H. WEINBERG, M.D.
Assistant Neurologist Western Pennsylvania Hospital
PITTSBURGH, PA.
As far back as 1715 Camerarius* described a
disease known in Germany as "Schlaffkrankheit"
accompanied by ocular palsy. The condition
was noted here and there on many occasions,
but it only drew marked attention in 1892 when
it was given the name of "Nona." Although
this epidemic was more or less localized in Italy
and Hungary, the medical press of all the civ-
ilized countries at that time is replete w^ith ac-
counts of this strange disease. It was fairly
well accepted that it was closely connected with
the influenza epidemic which was raging at the
time. It remained for Von Economo^ of Aus-
tria to recognize the disease as an entity with a
definite symptomatology and perhaps a definite
etiology. Von Economo studied his cases dur-
ing the winter of 1916-1917 and named the con-
dition Encephalitis Lethargica. His views are
supported by such authorities as Netter,' Mac-
Nutty,* Marinesco," Mathewson, Latham,* and
others.
When the epidemic first appeared in England
early in 1918, it was described under various
names such as Botulism, Toxic Ophthalmople-
gia, Epidemic Stupor, An Obscure Disease with
Cerebral Symptoms. Many other names were
used by the authors who were baffled by this
strange condition. There are many authorities
even now, who connect this disease with the re-
cent epidemic of influenza, but all the evidence
seems to be against such a view. I shall men-
tion only a few' of the reasons. The encephal-
itis epidemic appeared in both Europe and Aus-
tralia at a time when there was no influenza.
In New York the first cases of this disease ap-
peared only at the end of the influenza epidemic
and the height reached during the early months
of 1919, several months after the influenza epi-
demic. The influenza bacilli were never found
in the spinal fluid of such patients, nor in the
blood. As Etienne' points out, it differs particu-
larly from encephalitis following influenza in
which edema of the brain is the predominating
lesion. Lastly, this seems to be caused by a
•Read before the Allegheny County Medical Society.
filtrable virus, as proved by the researches of
Straus, Hirshfield, and Loewe,* who transferred
the disease from man to monkey and rabbit, and
from rabbit to monkey and rabbit.
The disease usually starts as a general infec-
tious process with fever, headache, general pains
all over the body, some digestive disturbances,
constipation, very toxic tongue, sore throat, and
occasional vomiting. One of the earliest and
most constant symptoms is diplopia. The acute
symptoms last but from two to five days in the
majority of cases, and then follows a general-
ized asthenia, paralyses, usually of the cranial
nerves especially the third and seventh, but it
may involve any part of the cerebro-spinal sys-
tem. Lethargy, stupor, and occasionally coma,
rigidity of neck, dysarthria, tremors, usually of
a Parkinsonian character, and choreiform move-
ments are seen. Many patients show marked
mental changes.
There were several attempts made to classify
the cases and group them, but owing to the
widespread nature of the infection, involving as
it does almost any part of the central nervous
system, this is almost impossible. Thus, Hall'
of England in his report of his first ten cases
divided them into two main groups, meningitic
and asthenic. MacNulty* groups his cases ac-
cording to the site of lesion and as to whether
localizing signs are present or not. Tilney and
Riley** in their report of twenty cases have
worked out nine groups. All this only tends to
confuse, and I think therefore, that the group-
ing of Abrahamson^^ is the easiest and most
logical. Abrahamson divides his cases into :
1. Types presenting focal neurological symp-
toms.
2. Types presenting general neurological
symptoms without focal signs.
3. Abortive types.
There is quite a host of subtypes one could
mention under types one and two depending on
the localization of the lesion as to whether it in-
volves only one or two areas of the brain.
The disease may be divided into three stages :
A prodromal, a stage of full development, and a
subsiding stage.
The prodromal stage may last from one day
to three weeks, some may show remissions even
during this period, many complain of dizziness,
headache, and diplopia for a day or two, then
work a few days and later develop the full dis-
ease.
I can do no better in the enumeration of the
symptoms and the relative frequency of their
occurrence than quote MacNulty.*
He divides the symptoms into those of a spe-
cific and a general character.
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October, 1920
ENCEPHALITIS— WEINBERG
Specific symptoms: Lethargy or drowsiness,
headache, vertigo, tinnitus, asthenia, diplopia,
blurred or misty vision, photophobia, tremors
and twitchings, delirium, irritability, mental de-
pression, restlessness, mental alteration, pains in
face, back, neck or limbs, pain in the eyes,
aphonia or difficulty in articulation, stiffness of
neck, hiccough, and sweating.
General symptoms: lassitude, fatigue, gen-
eral malaise, chills, diffuse pains, abdominal
pain, nausea, anorexia, vomiting, diarrhea, faint-
ing attacks, conjunctivitis, tonsilitis, and "sore
throat," bronchial catarrh, and parotitis.
The lethargy is one of the most characteristic
symptoms. The patient can be easily aroused
and he answers questions readily, but imme-
diately falls asleep again. The lethargy may
deepen into stupor and in some, usually fatal
cases, goes into coma. This last is not neces-
sarily evidence of a fatal prognosis. I saw sev-
eral patients recover after having been comatose
for several days.
In some cases the patients, although lethargic,
suffered from an obstinate insomnia. Few were
delirious at night.
Headache is very common and is one of the
earliest signs.
Vertigo is a rather characteristic and early
symptom.
Diplopia is very frequently complained of. It
usually disappears at the end of two to five days.
The temperature during the first few days
usually ranges between 100-102 F. and then re-
mains around 99 F. In the fatal cases there is
usually an ante-mortem rise up to about 107 F.
A rise in temperature after it once subsided
either indicates a complication such as broncho-
pneumonia, or a turn to the worse in the disease
itself.
Asthenia is usually very marked. A patient
we had in the West Penn Hospital who showed
a marked Dementia Precox trend complained
continually almost in an automatons manner that
he was weak, so weak that he was going to die.
The attitude of the patient once seen is never
to be forgotten. He lies with eyes closed, hands
usually folded across the chest, motionless, his
face is mask-like, and in the more severe cases
looks like a wax figure. These patients usually
show catatonia. Many show fibrillation of fa-
cial muscles. About one-half of the cases pre-
sent the appearance of Parkinsonian disease
even including the tremor.
Their speech is very characteristic. Usually
it is a droll, monotonous, nasal, hardly audible
mumbling, as if the patient were chewing his
words. Occasionally the patient shows a pecu-
liar halting, hesitant speech, followed by a sud-
den rapid torrent of slurred words, a sort of
festinating speech, as Abrahamson" aptly de-
scribes it. Dysarthria and aj^onia occasionally
occur. One patient showed a distinct negativism
and refused to speak for about ten days.
Many showed tremors, usually coarse and
regular. Parkinsonian in character. Some show
choreiform or athetoid movements.
Reflexes may be absent, but the majority of
cases show increased reflexes. Babinski sign is
quite common.
Sweating is rare. May be confined to certain
areas. Several showed a peculiar greasy ap-
pearance, mainly confined to face.
About ten per cent, of the cases showed des-
quamation. MacNulty* reports many kinds of
rashes. I only saw two cases with an erythem-
atous rash. This is probably due to the fact
that I saw but few cases early in the disease at
which time the rash appears.
Pulse usually normal, but tension is poor.
During the pyrexia the pulse is in keeping with
the temperature.
Respiration usually normal. In the fatal cases
failure of respiration caused by bulbar involv-
ment is noted as a terminal condition.
The mental state is usually abnormal. In
every case which presents lethargy more or less
marked I found irritability, disorientation, and
some confusion. Some showed distinct psycho-
sis syndromes. Two were definite dementia
precox, one Korsakoff's Syndrome and several
showed depressions.
Urine usually normal. May show albumin
during pyrexia stage.
Blood is normal.
Spinal fluid is of great aid in the diagnosis.
There is an increase of cells, usually twenty to
forty, but in several cases the cell count was
rather high. In one case 600 cells per cmm.
were found. The cells are small lymphocytes.
Only one showed a high polymorphonuclear
count. The fluid is clear and usually under
some pressure. This varies considerably with
the spinal fluid findings by the authorities
abroad, but our findings have been checked and
rechecked and we came to rely greatly on the in-
creased cell count in the fluid as an aid in diag-
nosis.
THE TYPES PRESENTING FOCAL NEUROLOGICAI,
SYMPTOMS
These show various paralyses. They may be
supranuclear, infranuclear or nuclear. There
may be cortical, subcortical, or cerebellar types.
A characteristic feature of the paralysis as Mac-
Nulty* points out is its progressiveness. Usually
one side is paralyzed first. The side that be-
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THE PENNSYLVANIA MEDICAL JOURNAL
October, 1920
comes involved first is always most advanced
and usually recovers before the side that be-
comes involved later. Another characteristic
feature is the rapid clearing up of the paralysis.
One of the cases, that of a girl of eleven, had a
complete hemiplegia later she developed bulbar
symptoms, was almost moribund and in about
ten days the patient was able to walk around
without leaving any trace of the paralysis except
that of the eye muscles. >.
The third and seventh cranial nerves are most
frequently involved. The lesion seems to be
mostly around the nuclei of the third to the sev-
enth, but the medulla often is involved, and in
the fatal cases the vagus nuclei are affected.
One case showed a complete paraplegia and
cerebellar symptoms, such as marked nystagmus,
turning of the head to one side, vertigo, adia-
dochokinesis, and dysmetria. The little girl that
I mentioned above had a complete Weber syn-
drome on one side, panophthalmitis of the left
eye and right sided hemiplegia, which constitutes
the Weber syndrome, and right facial paralysis
and choreiform movements of the left half of
the body giving a Benedict syndrome. Mono-
plegias or only paresis of one limb may occur.
TYPES PRESENTING GENERAL, NEUROLOGICAL
SYMPTOMS WITHOUT FOCAL SIGNS
Here we might consider the cases that present
definite syndromes such as Parkinsonian, cho-
reic, athetoid, and general epilepsy. I am also
inclined to place in this group all the cases that
show marked mental changes, most prominent
of which are dementia precox types, manic-
depressive, pseudo paretic, Korsakoffian, and
psychoneurotic. 1 met all these types in a series
comprising about sixty cases.
ABORTIVE TYPES
It is difficult to say how many constitute this
group, but I have no doubt that the number is
high, as owing to the obscure nature of the dis-
ease and the difficulty of diagnosing it, many
cases are being overlooked. In the Mount Sinai
Neurological Dispensary I saw several cases that
were being treated for colds, nervousness, hys-
teria, and what not, that presented mild symp-
toms of the disease, such as. slight somnolence,
slight paresis of the face, early diplopia and
tremors. Since my return to Pittsburgh I found
some cases, retrospectively, it is true, who have
suffered from obscure sicknesses, paralyses, and
weaknesses that cleared up within two or three
weeks. There is no doubt in my mind that these
patients were abortive types of encephalitis
lethargica. On the other hand, patients origi-
nally starting out as abortive types may proceed
and become full fledged cases which last for a
considerable length of time.
The course of the disease is not at all definite.
The usual duration is six to eight weeks, but
may last much longer. One case, that of a com-
plete paraplegia and cerebellar syndrome, was
practically unimproved at the end of four
months. Most of the patients even when they
leave the hospital show signs of having passed
through a severe illness. Some still show the
mask like face, others some residual paresis, still
others ravenous appetites, and some, mental
symptoms, especially irritation and anxiety.
The differential diagnosis is extremely im-
portant. The disease has been mistaken for so
many conditions that it is impossible to give
them all in a paper of this kind. I shall there-
fore confine myself to the most important,
poliomyelitis is by far the most important dis-
ease to be ruled out. It usually differs from
encephalitis lethargica in the following respects :
It occurs mostly in younger people, has a brief
prodromal period, onset usually abrupt, convul-
sions are very common, stupor is rare, speech
changes if present are not characteristic, cere-
bral cases occur but rarely, and if so are asso-
ciated with the ordinary spinal type, the para-
lysis is manifest immediately and at its maxi-
mum when it does appear, the paralysis of the
face is rarely bilateral, practically never progres-
sive, and residual paralysis is quite common,
there is also atrophy and reaction of degenera-
tion.
Brain Tumor — Several cases especially those
with fundi showing changes have been mistaken
for brain tumor. One case that of a girl of
twenty was very puzzling from that standpoint
and merits full description. She had an infected
mole removed one year before she took sick, and
the section diagnosed melanotic sarcoma. When
she was brought to the hospital at this time she
complained of severe diplopia, lethargy, and
ocular palsies. She had a temperature of about
100 F. Later she developed stupor, Jacksonian
epilepsy of the right arm, desquamation and se-
vere choked disks. Most of the neurologists at
the institution diagnosed sarcoma of the brain,
and only two held out for the diagnosis of en-
cephalitis. At autopsy a large hemorrhage of
the third ventricle was found and many small
punctate hemorrhages of the cortex and pons.
Sections examined showed the typical lesions of
encephalitis in various parts of the brain. The
remissions in this case, the high cell count in the
cerebro-spinal fluid, the temperature early in the
disease and finally the desquamation were the
outstanding features in favor of the diagnosis
of encephalitis, and the autopsy proved it.
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October, 1920
ENCEPHALITIS— WEINBERG
Hysteria — ^This is at all times a dangerous
diagnosis to make, and encephalitis in particular
is apt to be misleading on account of the impres-
sion the patient gives during his lethargic state
when he answers readily to questions, and when
a patient in a marked catatoniac state will be
seen to reach out for water that is standing by
his side. One of our fatal cases, a pregnant
woman, during the height of the epidemic in
New York, developed the sickness. She had
diplopia and was drowsy. The papers in New
York were full at the time with articles about
this new sleeping sickness and she made the
diagnosis on herself. The family physician was
called in and he diagnosed hysteria. The patient
told him that she feared this new disease and he
laughed at her, but to reassure her he called a
consultant who confirmed the diagnosis of hys-
teria. In two days a neurologist was called, a
correct diagnosis made and she was brought to
the hospital. She presented a true Korsakoffian
picture. The disease was rather mild for about
three weeks, but later developed bulbar symp-
toms, her temperature rose to 107 F., she had
acidosis and died during the fourth week of the
disease.
I shall only mention some of the other condi-
tions that encephalitis is to be differentiated
from. They are: Tubercular meningitis;
cerebro-spinal meningitis, cerebro-spinal syphi-
lis, typhoid, diphtheritic paralysis, uremia, botu-
lism, and the various psychoses which so many
patients show during the disease process.
Prognosis — Usually favorable. Mortality of
the cases I studied was about ten per cent. The
mortality reported by authorities abroad is much
higher. The English report twenty per cent,
and higher. Cases that are treated in hospitals
stand better chances of recovery. Sachs" re-
ports a much higher mortality among his private
cases met with in consultation work than in the
hospital cases. This is probably due to the
greater severity of the cases seen in consultation,
and also to the fact that the hospital patients get
better nursing and general attention. Frequent
remissions and late high temperature are grave
prognostic signs. High temperature usually
precedes the fatal issue. I feel also that preg-
nancy is of grave prognostic import. Three of
our five fatal cases in a series of forty were
pregnant women. I think that a pregnant
woman suffering from this disease should be
aborted to give her a better chance for recovery.
No pregnant woman of this series recovered,
but Neal" in her series of six cases reports one
of a pregnant woman who recovered. This case
was rather a mild one.
Pathology — Welsh" of Australia and Mari-
nesco" of Paris reported in detail their findings
in several fatal cases and their conclusions are
the same. It is an acute inflammatory process
which is mainly confined to the pons and me-
dulla, but may involve any part of the brain or
cord. Welsh** reports one case in which lesions
were found in the cervical region of the cord.
Bassoe and Hassin" also report a case, that of
an infant, in which changes were found in the
lumbo-sacral region of the cord. The pia occa-
sionally shows hyperemia.
There are usually small punctate perivascular
hemorrhages. The exudate consists mainly of
plasma cells, lymphocytes, and a few polymor-
phonuclear cells. The neuroglia cells are in-
creased in number. The parenchymatous tissue
is more or less involved, but the nerve cells, even
when in the midst of an islet of proliferated
cells, are seldom destroyed. The nerve cells
may be smaller in size and show changes in the
chromatophylic substances. Neuronophagia is
rare and when present is not at all marked.
Etiology — The etiological factor is not well
established as yet. Von Wisner'* working with
Von Economo reports that he isolated a Gram
positive coccus and on injecting this organism
into a monkey produced the disease. His work
could not be duplicated by the English authori-
ties who studied their cases thoroughly. Mari-
nesco' reports finding in the brain tissue of en-
cephalitic cases two species of microbes, the
most frequent a Gram positive short thick bacil-
lus and a diplococcus. Mackintosh" found the
bacillus to be an anaerobic organism, pathogenic
for mice. The diplococcus was much rarer.
Neither of these organisms caused the disease in
monkeys. Stafford" reports a case in which he
found large Gram positive diplococci in the
spinal fluid. The organisms were grown with
difficulty. He was not able to produce the dis-
ease in guinea pigs or rabbits, one of which was
injected directly into the spinal canal.
However, the work which gives most promise
is that done by Straus, Hirshfield. and Loewe*
at the Mount Sinai Hospital, New York. These
observers transmitted the disease by using either
an emulsion of brain tissue from fatal cases or
the nasal secretions of patients. They found
that it is a filtrable virus, and succeeded in
transferring the disease from man to monkey
and rabbit, and from rabbit to monkey and rab-
bit.
In their last communication Straus and
Loewe" claim to have cultivated a globoid body
which resembles the one described by Noguchi
as the cause of anterior poliomyelitis.
I am inclined to believe that the disease is
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THE PENNSYLVANIA MEDICAL JOURNAL
October, 1920
caused by a filtrable virus as is poliomyelitis, and
that it is a separate and distinct disease entity.
Treatment — Very little is to be said about
treatment. The best method is to force fluids
on the patient, promote active elimination, care-
ful and proper nursing and strict watchfulness
for untoward symptoms in which case active
interference may have to be resorted to, such as
intravenous glucose injections in case of marked
acidosis, or artificial respiration in case of re-
spiratory failure. Drugs are practically of no
avail, neither is the taking away of spinal fluid.
Discussion and Summary — From the stand-
point of the neurologist as well as that of the
general practitioner this disease is of great im-
portance. This being, to start with, an acute
infectious disease, and as it seems even epidemic
in nature, it should put the general practitioner
on his guard for manifestations of it. It is of
even more importance to the neurologist because
it enables him to study almost any neurological
syndrome, and besides, it enables him to have a
broad view and keener conception of disease
entities both neurological and mental. This dis-
ease which is acute in character and compara-
tively speaking, fleeting in its effect in the ma-
jority of cases, manifests itself sufficiently to
shed light on diseases which until now have been
looked upon as obscure in character. It particu-
larly applies to mental diseases and strengthens
the view advanced by such observers as Az-
heimer. Cotton,^" and more recently by Go;.-
line,^' Southard,^'' and Walker,^" namely, that
mental diseases are dependent on bodily changes,
be they due to nutritional changes, toxins, en-
docrinological disturbances, or changes result-
ing from infectious processes.
Not only does this disease produce such defi-
nite syndromes as Parkinson's, the Weber or
Benedict's (the pituitary syndrome), but in cer-
tain cases such definite mental syndromes as
dementia precox, Korsakoff's, depressions, and
as Mayer** pointed out, paretics,
A further study of pathological material and
correlation with clinical observations will enable
us to establish definitely the regions of the brain
involved in hitherto obscure neurological and
mental conditions.
I shall take this opportunity to express my
thanks to Dr. I. Abrahamson of New York for
the opportunity given me to study the material
at his disposal, for his excellent teaching, and
helpful advice.
Keenan Building.
REFERENCES
1. Camerarius, Ephem. Acad. I>opold., t7iS> P- 135-
2. Abstracted in Corr. Bl. f. schweiz. Acrzte. Jahrb. 191 7,
35, p. 1 147.
3. Societ. mcd. des Hosp. 34: 307, 1918.
4. Report of Local Gov. Board n. s. lai, London, 1918.
5. Report of Local Gov. Board n.s. lai, London, 1918.
6. Med. J. of Aust. 19 17, Vol. 2, p. 3S».
7. Bull, de la Soc. Med. des Hosp., Paris,
No. 18.
May 23, 1919. 4Ji
8. New York M. J. 109: 772, May 3, 1919,
9. Lancet, i: 508 (April 20) 1918.
10. Neurol. Bull. N. Y., Vol. 2, 1919, p. 106.
11. Preliminary Note read before New York Neurolog. So-
ciety, March, 1919.
12. New York M. J. 109: 8g^ (May 24) 1919.
13. Arch. Neur. & Psych. Vol. 2, No. 3, 1919.
14. Med. J. of Aust. Vol. 2, 352, 1917.
15. Arch Neur. & Psych. Vol. j. No. i.
16. Abstract Cor. Bl. f. Schw. Aerzte. Jahrb. 19 18, :o. 2,
March 16.
17. Local Gov. Board, n.s. London, 1018.
18. J. Lab. & Clin. M. Aug. 1919, 4, No. 2.
19. Jour. A.M.A. Oct. 4, 1919.
20. Alzheimer and Cotton quoted by Southard. Arch Neur. ft
Psych. Vol. I, No. 2, 1919.
21. Bost. M. ft S. J. 177: No. 10, 1917.
22. Arch. Neur. ft Psych. Vol. i. No. 2, 1919.
23. Penn. M. J. Feb., 1918.
24. J.A.M.A. 72:670 (March i) 1919.
IND.
THE "ANCIENT" AND THE "MODERN"
KIDNEY*
JULIUS H. COMROE, A.M., M.D., F.A.C.P.
Physician to the York Hospital, York, Pa.
Any endeavor to discuss the topic, assigned to
me by your most worthy president, in more than
a cursory manner, would necessarily be futile.
However, with your kind and charitable indul-
gence, a feeble attempt will be made to review
and emphasize the more salient features relating
to the various nephropathies as we more re-
cently have had them brought to our attention
by painstaking investigators, in contradistinc-
tion to the picture presented to those of us who
entered the field of the practice of medicine 'fif-
teen or more years ago. Limited time will not
permit even a brief resume of the older teach-
ings, but the newer thoughts to be offered will
provide ample opportunity for comparison.
Probably no other organ has suffered more as
a result of faulty diagnosis, and therefore treat-
ment, than the kidney. It is rather distressing
to acknowledge that serious nephropathies have
not infrequently been entirely overlooked, al-
though the more common error has been to at-
tribute urinary changes, caused by disease of
the heart and arteries, in particular, to primary
renal disease. Too often, the various forms are
lumped together as "nephritis" or "Brights' Dis-
ease,"— no serious attempt being made to differ-
entiate the inflammatory, circulatory and degen-
erative varieties, or to determine the toxic or in-
fectious etiologic factors.
The kidneys are admittedly the most impor-
tant excretory organs in the body, and it is
therefore not surprising that they should be so
prone to frequent injury. They serve to re-
move from the body various waste products of
metabolism, and play a most important role in
•Read, by invitation, before the Lancaster City and County
Medical Society.
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October, 1920
'ANCIENT" AND "MODERN" KIDNEY— COMROE
maintaining a proper concentration of the body
fluids, and in preserving the normal chemical re-
action of the organism. The total output of
urine provides valuable information as to the
water equilibrium ; the specific gravity furnishes
a gross measure of the solids excreted ; the re-
action is of importance owing to its relationship
to the various conditions of acidosis in the body.
It must be borne in mind that, under normal
conditions, the urine contains almost the entire
output of the end products of protein metabol-
ism, and a large proportion of the excess of
mineral constituents. Although the fats aod
carbohydrates leave the body mainly as carbon
dioxide and water through the lungs, — in cer-
tain diseases, their metabolism is incomplete,
and the resulting accumulation of intermediary
bodies is eliminated in the urine, e.g., the ketone
bodies in acidosis, and glucose in diabetes. Like-
wise, the excretion of inorganic matters, such as
chlorid-retention in pneumonia, seek the same
outlet, as do certain foreign and toxic substances
in the blood, arising from the metabolic products
or absorbed from the intestines after being ren-
dered innocuous. Add to this the injuries that
may occur from the elimination of drugs and
various poisons, exposure, traumatism, the nu-
merous infections, pregnancy, syphilis, etc. ; and
it is not difficult to understand why these organs
are constantly the subject of many insults.
Modem diagnosis has been aided considerably
by the rapid strides of the natural sciences of
physics, chemistry and biology, and the more
recent advances in applied anatomy, physiology
and pathology. Each kidney should be looked
upon as a very complicated organ, composed of
a series of "secretory xmits," each unit compris-
ing its glomerulus and attached tubule, sur-
rounded by blood vessels and a certain amount
of connective tissue pertaining to that tubule,
and filling up the "interstices" between neigh-
boring secretory units. It has been estimated
(Max Broedel) from serial sections and careful
measurements that there are approximately fo"ur
millions of tubules and glomeruli in the normal
kidneys. As single parts of the secretory units
and of the interstitial tissue may be separately
diseased, it follows that the most variable clin-
ical and pathological pictures may be produced.
During the past fifteen years, considerable
light has been added, by competent observers, to
our knowledge of the histology and pathology
of these organs, as well as to the proper under-
standing of the functions of their individual
parts, and the manner in which these functions
are disturbed by various lesions. Takayasu has
shown quite conclusively that there may be
marked disturbances of function of a portion of
the kidney when little or no evidence of a path-
ological lesion is demonstrable. Apparently
successful efforts are being made to ascertain
the exact points in the normal kidney at which
the various urinary constituents are thrown off,
such as water, sodium chloride, nitrogenous sub-
stances like urea, uric acid, etc.; as it appears
that each substance which is eliminated in the
urine is subject to its own laws of excretion.
Water and some of the salts (sulphates, phos-
phates and carbonates) are 'excreted by the
glomeruli, whereas urea, uric acid, and perhaps
sodium chloride, by the tubules. Uranium ni-
trate, potassium and ammonium chromate and
bichloride of mercury, affect chiefly the tubular
epithelium; arsenic, cantharides, and snake
venom attack the glomeruli chiefly; diphtheria
toxin acts more diffusely, affecting both the
glomeruli and the tubular epithelium. These
phenomena coincide with Bowman's vital theory
which presumes the selective action of the cells,
and assumes that the glomerular epithelium re-
moves from the blood the water and the salts of
the urine by an act of secretion, in contradis-
tinction to Ludwig's view that the secretion of
urine is a simple process of filtration, with the
glomerulus acting as a filter, eliminating front
the blood not merely water, but also the solidi
constituents of the urine (inorganic salts, urea»
etc.). Specific secretory nerves for the kidney
have not yet been demonstrated, — the secretion
being directly dependent upon the rate of the
blood flow. The kidney being extremely vascu-
lar, it has been estimated that, under the influ-
ence of diuretics, within a minute's time, an
amount of blood equal to its own weight flows
through each kidney.
Quite recently, colloid chemistry has become
increasingly prominent in an attempt, both clin-
ically and experimentally, to clarify the prob-
lems of the various nephropathies. All the pro-
teins of the economy, as well as the fats and
carbohydrates, — even the blood plasma — are in
a colloidal state. Substances in a colloidal state
differ from crystalloids (like solutions of so-
dium chloride, sugar, etc.) in that they do not
diffuse on dialysis, owing to the fact that the
dispersive phase (colloidal phase) consists of
particles too large to pass through the pores of
parchment paper or animal membrance. Life
depends upon the existence of substances in col-
loidal states in the body cells. All protein sub-
stances have a specific affinity for water, de-
pending upon the conditions under which the
colloid is placed. Thus, both acids and alkalies
change this avidity for water, increasing it, while
salts may either increase or decrease it. It also
appears that the bromides, nitrates, chlorates,
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10
THE PENNSYLVANIA MEDICAL JOURNAL
October, 1920
and chlorides increase the capacity for swelling,
while acetates, citrates, tartrates and sulphates
decrease this capacity, in the order in which
these drugs are mentioned.
Martin Fischer quite recently has advanced
the theory that edema is due to increased affinity
of the colloids of the tissues for water, — this in-
creased avidity being due to excessive acids, re-
sulting either from abnormal production or
inadequate elimination. It is too early to either
entirely accept or refute his hypothesis. He
therefore proposes, as treatment, the neutraliza-
tion of the acids in the tissues by alkalies and
the administration of sodium chloride to les-
sen the colloids' affinity for water, and recom-
mends the intravenous injection of a solution
containing sodium chloride, 14 grams, crystal-
lized sodium carbonate, 20 grams, and water to
make 1,000 c.c.
This problem of edema in nephritis is a most
important one, and is deserving of more detailed
study. Clinically, it is ofttimes difficult to de-
termine whether the underlying causative factor
is one of the nephropathies, cardiac insufficiency,
or some such condition as angioneurosis, anae-
m.ia, cachexia, etc. It is more generally agreed
that edema of renal origin depends upon ( 1 ) in-
jury to the blood vessels of the glomeruli ; thus
obstructing the lumina or interfering with the
contraction and dilatation and preventing the
excretion of sodium chloride and water in
proper amounts, and (2) a lesion of the small
blood vessels all over the body, leading to in-
creased permeability of the same. Therefore,
in the consideration of the therapeutics of this
symptom, both of these factors must be care-
fully studied. The experiments of P. F.
Richter, in 1904, followed by those of Chitten-
don and Alexander Lambert in 1899 and Woro-
schilsky in 1890, would seem to confirm this
view. Cohnheim and Lichtheim found that
large amounts of normal salt, equal to 92% of
the body weight, could be injected into an ani-
mal without producing subcutaneous edema, al-
though ascites and dropsy of the various organs
readily appeared. Pearce, as a result of his own
careful researches, considers all three factors as
essential to the production of renal edema, viz :
(1) nephritis, (2) vascular injury, and (3) in-
crease in the body fluids. Schiayer and Hed-
inger, in various types of experimental nephritis
to determine if there was any disturbance of the
vaso-motor control of the kidney, concluded that
in the vascular type (caused by arsenic and
cantharides) the vaso-motor action of the kid-
ney is disturbed, both contraction and dilatation
being impaired, and diuresis fails to appear after
the use of sodium chloride or caffein. In the
type of nephritis where the poison acts particu-
larly on the tubular epithelium (chromium and
sublimate), little, if any such disturbance is
noted. It would be quite conservative, there-
fore, to conclude that renal edema usually re-
sults from (1) lessened permeability of the
renal vessels, (2) increased ingestion of fluids,
and (3) increased permeability of the peripheral
vessels.
Closely allied with the excretory function of
the kidneys are the findings attributing an in-
ternal secretion to the kidneys. Tigerstedt and
Bergman were the first to report on the presence
of a pressor substance, "renin," in kidney e'x-
tracts. This substance, soluble in normal saline
and in alcohol, was confined chiefly to the corti-
cal portion of the kidney; was non-dialyzable,
and destroyed by boiling. Very small amounts,
when injected intravenously, caused a rise in
blood pressure, up to 30 m.m. ; or more. An
increased secretion on the part of the supra-
renal glands has been reported by Schur and
Wiesel, Goldzieker, and others ; Wiesel, in ad-
dition, found an increase in the chromaffin tis-
sues in the autonomic nervous system. French
writers also report hypertrophy of the supra-
renal glands in nephritis.
The results of these experiments lead us log-
ically to the very important subject concerning
the relationship of blood pressure to the ne-
phropathies. The investigations of Paessler and
Heineke and those of Carrel and Janeway, bear-
ing upon the changes in the blood pressure after
experimental reduction of kidney substance in
the body, affirm the clinical facts concerning the
co-existence of arterial hypertension and cardiac
hypertrophy in renal disease. Their observa-
tions show that when the amount of kidney sub-
stance is reduced beyond a certain limit, hyper-
tension results, although the exact modus oper-
andi is not made clear. It is presumed by the
majority of investigators that a toxic influence
leads to the hypertension, although some accept
the glomerular reflex theory of A. Loeb. While
the loss of a large number of glomeruli, or in-
jury thereto, results in hypertension (in the
glomerular and interstitial varieties), extensive
epithelial injury to the tubules, without glo-
merular lesions, seems to result, at times, in
hypotension (as is noted clinically in the paren-
chymatous and amyloid kidney). Traube
claims that constriction of the renal vessels alone
is responsible, and more recently, Aluens has
confirmed this view, as have also Johnson, Gull
and Sutton. The weight of evidence seems to
favor the constriction of the entire arterial sys-
tem. Thus Hasenfeld and Hirsch found hyper-
trophy in both ventricles in 82% of the cases. —
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October, 1920 "ANCIENT" AND "MODERN" KIDNEY— COMROE
11
an increase in blood pressure of four weeks'
duration being sufficient to produce cardiac hy-
pertrophy. Loeb's explanation assumes glo-
merular involvement in all cases, interfering
with the proper blood supply of the kidney, —
the afferent vessel to the glomerulus becoming
distended and causing a reflex which results in
local vaso-dilatation. To accomplish this end,
vaso-constriction of the splanchnics takes place,
increasing blood pressure.
From a therapeutic standpoint, therefore, we
should view hypertension as a compensatory
measure, — an effort to force more blood through
the kidney in order to increase elimination.
Clinically, it is a safe rule, when we find a sys-
tolic pressure of 160-180 m.m., or more, asso-
ciated with evidences of a hypertrophied left
ventricle, all other things being equal, to think
of the presence of contracted kidneys.
Renal diagnosis, prognosis and therapeutics
therefore, bear a most important relationship to
the degree of accuracy of our completed studies.
By following the water excretion, the excretion
of total solids and of electrolytes and the excre-
tion of normal constituents of the urine (nitro-
genous bodies, sodium chloride, etc.) and of
certain foreign substances (phenolphthalein,
lactose, theocin, creatinin, etc.), we can draw
valuable conclusions not only regarding the gen-
eral sufficiency or insufficiency of the renal func-
tions, but also, and especially, regarding the
capacity of the kidney to excrete single sub-
stances. From these studies, we are learning in
what direction the kidneys should be most pro-
tected in the different forms of renal disease.
The researches of Albarran, Israel, Caspar
and Richter and von Koranyi are valuable in
this connection. The more important functional
tests that have been developed include the (1)
phenolsuphonephthalein, (2) indigocarmin, (3)
cryoscopy of the blood and urine, (4) determi-
nation of urea, (5) artificial polyuria test, (6)
potassium iodide test, (7) lactic acid test. The
most widely employed test, and a most invalua-
ble one in our diagnostic and prognostic arma-
mentarium, is the phenolsulphonephthalein test,
introduced by Rowntree and Geraghty, which is
so universally understood and used that no fur-
ther reference will be made to it here.
Schlayer and Takayesu (Romberg's Clinic)
believe, as a result of their experiments, that so-
dium chloride and potassium iodide are ex-
creted by the renal tubules, and that lactose and
water are excreted by the glomeruli. In 1909,
they found that destruction of the tubular epi-
thelium impaired the secretion of sodium chlo-
ride and potassium iodide, — the greater the
injury, the worse the secretion. In animals in
which the renal vessels (glomeruli) were in-
jured, the excretion was found to be delayed.
In the practical application of the lactose test,
20 grams of milk sugar, dissolved in 20 c.c. of
distilled water (solution being Pasteurized at
75° -80° for four hours on each of three succes-
sive days) are injected into the vein at the bend
of the elbow. The urine is collected at hourly,
or half hourly intervals and tested with Ny-
lander's solution until the reaction for sugar
ceases to be positive (the excretion may be
quantitatively determined by polarimetry.
Normally, all the lactose is excreted in four to
five hours; in many cases, it is delayed until
seven to twelve hours, or more. In such in-
stances, the author believes, the renal blood ves-
sels are diseased, in direct proportion to the
degree of delay.
In the potassium iodide test, 0.5 grams are
given by mouth and the urine tested every two
hours for potassium-iodide by Sandow's
method (a little chloroform is added to the
urine, followed by a few drops of sodium nitrite
solution and a few drops of dilute sulphuric
acid. Shake well, and the free Iodine will be
dissolved in the chloroform. Instead of the
chloroform, we may add the sodium nitrate so-
lution and the dilute sulphuric acid, and then a
little starch solution, which will turn blue in the
presence of free Iodine). Normally, excretion
is completed in thirty to fifty-five hours, but in
certain renal diseases, the excretion is prolonged
beyond sixty hours. In these latter cases of de-
layed excretion, it is presumed that the renal
tubules are diseased. The application of these
methods must be employed with great caution
as to their clinical interpretation, and certain
extra-renal factors must always be borne in
mind in each individual study.
Of the urinary changes great importance must
be attached to hyposthenuria, a condition in
which the kidney is no longer able to excrete a
concentrated urine, riclj in metabolic products
and salts, as a result of which, the twenty-four-
hour urine has a constantly lower specific grav-
ity than normal. In ascertaining its presence,
the specific gravity must be taken repeatedly
during the twenty-four hours. According to
Schlayer, such a thin urine can arise only in one
of two ways, (1) either through lessened pro-
duction of solid substances or (2) increased
production of water. In the first instance, the
hyposthenuria appears to be due to the injury
to the cells of the renal tubules ; in the second,
to an oversensibility of the renal vessels.
Schlayer speaks, therefore, of a tubular and a
vascular hyposthenuria. To distinguish the two
varieties, we note that in the tubular type, the
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THE PENNSYLVANIA MEDICAL JOURNAL
OCTODER, 1920
concentration remains permanently the same ; it
is always low. The addition of sodium chloride
to the food does not raise the specific gravity
and the total amount of sodium chloride ex-
creted in the twenty-four hours cannot be in-
creased by feeding sodium chloride, since the
tubules do not functionate properly or ade-
quately. In the vascular variety, the concentra-
tion remains also at the same height, but the
specific gravity may be much higher than in the
tubular form. Here, an addition of sodium
chloride to the diet is quickly eliminated with in-
creased output of water, but the concentration
remains the same. The renal vessels seem to be
oversensitive and to respond to every secretory
stimulus by producing larger amounts of water.
Albuminuria, per se, need not signify renal
disease, as it frequently appears in the urine in
various inflammatory affections of the lower
urinary passages (pelvis of the kidney, ureter,
bladder, urethra), and in women, leukorrheal
discharges from the vagina, menstrual blood,
etc., may be responsible for its presence. Even
in true albuminurias, we must distinguish be-
tween those due to serious renal disease, or to
severe cardiac insufficiency, on the one hand,
and those of little clinical import, as they appear
in the so-called physiolog^ical albuminurias (in-
cluding cyclic and orthostatic albuminuria), on
the other. It is generally agreed that albumin
is given out by the glomeruli, not only in glo-
merular nephritis, but also in renal disease in
which the glomeruli appear to be histologically
normal.
A further reference to orthostatic albuminuria
will not be amiss. This interesting condition,
which was carefully studied by Ludwig Jehle
and others, is characterized by the excretion of
albumin in the urine when the patient is in the
erect posture and its disappearance when the
patient assumes the horizontal position. It is
probably caused by a renal circulatory disturb-
ance, resulting in a certain amount of stasis as-
sociated with decrease in kidney function plus
oliguria and low salt excretion. When the dis-
turbance is eliminated by resumption of the
horizontal position, there is no impairment of
kidney function as measured by salt and water
excretion. The patients presenting this condi-
tion usually have a decided degree of lumbar
lordosis. Functional tests with phenolsulphone-
phthaleim in these patients invariably show
normal results.
No discussion of the significance of casts will
be undertaken in this review, except to empha-
size the fact that, contrary to past teachings, the
varieties of casts present are of very little as-
sistance in distinguishing the different forms of
renal diseases from one another. Blood casts,
however, do usually point to a glomerular ne-
phropathy.
It is naturally expected that the subject of
uremia will be referred to in this discussion.
From thirty to thirty-four grams of urea are
eliminated daily by the normal adult on a mixed
diet. Since one gram of proteid will yield ap-
proximately one-third gram of urea, this would
correspond to a proteid destruction of ninety
to one hundred grams. Urea is formed chiefly
in the liver ; when ammonia carbonate is added
to the blood and perfused through the liver, it is
converted into urea. As a result of digestion,
proteid material is broken up into the consti-
tuent elements and the nitrogen appears chiefly
in the form of ammonia, monamino acids, and
diamine bodies, which are apparently retained.
The clinical symptoms of uremia are best ac-
counted for on a basis of intoxication. Arcoli
considers that there is more than a constant or
single intoxicating agent, although there still ex-
ists considerable doubt as to the character of the
h)rpothetical poison or poisons which may be
retained within the blood instead of being elimi-
nated as normally. This evidence is by no
means conclusive because (1) the removal of
the kidneys does not produce a symptom-
complex resembling uremia — as might be ex-
pected. Likewise, (2) in complete anuria, from
obstruction of the ureter lasting ten to twelve
days or longer, death ensues without uremic
symptoms. Further, (3) attempts to produce
uremia by the introduction into the organism of
large amounts of urea, creatinin, etc., have been
unsuccessful. The more nitrogen retention in
the blood, the greater the danger of uremia ; in
fact, it is very probable that uremia develops
only in those cases of nephritis where nitrogen
retention is marked; although Van Noorden
reports one rare case of uremia in which nitro-
gen retention was absent. Feltz and Rourke
advance the theory that the potassium salts, ow-
ing to their toxicity, are responsible for uremia,
but this view has not been generally substanti-
ated. The most plausible hypothesis, therefore,
is that this symptom-complex is produced by
the retention of some unknown toxic substance
— the product of nitrogenous metabolism. The
more recent studies of the physiological chem-
istry of the blood, which make it a compara-
tively simple matter to quantitatively ascertain
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FLORENCE NIGHTINGALE— WALSH
13
the retention of uric acid, urea and creatinin,
have been of great value, especially from the
standpoint of prognosis and treatment. It has
been quite conclusively demonstrated clinically,
that when there are over five (5) mg. of cre-
atinin in one hundred (100) c.c. of blood, there
is almost invariably a fatal issue.
With a completed picture of the foregoing
facts before us, it is proper to conclude- that it is
far more easy to ward off the nephropathies
than to cure them, hence prophylaxis is very im-
portant. To prevent the ascending (urinogen-
ous) diseases, we should endeavor to avoid (a)
all the obstructions to the urinary outflow, and
(b) all infections of the urinary passages, or to
assure their very early and proper treatment.
To eliminate or minimize the descending (haenia-
togenous) nephropathies, we must learn how
the numerous toxaemias and bacteriemias may
be avoided. Thus, the prophylactic measures
to be taken against the toxic tubular nephra-
phathies (sublimate kidney, chromate kidney,
phosphorus kidney, etc.) are quite evident. We
have not learned how to prevent the pregnancy
nephropathy in women who are prone to it, but
the knowledge that employing of the uterus
cures it, stands us in good stead. The toxic
glomerular types are often due to streptococcic
toxines; therefore this possibility should be
thought of in every streptococcic infection, such
as streptococcic sore throat, tonsillitis, "bad
cold," etc. Other foci of chronic infection
should be watched for, and if found, removed.
Such causes include sinusitis, pyorrhoea —
alveolaris, abscesses of the roots of the teeth,
otitis — media, and chronic infections of the ap-
pendix, gall bladder, prostate, tubes, etc. After
the onset of scarlet fever, patients should be
kept in bed for at least four weeks ; the body
kept warm; associated with the application of
warm baths only ; and a diet of milk and cereals.
To prevent "contracted kidney," due to athero-
sclerosis of the small arterioles, warn patients
against overindulgence in food, especially pro-
teid food, alcohol, tobacco and the pleasures of
sex and work. The dietetic studies proposed by
Arthur Y. Chace, in the "Medical Clinics of
North America," in the November, 1917, issue,
marks a decided advance in prophylaxis and
treatment of the various nephropathies and their
complications.
In conclusion, I can think of no more appro-
priate or valuable maxims than always to re-
member that "every renal patient is also a car-
diac patient" — therefore, "protect the kidneys
and control the heart."
THE CENTENARY OF FLORENCE
NIGHTINGALE*
JOSEPH WALSH, M.D.
PHILADELPHIA, PA.
In connection with the conferring of the di-
plomas, the pleasurable duty has been delegated
to me of offering you a word of congratulation.
You now belong, by right of law, to the oldest
profession in the world, for though nursing as
an art to be cultivated, and as a profession to be
followed is modern, nursing as a practice origi-
nated in the dim past when the first mother
stooping over her sick child cooled its brow with
water from the brook ; and, we have in one of
the apocryphal books of Solomon a touching
picture of Eve, then an early grandmother,
bending over the little Enoch showing his mother
how to soothe his sufferings and to allay his
pains.f
It is a far cry f rom.the plains of Mesopotamia
to the Chester Hospital ; yet, the length of time
is simply an indication of the slowness of prog-
ress. It was even a long stretch to the founda-
tion of the first hospitals.
Hospitals, as we know them, were introduced
by Christianity about the third century. The
well-to-do among the old Romans were treated
in their own houses, or in the private homes of
individual physicians, the great mass of the
serving population, like domestics, farm hands,
clerks in stores, etc., were slaves, and when their
illness was serious they were exposed on the
Island of ..^sculapius on the Tiber and allowed
to die, or get well as the gods wished. All chil-
dren bom crippled, or otherwise apparently un-
healthy, or even children whom the parents did
not want, were simply thrown on the street.
One of the first acts of Christianity was to ele-
vate the status of women from that of practic-
ally a chattel, allowing them an equal part in
the deliberations and conferences, and I would
not be surprised if it were yet shown that the
foundation of hospitals and humanitarian insti-
tutions is one of their contributions to the ad-
vance of civilization.
The training school for nurses is such a recent
institution that it is still possible to find many
places where it does not exist. Twenty- four
years ago, when I studied in Europe, some of
the largest European hospitals were devoid of
them. In Paris the Salpetriere Hospital, one of
the best known in the world had only lay at-
tendants. These lay attendants were strong
husky girls from the country, and during the in-
•Graduating Address to the Nurses of a Chester and Wil-
intneton Hospital, June 8 and 17, igao.
tThougb not quoted verbatim this idea is from an address of
Sir William Osier.
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THE PENNSYLVANIA MEDICAL JOURNAL
October, 1920
tervals, when they were not actually looking
after patients, they were employed in wheeling
ashes in a wheelbarrow from the boiler rooms
to the ash dumps and transporting back coal in
the same fashion.
I have never been able to give an addr-ess to
nurses without some reference to Florence
Nightingale; in this, the Centenary year of
her birth, it would surely be amiss to overlook
her. As Hippocrates, the Father of Medicine,
is the type on which all physicians can mould
themselves with profit to themselves and credit
to their profession, and has remained so for
twenty-five centuries, Florence Nightingale will
remain the type of the ideal trained nurse for-
ever.
Modest, retiring, and even shy, with the
strongest antipathy to even honorable notoriety,
she was weaned by the circumstance of her time
into the greatest publicity. And in spite of her
distaste for it, she went heroically on, overcom-
ing her shyness in the face of life and death so
that those around her failed to realize the mas-
tery of self she was exercising; and, when the
end came, every nation, and every people was
proud to have had her live, proud to feel that
she was a human being like ourselves — proud to
claim this kinship with her.
How different from her life is that of Francis
Bacon. As this year marks the centenary of
her birth, it marks the tercentenary of the pub-
lication of his brilliant work on inductive phi-
losophy. In the domain of intellectuality two
names stand out, Aristotle and Bacon. In spite
of the intellectual plane on which Bacon stands,
we regret that he lived. There is nothing he
added to knowledge, which we would not be
willing to forego to have the stigma of his life
wiped from the page of human history. With
all his intellectuality he only succeeded in writ-
ing his name high with those of Judas Iscariot
and Benedict Arnold.
Lacking in intelligence to proper'y estimate
as baubles distinctions bestowable by govern-
ments, he cringed for an Earldom, and to obtain
it betrayed his best friend Essex, the man who
helped him over the rough steps of a beginning
career, and had always remained his supporter.
It was Bacon's efforts that actually sent Essex
to the gallows for without his brilliant intel-
lectual attainments to bolster them up', the
charges against Essex would surely have fallen
to the ground. Up to his eyes in debt Bacon
retrieved his fortunes by marrying the rich
widow. Lady Hatton. To gain credit with
Queen Elizabeth, this big intellectual man stood
by while poor old Peacham was put to the tor-
ture in an endeavor to make him confess that he
had circulated ideas against the divine right of
kings, when there was never a scintilla of evi-
dence to prove it. Eventually as Lord Chancel-
lor, the highest officer of justice in the realm,
corresponding to the Chief Justice of our Su-
preme Court he was convicted of taking bribes
from those who had come before him for jus-
tice, for the best defense that he could put up
was that he had taken fewer bribes than the
previous Lord Chancellors.
You have just passed through a professional
course, and from my experience with nurses'
schools, and my personal acquaintanceship with
your directress, I am sure you learned the im-
portant truth, either directly or by implication,
that education is not merely a matter of increas-
ing the intellectuality, but, also, of developing
the intelligence and strengthening the will; de-
veloping the intelligence, or common sense, so
as to distinguish between the important and the
trivial in every day affairs, and strengthening
the will so as to do what is right even though it
is difficult or different from what you see done.
Bacon's education failed on two counts, the in-
telligence, or common sense to recognize that no
one in this world can honor or bring discredit
upon us but ourselves; second, though he, un-
doubtedly, knew what was right, he had not the
stability of will to do it, but followed in the foot-
steps of the politicians of his time.
In this comparison with Florence Nightingale
we cannot help recalling the first woman novel-
ist, Frances Bumey, the author of the delightful
"Evelina." With a literary capability to enter-
tain and instruct the world, which was raising
her niche by niche high in the temple of fame,
but with a love for publicity and a desire for
association with the socially great, she gave up
lier real opportunity, her writing, and descended
from her pedestal to practical oblivion to accept
what appeared to her a distinction — the position
of maid of honor to Queen Charlotte, the wife
of George III.
In her own sphere she counted as personal
friends and enjoyed the frequent companionship
of the writer, Samuel Johnson ; the actor, David
Garrick ; the painter, Joshua Reynolds ; the
orator, Edmund Burke, and innumerable like
them. She gave these and her wonderful writ-
ing up, it is ridiculous to relate, to stick pins,
lace the stays, adjust the hoops, and mix snuff
for an unappreciative mistress, who spoke Eng-
lish badly, and hadn't an idea in any language.
To make matters worse in her new royal apart-
ments, the only one on a social footing with her,
and who was her perpetual companion was the
maid of honor the queen had brought with her
from Mecklenberg Strelitz, according to Ma-
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October, 1920
FLORENCE NIGHTINGALE— WALSH
15
caulay an ignorant, irritable, old hag named
Madame Schwellenberg.
Poor little Fanny ! Needless to say, when too
late she regretted it. With an intellectuality of
no mean degree, she lacked the will to go on
with work requiring personal initiative, and
lacked the intelligence to recognize behind the
habiliments of a queen the form and mind of a
nobody.
The career of Florence Nightingale shows a
very different brand of education — an education
which rings true. Like Bacon she was a life-
long student. Before she considered herself
learned in her profession, she spent many years
in its study. It is possible that more than once
in the past three years some of you may have
thought the curriculum long ; Florence Nightin-
gale doubled it, visiting and remaining at various
of the hospitals on the continent with the Sis-
ters of Mercy, the Sisters of Charity,, and for
two periods at the Lutheran Deaconesses Hos-
pital at Kaiserswerth under the tutelage of Pas-
tor Fliedner and his wonderful wife.
On taking up her work in London, her indus-
try and earnestness were so remarkable that it
is not surprising it was on her the government
called even as early as three years later. This
call in the autumn of 1854 was to one of the
great emergencies of the British Empire. The
Crimean War had begun in the spring, there had
been several reverses, there were five thousand
wounded in the large English Base Hospital at
Scutari, and the management had broken down
so badly as to become one of the scandals of the
age. Every necessity for the sick and wounded
was lacking, and patients lay weltering in pus
and blood without being dressed till the band-
ages became attached to the flesh. Every
writer of the time states the conditions as in-
describable, for in addition to a disorganized,
over-crowded, absolutely filthy hospital, filled
with vermin and rats, every medical and surgi-
cal infection was running rife — cholera, typhus,
typhoid, dysentery, erysipelas, gangrene and
lockjaw.
All England was aroused, and the cry of
every English heart, and the expressed cry of
the London Times, was — "Haven't we any com-
petent daughters of England who, for the love
of God, or the sake of humanity, are willing to
risk their lives and go to the front to try to do
something."
This cry fired the spirit of half the women in
Britain, and the difficulty now was to choose
from the number applying. Florence Nightin-
gale, having offered her services, was made the
leader, and it was she who made the selection.
Within a week from the publication in the
Times, they had sailed, and two weeks later
started in their work at Scutari. This band of
thirty-eight, which Florence Nightingale took
with her, was composed of fourteen Church of
England Sisters, ten Catholic Sisters of Mercy,
and fourteen lay women. Among the first of
the newly wounded coming under their care
after arrival, was the petty remnant of the six
hundred who participated in the charge of the
Light Brigade.
By far the most important of the mismanage-
ment at Scutari was. due to the official red tape
surrounding everything. With a capability
equal to the great emergency, Florence Nightin-
gale ruthlessly broke through it. Locked up
stores with keys inaccessible, because hidden be-
hind the doors of officialdom, she opened by
force. On her own authority she commandeered
assistance, and when necessary from her own
pocket purchased new supplies, and in an in-
credible space of time, cpnsidering her thirty-
eight nurses to five thousand patients, had ac-
complished an Augean task worthy of a real
Hercules, while preserving the friendship of her
associates, endearing herself to the patients,
commanding the respect of the officers, and the
admiration of the world.
Beginning without reason, and ending without
accomplishment, the Crimean War will, never-
theless, always be remembered for two events :
first, the sublime charge of the Light Brigade
at Balaclava, when under mistaken orders the
illustrious six hundred rode unhesitatingly into
the cannons' mouths; and, second, the arrival
ten days later of this band, this arrival becom-
ing for all future ages, the spectacular introduc-
tion onto the stage of life of the modern trained
nurse in the person of Florence Nightingale.
On the cessation of hostilities, Elorence
Nightingale's name was in every mouth in Brit-
ain, there was not a child in arms who had not
heard her. With the exception of Jeanne D'Arc,
the world never beheld such enthusiasm over a
woman. A man-of-war was placed at her dis-
posal by orders of the Government to bring her
home, and a triumphal reception planned, but in
the modest unassuming manner natural to her,
she slipped back on a French ship, and was in
the midst of her friends in the country before
the news of her arrival leaked out. As a testi-
monial, a purse was started, but learning she
would be unwilling to accept it, the $250,000 col-
lected was devoted to the foundation of the
Nightingale School for Nurses.
While Bacon married for money to acquire
ease, turned traitor for an Earldom, and took
bribes from people who came before him for
justice, Florence Nightingale left a life of ease
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THE PENNSYLVANIA MEDICAL JOURNAL
October, 1920
for that of the hardest work, risked her Ufe to
help the men who defended her, and refused a
fortune legitimately bestowed, because she
would be beholden to nobody.
Following a period of recuperation, which she
sorely needed after her two years strenuous
work in the East, Florence Nightingale assumed
the Directorship of the Nightingale School for
Nurses, and here were educated girls who grad-
ually drifted to all parts of the world spreading
the ideas of the Mother of Trained Nursing.
Though founded in England, Trained Nurs-
ing has had its greatest development in America,
and we have carried it so far that I have no
hesitation in saying that the education of the
Trained Nurse to-day is probably the broadest
and most satisfactory extended to woman. In-
struction in cleanliness, not only ordinary but
scientific cleanliness, in anatomy and physiology,
in the knowledge and management of disease, in
preventive medicine and domestic science, makes
the nurse one of the most valuable assets of a
community. Moreover, in spite of the fact that
considerable time is spent in increasing the in-
tellectuality by the study of deep sciences, she
has such a close-up view of life at its worst and
at its best, that she acquires special capability in
the estimation of things of the world at their
proper value, and she is obliged to do so much
in the way of duty which is disagreeable that
the will power to do right ought to be hers for-
ever. No wonder that the ranks of nurses are
so depleted by matrimony, for there is no sys-
tem of education which makes a girl more fit to
become the head of a household.
With this I have come to what I was dele-
gated to do — to congratulate you on your choice
of profession, and the success you have achieved
in mastering it. We wish you a busy and useful
life, and if you have this, we are sure it will,
also, be a happy one.
2026 Chestnut Street.
REMEDIES APPLIED FROM THE OUT-
SIDE AS IMPORTANT AS THOSE
APPLIED FROM THE INSIDE
J. MADISON TAYLOR, A.B., M.D.
Professor of Physical Therapeutics and Dietetics, Medical
Department, Temple University
PHILADELPHIA, PA.
A most promising step toward complete reme-
diation of disuse, disease and the effects of dis-
ease, is to develop measures applied from the
outside capable of regulating and readjusting
function, structure, conduct and growth energies
as a whole in order to enhance inherent re-
sources. This includes fortifying the organism
to resist disease and its effects, and also the put-
ting of disturbed parts in order, for the purpose
of restoring function and readjusting forces
local and general.
The resources of drugs are now admirably
elaborated and their actions fairly well under-
stood as agencies applied from within (phar-
macodynamics). Not so with that large and
ever increasing group of supplemental, acces-
sory, or auxilliary remedies applied from with-
out (bio-kinetics) which still are somewhat
confused. They deserve equal consideration,
attention and constructive criticism. The ex-
perimental stages have long passed. However
the epoch of prejudice, preferential disbelief and
extensive disregard still lingers.
While the prime objective in all remediation
is to find and remove the pathogenic starting
point, the effects of disorder acute or protracted
deserve equal effort. A large proportion, per-
haps as I believe by far the largest proportion,
of these defects can be reUeved through so-
called physical remedies by some of the mani-
fold modalities of motionkinetogenics or bio-
kinetic agencies.
Among the endeavors should be set in order
the effects of disordered, suppressed or de-
pressed energies, to release the one and to rein-
force the other, to bring back into normal
channels not only transmitted force but retarded
fluids, reflexes, cells; to repair structures, to
remove compression on nerves, blood vessels,
lymphatics, tubular and spherical organs, intra-
articular structures, to replace muscles in posi-
tions of advantage, to expedite oxidation of
stagnated structures, to raise local or general
temperature or apply cold to parts. In short, to
expedite the elimination of retained waste pro-
ducts, muscle toxins, to accelerate or check blood
distribution, to remove cataboiic products or
whatever else tends to perpetuate disorder, disa-
bility or decrepitude. This series of objectives
can be achieved only or most economically and
completely by regulating, reeducating or read-
justing through some form of motion.
Medical schools do not as yet supply adequate
teaching of externally applied restorative and
reparative remedies. The older clinicians show
little or no interest in them, the younger men
show some, but almost no group of students
have had systematic instruction in either prin-
ciples or practice of miscalled "physical rem-
edies." A much better term would be kineto-
genics, since they are the manifestations of some
form or modality of motion.
For forty years I have urged the subject upon
attention and am strongly of the opinion that this
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REMEDIES APPLIED EXTERNALLY— TAYLOR
17
teaching should be supplied, and myself do so at
the Medical Department of the Temple Uni-
versity.
Appended is an outline of a series of lectures,
demonstrations and conferences attempted by
myself and which would seem to deserve
recognition by all Medical Schools. My stu-
dents take increasing interest in the subject.
The reason seems to be the method pursued.
The method employed is to lecture for a half
hour, mostly citing typical cases, then explaining
the principles by setting forth steps of progress,
diagnosis and evolvments, also by arguing from
particulars to generals, by demonstrations of
methods, of procedures, of adjustments, of acts,
movements, and the like graphic methods. All
the while frank conferences, comments, queries
are invited, thus often bringing out surprising
side lights. For the rest of the hour we confer,
seminar fashion, and a few primitive demon-
strations are made on a student. What a man
experiences, feels done on himself as well as
sees, he is likely to comprehend and remember.
Not so sure is the spoken word or printed page.
It is a matter of common knowledge that
oftentimes our ordinary remedies, medicines,
exhortations or loosely considered "doings" fail
to bring about hoped for results. Sometimes
we are aware of, and deplore the deficit, just as
often we serenely leave the rest of the job to
"nature," assuming there is no further need for
expert aid. Hence occur unwarranted delays,
decrepitudes and even insidious progress of dis-
ease, often permanent disablement. Why? In
our student days the teachings had most to do
with medication, drug remedies, in short bio-
chemistry, and little or only incidental or em-
pirical "auxilliary measures." What little was
said was casually mentioned, rarely emphasized
or clearly defined or scientifically and practically
explained.
Fortunately for suflfering or disabled human
kind, the resources of supplemental or accessory
(bio-kinetic) therapeutics have become vastly
greater more effective indeed eminently efficient,
by reason of increased attention to disorders due
to anatomical disarrangements in shape, in
structural tone, or to undue tension relaxation,
or spasm, of disorders shown in subordinated
sensory factors such as latent tendernesses sunk
below the field of consciousness and neglected.
These alterations of feeling when the adviser
knew less of their significance, were too often
blithely disposed of as growing pains, gout,
rheumatism or "hysteria." At the most the cli-
nician omitted to search for, or to analyze the
phenomena of their origins or significances.
In short the principles of bio-physics are so
little taught or emphasized that the student has
come to look upon attempts to utilize this group
of remedies as negligible. As a consequence the
patient suffers needlessly and our full duty to
him fails by so much to be discharged. When
the patient becomes aware of this omission he
usually seeks the aid of those who claim to be
able to give the help he desires and oftentimes
with gratifying success. These claims while
oftentimes bizarre, inexact, even hyperbolic, are
frequently justified by the results obtained.
My constant purpose is to search out the best
of these resources from the now extensive lit-
erature, scattered here and there, correlating the
valuable hints, measures, principles, efficient
short cuts to radical betterments and to present
them in succinct practical form.
By a glance over the category of subjects to
be mentioned or demonstrated, it will be seen
the resources of bio-kinetics have become aston-
ishingly large. Reputable and well accredited
procedures are most promisingly supplied. My
main purpose is to briefly describe those meas-
ures which require no apparatus, no special
equipment except those which can be found in
any ordinary household and are generally avail-
able. The intelligent hand is always a ready in-
strument and acts as the ever faithful agent of
sound reasoning; the handmaid of the brain.
When the resources of hand treatments, through
tactile application, are set forth as means of
diagnosis it will be found that they will also
supply a surprisingly large and varied group of
excellent agencies for repair.
Then follows the whole subject of regulation
of conduct, the reeducation or expert training
of muscles, of voluntary and semi-voluntary
structures, the overcoming of limitations, con-
tractures, the stimulation and regulation of re-
flex arcs, of cardio-vascular-renal, of respiratory
and other organic mechanisms, the development
of structure, of external belly walls, adjustments
of the articulations, release of intra articular
pressure, of the skin, of the subdermal and
many other structures closely allied physiologi-
cally.
Then we may proceed to consider the re-
sources of local supports, or temporary fixation,
whereby structures in positions of disadvantage
can be placed in positions of improved advantage
to function. Thus is afforded a vast improve-
ment in neuronic, pneumatic and hydraulic me-
chanisms.
We can employ the simplest of agencies, such
as to concuss over-subsidiary centers and to
guide, control, enhance and to regulate the major
reflexes. There is also the expert use of heat
and cold, of light and air, of electricity and the
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THE PENNSYLVANIA MEDICAL JOURNAL
October, 1920
like. These last, electrogenic, hot and cold air,
of water as by remedial baths, and the like
themogenics, constitute special domains of en-
deavor. Meanwhile the subject of my demon-
strations is confined to the simplest instrumen-
talities, mainly those which can be found in any
ordinary household or office.
It will thus be seen I am attempting to sum-
marize the group of relatively novel therapeutic
resources to act as supplements to the already
proven, established and highly elaborated re-
sources of the laboratory and of drugs, vaccines,
bacteriogenic agencies (pharmacodynamics).
When these reach their limits there yet remains
many more readily available and to make use of
them judiciously in order to expedite their per-
formance (function) or to bring back into the
field of action impaired structures, proficiencies,
confidences, endurances.
Health is substantially a balance between
those energies always at work in the organism
and those energies with which the organism
comes in contact from without. This is a pro-
cess of constant adjustment and readjustment
to new situations, or to old and familiar but
disturbed relationships. The result is a nicety
of poise between energies and exergies. Thus
automatisms are revivified, restored, enhanced,
rehabilitated, and maintained. In order that
health shall be preserved, or regained promptly
when disturbed, the diverse mechanisms of that
unity of body and mind (psycho-physical one-
ness) must be put in order and kept in order, or
at least not permitted to remain in too great dis-
order.
Among th6 special mechanisms of force dis-
tribution to be reckoned with and directly in-
fluenced, are the larger reflexes, also the nerves
in continuity, nerve centers and subcenters in-
volved, an estimation made of their existing
state, whether the component parts are in bal-
ance or disturbed, whether the cycle of struc-
tures and energies is well poised or in commo-
tion, overstimulated, irritated, or exhausted.
. As a result of such disorderliness from what-
soever source, conditions are frequently met of
tonic or intermittent spasm, which, when unduly
prolonged, becomes a cramp, and acts as basis
for transferred pains, also disturbances (hyper
or hypo-tonus) of circulation, of blood, lymph
and other hydraulic apparatus. This illustrates
the secondary representation of nervous connec-
tion, that of "acting by deputy," in accord with
niles more or less familiar or empirically in-
ferred. The significance of pains, their char-
acter, origins, grouping, etc., is most important
to keep in mind, for example the difference be-
tween sympathetic and peripheral disarrange-
ments, disorders, diseases or effects of these, of
impaired function or of pain.
Peripheral lesions are manifested by impo-
tence, paresis, and by acute or intense pains,
irregularities of intra organic pressure, as of
viscera and of joints, those of central or sympa-
thetic origin by spasm, by contracture, by circu-
latory and trophic disturbances and by less
intense, rather by vague or dull pains or aches
or by tendernesses on pressure or on movement.
Both kinds of pain may become associated, the
origins being from both sources.
Sources of focal irritation must always be
searched for, acute or subacute or chronic,
whether traumatic, metabolic or septic, some of
which are capable of being removed, others are
not, or not yet; many are capable of being
partly neutralized, or intelligent steps can thus
be taken to learn their identity and nature by
exclusion, or to modify or limit them till radical
measures can be applied. Infection as a cause
gets much attention but not always these remote
or subordinated or complex effects.
Bear in mind that no matter how completely
the central-sympathetic-pain cause be removed,
often the peripheral painfulness or tenderness
persists and is only capable of being removed
by intelligent use of some form of movement
making (i.e. bio-kinetic) instrumentalities.
Among the most useful of these movement
instrumentalities are manipulative replacements,
restitutions, "manual operations," designed to
meet emergencies, to readjust urgent morpho-
logic, reflex, sensory and other causes of dis-
turbance, likewise to act as practical contribu-
tions to relief or cure of some acute and of more
protracted or chronic states, leading to the re-
establishment of impeded function or disordered
relationships.
The real cause for decrepitude is often some
confused left over states (morphologic reflexo-
pathic residua) which can be set right by a
shrewd touch, or push, or movement or support.
The object of the demonstrations is to aid the
practitioner in forming habits of promptly ap-
praising the point of origin or the chief element
of disturbance, to relieve that and then proceed
to deal with the next or associated factors in
disturbance. Furthermore, by these "safety
first" measures latent powers are released, or
strengthened, or stabilized whereby medication
can be made to take better effect.
Most causes of disadvantageous conditions
will be found arising in primary motor levels or
planes in the functioning of movement, of sup-
port, of associated action, which, when they are
set in better adjustments or relationships, will
go far toward placing the parts again in posi-
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October, 1920
SELECTIONS
19
tions of advantage, hence of functional poise
and efficiency. The element of rythm is all im-
portant, and hence a training in nice adjustments
of rythm, or of balancing of forces, is desirable.
The equation between the whole dominating
the part, or the part dominating the whole, de-
serves attention, analysing the action, reaction
and interaction, correlating their effects and de-
termining what shall be done to restore the crea-
ture to the original state of stabilization.
SELECTIONS
THE NEW RURAL CLINIC
City Specialists Take Latest Medical Science to Coun-
try, Diagnosing PuszUng Cases
Work-worn hands clasped in her lap, she sat watch-
ing a closed door in the Goshen, N. Y., high school.
"It's a long wait, isn't it?"
Her fingers plucked at the skirt of her black lawn
dress, but her glance did not stray from the closed
door.
"Yes, but it's worth it. If that X-ray machine only
shows what's wrong with him I won't mind sitting
here a week. For six months now he's been failing,
changing doctors and medicines until he's clean dis-
couraged, but if we find out where the trouble lies he
can fight again with some heart."
The door opened, and a man whose sunken eyes and
_hollow cheeks testified to hours of sufTering, fared
forth. A huge Turkish towel was draped over his
shoulders and a Red Cross worker carried his coat,
shirt, collar and tie. He smiled at the eager little
woman who stumbled toward him.
"One more doctor — and then I'm through."
"Didn't— didn't he tell you what it is— the X-ray
man?"
"No; he's only just taken the picture."
His wife dropped back on the bench.
"I s'pose it's the hope of finding out what's really
the matter with him that has brightened him," the
woman said. "Jim's no coward, but it's hard to fight
when you don't know what you're fighting.' '
On the long, narrow benches which lined the main
hall of the Goshen High School many were waiting.
Waiting their turn to appear before the specialists,
the experts, physicians, surgeons, dentists, chemists
and X-ray operators who had come long distances to
cooperate in Orange County's first rural consultation
clinic. A tired mother led two victims of infantile
paralysis, aged 7 and 10, to the door marked "Ortho-
pedic Surgery," the little girls dragging heavy bracks.
A motherly looking woman, wearing a flowered hat
and a Red Cross apron, climbed the main staircase
carrying a basket of milk bottles.
In the laboratory where Goshen boys and girls ordi-
narily do practical work in physics and chemistry an
expert from the State Department of Health was
making blood tests. In the library the long table had
been padded, covered with clean sheets and trans-
formed into an examination table by a gynecologist
from New York City. In one of the largest class?
rooms Dr. C. B. Witter of the General Electric Com-
pany had installed a field X-ray equipment. Behind
the closed door of each recitation room experts were
examining men, women and children in a merciful ef-
fort to diagnose ailments which had baffled family
physicians. White-capped nurses flitted from room to
room. Red Cross workers sought out tired watchers
to carry them off to the auditorium where a whole-
some lunch of fresh milk and sandwiches awaited
their coming.
Strange scenes these to be enacted in a public school
building. They are those of a new social service, full
of the broadest promise.
Warned by the number of men from farms who
could not qualify for military service, and by that
equally large group whose physical unfitness made
them easy prey for disease and epidemic, the State De-
partment of Health has started, in rural districts, a
campaign of preventive medicine and efficiency
through health which compares favorably with similar
movements in cities. — New York Times, September
12, 1920.
THE HEALTH CENTER BILL*
Least of all do I admire those who are given too
much to criticism. I will ask your pardon therefore,
if in the few minutes at my disposal I appear to be
mostly critical. I realize the great work being done
by our State Department of Health and by the health
officers of this State. If the time were at my dis-
posal I could praise as well as criticize-.
I am not by experience or special training qualified
to express an opinion concerning many features of
the proposed plan for state subsidized health centers.
I have, however, had a number of contacts with the
propaganda being distributed by those in favor of the
plan. I believe that all of you will agree with me that
real progress must be based upon real truth. True
progress never comes from marshalling together a
mass of false statements, or half truths, or even little
truths in improper or false perspectives.
During the past two years it has fallen to my lot to
spend considerable time in studying the relationships
of the medical profession to the public in general. As
a result of these studies I have come absolutely to the
opinion that the medical profession has nothing to
fear from the real truth concerning any problem relat-
ing to the practice of medicine. Also let me say that
I believe that much of the difficult situation now con-
fronting the profession is the direct result of mis-
leading statements and propaganda fed to the public
from medical and semi-medical sources. I regret to
say that in my opinion some of these misleading state-
ments have come from our own state department of
health and from others actively engaged in public
health work.
By way of preliminary illustration let me mention
just one type of statement and how it reacts against
the medical profession. For a number of years I had
read here and there statements to the effect that with
the present development of medical knowledge about
one-half of sickness as it occurs in average communi-
ties is really preventable. Such statements seemed
harmless enough and I attributed them to the over-
enthusiasm of some public health workers more inter-
ested in imparting their enthusiasm to others than they
were in the fundamental biological factors controlling
the situation. However, when I came to study the
'State Sanitary Officers Convention, SaratOKa, New York,
September 8, 1910. By E. MacD. Stanton, M.D. F. A. C. S.,
Chairman^on Public Information, Schenectady County Medical
Society, Schenectady, N. Y.
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20
THE PENNSYLVANIA MEDICAL JOURNAL
October, 1920
problem of Compulsory Health Insurance this appar-
ently innocent statement took on an entirely new sig-
nificance. I was surprised to find that in the opinion
of the public about four-fifths of the argument for so-
called health insurance centers around the belief that
according to the present development of medical sci-
ence about one-half of disease could be readily pre-
vented. The public argues thus. We are told by medi-
cal authorities, even by men representing the State
Department of Health, that something like one-half
of sickness as it now occurs, is preventable. It is not
prevented. Therefore, there is something radically
wrong with medicine as it is now practiced. Mr. An-
drews, Mr. Lapp and 'others tell us that Compulsory
Health Insurance will produce the desired results,
therefore, let us have health insurance. Time and
time again, no matter where the argument starts, this
is the final picture that appeals to the lay public As
a matter of fact the very name of health insurance is
based on this misconception, and in order to incor-
porate the alleged preventive medicine possibilities
into the scheme it is practically stripped of all sem-
blance of a real insurance proposition.
Do the individual members of this audience really
believe that with the human animal as he is now con-
stituted and by the use of really practical means it
would be possible to prevent anything like one-half
of the sickness which actually occurs each year in
your own communities? Search as I may I have never
been able to find any data which would support such
a claim. I can find much data both biological and
medical which is directly opposed to any such claim.
I believe that it is the duty of our State Department
of Health to furnish us with a true picture as to just
what are the proven possibilities of practical preven-
tive medicine as they may relate to the average mor-
bidity to be expected in New York State. It is the
duty of the health officers of this state to demand that
the department furnish them with such a picture be-
cause nothing can be more unjust to the medical pro-
fession than to infer that certain results could or
should be accomplished when the cold hard facts do
not support the assumption that these results could be
accomplished even under ideal conditions. I regret to
say that my very first contact with the propaganda for
the health center project was to hear a representative
of our State Department of Health quote the state-
ment of a lay commission to the effect that a properly
organized medical service could reduce sickness by
one-half.
Now let us turn again to the Health Center propa-
ganda. A member of the State Department tells us
that "Experience has further shown that the best re-
sults in diagnosis and treatment can only be obtained
by the coordinated efforts of a group of specialists
working together." No one will accuse me of under-
estimating the value of group medicine. I have been in it
all my life, but the propaganda for the so-called health
centers does not put group medicine in its proper per-
spective. In the great majority of cases the real diag-
nosis must still depend upon the careful history and
physical examination of one responsible physician.
The family physician is and always must be the real
backbone of medicine and I can not see how either he
or the public is really going to be benefited by propa-
ganda which infers that he is not capable of doing his
work properly.
In a definitely inspired communication appearing re-
cently in the New York Times we are told of the State
Department's group diagnostic clinics and that "At
the present time a rural physician who has a difficult
or obscure case must send his patient to a large city
to consult specialist after specialist and at a great ex-
pense before a diagnosis can be made." Was this
statement the strict truth stated in its proper per-
spective? In Schenectady County, and similar condi-
tions obtained in most other counties, we have an
abimdance of specialists, and I believe that they are
as well trained and use as good judgment in their
work as do the specialists anywhere. It is inferred
that the average man can not afford to consult these
specialists. As far as I can ascertain any person in
Schenectady County can have all ordinarily necessary
examinations made for a total cost of about two pairs
of shoes. In most cases it need be less than this. The
exceptional case is like the swallow which does not
make the summer. To describe the very exceptional
case and exceptional specialist as representing the true
condition of affairs is not fair to the great group of
men who have given special time' and special study to
their work. Neither will it help to solve the problems
of the practice of medicine.
In localities where specialists fees are too high the
chief cause can usually be traced to the clinics. It is
rather hard to get something for nothing in this world,
and when a community compels its medical men to
give half of their time to clinics, then the other half
of the community is of necessity compelled to pay
double for what it gets.
On the next page of the paper I first referred to we
are told that in cases of serious illness it costs $25 or
$30 per day for medical attention. Is this the strict
truth such as should be furnished to the lay critics of
medicine as it is? As a matter of fact any one sick
in Schenectady County can get very adequate hospital
attention, including nursing, laboratory examination
and care by their physician of choice for not over $5
per day. Even in surgical cases the average cost of a-
four weeks' illness, including surgeon's fees, hospital
and accessory charges for our pay patients, unless
they elect to have the luxury of a special nurse, is only
$6 per day. In some cities the hospital charges are
higher than with us, but at most this makes a differ-
ence of only about $1 per day.
Is it strict scientific accuracy for us to have all this
propaganda for state-subsidized so-called health cen-
ters without telling us how similar state subsidies
have worked in other states? Surely such a simple
scheme for a medical Utopia as getting money from
the taxpayers has not been overlooked in all of the
states until 1920. This plan has been in operation for
many years, more than a quarter of a century in Penn-
sylvania. I have lived in Pennsylvania and while I
do not want to pass judgment as an expert my obser-
vations always led me to believe that it was bad for
the doctors and worse for the public. One thing is
sure, and that is that after all the years Pennsylvania
has fallen decidedly behind New York State both in
the relative number of physicians and the relative
number of hospital beds available.
To my mind one of the most misleading statements
which has been put forth in connection with health
center propaganda is that it is a complete answer to
compulsory health insurance. This statement has been
frequently made. From the experience of Pennsyl-
vania I would say that it will tend to foster rather than
to prevent compulsory health insurance. As a mat-
ter of fact the proponents of the two plans are bark-
ing up different trees. The two projects do not cover
the same ground. To my mind sickness insurance ap-
plied to the insurable portion of the sickness problem
and stripped of the cure-all fallacies, jof trying to
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October, 1920
SELECTIONS
21
cover by the insurance method the common run of
short-time illness, would be far more efiFective than
the so-called Health Center plan.
We are told in the July Bulletin of the New York
State Department of Health, page 195, that the
Health Center plan as adopted in Erie Cotmty is a
forerunner of free health, by which is meant that rich
and poor alike will some day enjoy the highest pos-
sible degree of medical skill with the cost spread on
the general tax rate. This statement is printed in the
official bulletin of our State Department. It is spread
broadcast for layman as well as medical man to read.
It will be quoted freely by all those paid secretaries
and other parasites of modem society whose salaries
depend upon their uplifting something or somebody.
The statement should represent the real truth, scien-
tifically accurate as far as it could be in July, 1920.
Is it the truth and is it accurate? There are 15,000
physicians in this state working on an average as
hard as men can work efficiently. We need no less —
we could use more. Certainly we could not induce
15,000 men to undertake the arduous years of training
and expense to become a physician without offering
them a promise of an average gross income of at
least $6,000 each, which would mean a net income of
about $3,500 per year. For a position under State
Medicine minus the not inconsiderable satisfaction of
a free occupation I am sure that even the $3,500 net
would not be sufficient inducement. And yet do you
realize that $6,0O0Xl5,0O0=$90,00O,0OO. I for one do
not believe that the htlTnan animal is so constituted
that 10,000,000 of these beings in the State of New
York will ever be induced to raise $90,000,000 in taxes
for just one item of this universal free medical care
even though it be labeled under the absolutely false
title of "Free Health."
I wonder if the bulletin gives us the whole truth
concerning "Free Health" imder municipal medicine
in Erie County. In the Canadian papers I have been
reading advertisements of the Buffalo Department of
Hospitals and Dispensaries offering pupil nurses an 8-
hour day, no menial labor, all the usual inducements
of a training school and $20, $25 and $30 per month
cash while in training. It might be very interesting
to know what there is about the municipal free health
plan in Erie County that necessitated their advertis-
ing such inducements to pupil nurses.
I venture to predict that when we organize the
whole state on a plan that requires us to furnish board,
room, clothing, teaching, training and $20, $25 and $30
per month to pupil nurses in training that we will
have some trouble inducing the taxpayers to foot the
nursing expenses incident to the "Free Health"
scheme. Also from my knowledge of the human ani-
mal as he is actually constituted I will venture to sug-
gest that possibly about this time we might be com-
pelled to offer $50, $60 and $70 and $80 to medical
students while in college and that for recruits we
would get a class of fellows who had doubts of their
ability to earn their own living in freely competitive
undertakings not associated with state subsidies.
In conclusion let me again state that I have no fears
of real scientifically accurate truths concerning the
practice of medicine. I do dread and somewhat fear
the propagandist. I want to ask you of the New
York State Sanitary Officers' Association to see to it
that the public is given only the real truth concerning
one of the most vital points of contact between the
physician and the public — namely, in regard to the
practical possibilities of preventive medicine .
HOSPITAL CLOSES DOORS TO FEE
SPLITTERS*
"The reprehensible practice of fee splitting haj not
disappeared from the ranks of the profession, but
the men who are thus addicted cannot escape the stain
indelibly stamped on their characters, and sooner or
later the external symptoms become so manifest
that he who runs may read. Like the leper of old,
these people defile all whom they touch. The Ameri-
can College of Surgeons has established what is per-
haps the most drastic regulation governing the be-
havior of their fellows in this respect. If that regu-
lation can be faithfully enforced, the college can make
the practice so disgraceful that he would be a bold
fellow indeed who would attempt defiance of the rule.
An added weapon against the fee splitter is develop-
ing through the recent movement toward grading hos-
pitals, the first instance of which has just come to our
notice through the action of St. Luke's Hospital in
St. Louis. This action effectually closes the doors of
that institution to the fee splitter. A communication
from Dr. M. B. Clopton, acting secretary of St.
Luke's Hospital Staff, conveys the information that
the staff recently ' adopted the following motion by
unanimous vote:
"'It is moved and seconded that the staff of St.
Luke's Hospital is' absolutely opposed to the division
of fees in any form whatsoever, and we desire to rec-
ommend to our Board of Directors that the use and
benefits of St. Luke's Hospital be denied to any phy-
sician or surgeon known to practice "fee splitting." '
"The staff furthermore ordered a copy of the reso-
lution sent to every hospital in St. Louis with an in-
vitation to take similar action. At this writing sev-
eral hospitals have notified Dr. Clopton that the staffs
had adopted a similar regulation."
THE NATION'S GREATEST NEED: A NA-
TIONAL DEPARTMENT OF HEALTH*
No one doubts the need for increasing Federal ac-
tivities in cooperation with the state public health au-
thorities for the prevention of disease, but there is an
honest difference of opinion as to how the desired re-
sults may be obtained. Personally I feel that a Na-
tional Department of Health is the best plan for se-
curing adequate protection for the more than 100,000,-
000 citizens whose health and lives should be safe-
guarded by our government. The very fact that the
nation considered the prevention of disease of suffi-
cient importance to create a department charged with
carrying on health work would create in the minds of
the people of the United States a respect for personal
hygiene and public sanitation that would mean much
in the cooperation by the public with the National
health authorities in their effort to prevent disease.
Health and life are surely of as vital importance to
the welfare of the nation as agriculture, commerce
and labor, the governmental functions of which are
provided for in great departments, with officials at
their head who sit in the President's cabinet. Property
and life are protected from foreign invasion by the
War and Navy Departments. Is it not of as much im-
portance to the welfare of the nation to protect its
citizens from preventable diseases, enemies that dis-
able and kill more people in the United States every
*The Journal of the Missouri State Medical Assn., Septem-
ber, 1920.
'Extracts from the President's Address, American Medical
Editors Association, New Orleans, La., April 26-27, 1920.
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22
THE PENNSYLVANIA MEDICAL JOURNAL
October, 1920
year than have been wounded and slain in ail the wars
in our history?
"Health is a purchasable commodity" is a trite say-
ing; but it may be considered as a truism that the
effectiveness of national public health work depends
to a large extent upon the size of the government ap-
propriations for that purpose. The United States
Public Health Service has done magnificent work con-
sidering the penurious policy of the government in
providing funds for the prevention of disease. It is
now one of the small bureaus of the Treasury De-
partment; and the Secretary of the Treasury prob-
ably devotes as much as eight hours a month to the
consideration of the Bureau of Public Health, and
then he feels that he is taking time that is needed for
what he regards as more important business. Does
any one doubt but that a cabinet officer devoting all
his time to the duties of Secretary of Health would
be able to secure larger appropriations and more effec-
tive administration for his department than could be
secured in any other way?
A cabinet officer must be close to the 'President, and
he also must be a man of influence in the administra-
tion or he would not have received his appointment.
It is therefore certain that .the administration in con-
trol of both branches of Congress would support any
measure that he might advocate. A physician in the
President's cabinet, in one year, could bring about
more constructive legislation for the prevention of dis-
ease than we have been able to secure in a decade.
From the viewpoint of practical politics, an important
consideration when the public treasury has to be
opened for appropriations, a department of health with
a physician in the President's cabinet is our best hope
for adequate support for national public health work.
PREPARING THE BILL FOR A DEPARTMENT OF HEALTH
In my opinion there is little doubt that the great
majority of physicians in the United States desire a
national department of health. There are already sev-
eral bills in the Senate and the House of Represen-
tatives providing for such legislation. The bills of
Senator Owen, Democrat, of Oklahoma, and pi Sena-
tor France, Republican, of Maryland, are best known to
the medical profession. Both are good, though there
are differences in their provisions. It seems to me
that a committee consisting of three state health offi-
cers, the Surgeon General, and two other surgeons of
the U. S. Public Health Service, and three physicians
representing the general medical profession should
confer with the committees on health and sanitation
in the Senate and House and agree upon a bill. This
could be done in a week and the bill can be intro-
duced both in the Senate and House. This bill should
be as brief as possible, providing only for the estab-
lishment of a department of health with a cabinet offi-
cer at its head. There should be a clause providing
that the present U. S. Public Health Service should
be the nucleus for the department of health, and an-
other providing for an appropriation for the first year
sufficient for the proper organization, including the
salaries of the secretary and his assistants, whose first
duty should be to investigate the public health activi-
ties in all the departments of the government ; and
when they are familiar with them they could work out
a plan and prepare a bill correlating them under the
Department of Health. The Secretary of Health and
his immediate assistants would most likely be of the
same' political faith as the President and the majori-
ties in the Senate and House. They would therefore
be in a position to secure the legislation, and the ap-
propriation to provide, for an adequate National De-
partment of Health.
The Secretary of Health would also be associated
with the heads of other departments of the govern-
ment that now carry on functions that should be in
the Department of Health. For instance, the Depart-
ments of Agriculture, Labor and Commerce are all
engaged in activities that properly belong to the public
health service; and the secretaries of those depart-
ments will have to be dealt with diplomatically to
keep them from opposing legislation that they might
think would reduce the prestige of their departments.
It has been suggested that a committee be appointed
by the President, and that Congress be called upon to
appropriate sufficient funds for its maintenance, with
powers to investigate all the governmental health ac-
tivities and that this committee would then be in a
position to recommend comprehensive legislation pro-
viding for advanced public health legislation. This
plan would involve a delay that might prove fatal to
any proposed constructive legislation ; and in its work
the suspicion of the various heads of departments
would be aroused and they might become hostile to
any legislation that would take away any of their
functions. Investigating committees are not very
popular in Washington because they have been abused
so much. It is also unfortunately true that Congress
does not take investigating committees very seriously.
— SearlE Harris, M.D., Editor Southern Medical
Journal, Birmingham, Ala.
NEW AND NONOFFICIAL REMEDIES.
Tablets Ovarian Substance — Armour 5 grains. —
Each tablet contains 5 grains of Ovarian substance-
Armour (See New and Nonofficial Remedies, 1920, p.
202). Armour & Co., Chicago.
Corpus Luteum Tablets-Armour 5 grain.— Each con-
tains 5 grains of desiccated corpus luteum-Armour
(see New and Nonofficial Remedies, 1920, p. 203).
(Jour. A. M. A., Sept. 18, 1920, p. 815.)
Tablets Anterior Pituitary-Armour 5 grains.— Each
tablet contains 5 grains of desiccated pituitary sub-
stance (anterior lobe). Armour (See New and Non-
official Remedies, 1920, p. 207). Armour & Co.,
Chicago.
Sodium Diarsenol. — A brand of sodium arsphena-
mine. Sodium diarsenol is marketed in ampules con-
taining 0.15 Gm., 0.3 Gm., 0.45 Gm., 0.6 Gm., 0.75 Gm.,
and 0.9 Gm., respectively. Diarsenol Laboratories,
Inc.. Buffalo, N. Y.
Riodine.— A 66 per cent, solution in oil of an iodine
addition (see Iodine Compounds for Internal Use.
New and Nonofficial Remedies, 1920, p. 143). Riodine
is supplied only in the form of Riodine Capsules 0.2
Gm. E. Fougera & Co., Inc., New York (Jour. A. M.
A., Aug. 14, 1920, p. 477).
Benzyl Benzoate-Seydel.— A brand of benzyl ben-
zoate complying with the tests and standards of New
and Nonofficial Remedies. For a discussion of the ac-
tions, uses and dosage of benzyl benzoate, see New
and Nonofficial Remedies, 1920, p. 48. Seydel Manu-
facturing Company, Jersey City, N. J.
Ovarian Residue-H.W.D.— The residue from the
fresh ovary of the hog, after the ablation of the corpus
luteum. Ovarian Residue is used for the same condi-
tions as the entire ovarian substance, but is claimed to
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October, 1920
PROPAGANDA FOR REFORM
23
have the advantage of being somewhat more stable.
Ovarian Residue-H. W. D. is supplied in the form of
5 grain tablets only. Hynson, Westcott & Dunning,
Baltimore (Jour. A. M. A., Aug. 7, 1920, p. 378).
Sterile Solution of Lutein-H. W. D. — Each cubic
centimeter contains the water-soluble extract of 0.8
Gm. Lutein-H. W. D., freed of protein in physiological
solution of sodium chloride for a discussion of the ac-
tions and uses of ovary preparations, see New and
Konoflicial Remedies, 1920, p. 201. The solution is
supplied in the form of Ampules Sterile Solution of
Lutein-H. W. D., containing 1 Cc. Hynson, Westcott
6 Dunning, Baltimore.
Sodium Arsphenamine. — Sodium Arsenphenolaraine.
— This sodium salt of 3-diaraino-4-dihydroxy-l-ar-
senobenzene with a stabilizing medium. The arsenic
content of three parts of sodium arsphenamine is
equivalent to two parts of arsphenamine. Sodium
arsphenamine has the same actions and uses as those
of arsphenamine; its advantage over arsphenamine is
that it does not require addition of alkali before use.
To prepare the solution the sodium arsphenamine is
added to the required amount of sterile water and dis-
solved by gentle agitation.
PROPAGANDA FOR REFORM.
Using Unfit Ether. — In the case of Moehlenbrook
versus Parke, Davis and Company et al., the Supreme
Court of Minnesota denied the surgeons who had ad-
ministered the ether a new trial, after a verdict had
been entered against both the manufacturer and the
surgeons. The Supreme Court holds that for the
death which resulted from the use of the unfit ether
both the manufacturer and the surgeons were responsi-
ble. The surgeons were held to be negligent in admin-
istering to a patient ether that was unfit for use and
in their care after the ether was administered (Jour.
A. M. A., Sept. 11, 1920, p. 763).
Digitalis Therapy. — Thanks to the development of
appropriate methods of physiologic assay, digitalis
preparations can now be evaluated in terms of their
real potency, and products can be prepared which are
stable and constant as the pharmacopeia! standards
demand. Physicians have learned, largely through the
leadership of Cary Eggleston, how to estimate digitalis
dosage on the basis of body weight. As the possibil-
ity ©Overdosage can be recognized by the occurrence
of symptoms such as nausea, or by the electro-cardio-
graph, it becomes possible to push the dosage speedily
to the limit of tolerance, with corresponding therapeu-
tic advantage. There remains, however, the impor-
tant need of differentiating more clearly the patients
for whom digitalis is actually indicated (Jour. A. M.
A., Aug. 7, 1920, p. 417).
Some Misbranded Venereal Nostrums. — The follow-
ing preparations have been the subject of prosecution
by the federal authorities under the Food and Drugs
Act on the ground that the therapeutic claims which
were made for them were false and fraudulent : In-
jection Cadet (E. Fougera and Co., New York), a
dilute watery solution of copper sulphate and uniden-
tified plant material. Knoxit Injection (Beggs Manu-
facturing Co., Chicago), a solution of zinc acetate with
alkaloids of hydrastis, in glycerin and water. Knoxit
Liquid, a solution of zinc acetate with alkaloids of
hydrastis, in glycerin and water. Knoxit Globules, es-
sentially a mixture of volatile and fixed oils and
oleoresins, including copaiba balsam, cinnamon and
cassia. Grimault's Injection (E. Fougera and Co.,
New York), a weak watery solution of copper sul-
phate and plant extractives, probably matico. Halz
Injection (Edw. Price Chemical Co., Kansas City,
Mo.), consisting essentially of zinc sulphate, boric
acid, glycerin, traces of alum and formaldehyd and
water. Tablets which seem to go with the product
consisted essentially of calcium and magnesium car-
bonates, copaiba, a laxative plant drug, plant extrac-
tives, a small amount of an unidentified alkaloid, sugar
and starch. Knoxit (Frederick F. Ingram Co., De-
troit), consisting essentially of opium, berberine, a
zinc salt, glycerin, alcohol and water. Crossmann Mix-
ture (Wright's Indian Vegetable Pill Co., New York
City), essentially an alcoholic solution of volatile oils,
including balsam copaiba and cubebs. Santal-Pearls
(S. Pfeiffer Mfg. Co., St. Louis, Mo.), consisting es-
sentially of a cinnamon-flavored mixture of santal oil
and copaiba. Cu-Co-Ba-Tarrant, Tarrant Co., New
York City), consisting essentially of a mixture of ex-
tract of cubebs and copaiba with magnesium oxid.
Hygienic and Preservative Brou's Injection (E.
Fougera and Co.), consisting essentially of acetates
and sulphates of zinc and lead, morphin, water and a
very small amount of alcohol (Jour. A. M. A., Sept.
25, 1920, p. 891).
Sukro-Serum and Aphlegmatol. — About two years
ago, American newspapers contained accounts of an
alleged cure for pulmonary tuberculosis "discovered"
by Prof. Domenico Lo Monaco of Rome, Italy. Re-
ports indicated that this so-called Italian Sugar Cure
for Consumption consisted of the intramuscular injec-
tion of solutions of sucrose (saccharose — cane
sugar). Now the Council on Pharmacy and Chem-
istry reports on two proprietary preparations based
on the "sugar cure" which are being exploited in
this country : Sukro-Serum and Aphlegmatol. Sukro-
Serum is marketed by the Anglo-French Drug
Company. A circular issued by this company de-
scribed Sukro-Serum as a "STERILIZED SOLU-
TION OF lacto-gluco-SACCHAROSE." By reading
this circular to the end, however, one learns that
"Sukro-Serum" is not a "serum" in the ordinary sense,
but apparently it is a solution of ordinary sugar
(sucrose). Aphlegmatol is sold by G. Giambalvo &
Co. The circular enclosed with a package of this ~
preparation contains the following, with reference to
the composition: "A solution of Hydrats of Carbon
after the formula of Professor D. Lo Monaco, Direc-
tor of the Institut of Physiological Chemistry of the
University of Rome. Contents: Sucrose (C^,H^,0^^)
Glucose and Galactose (C,HjjO„)." The preparation
was found to contain a reducing substance, probably
glucose, amounting to about 7.4 per cent. After hy-
drolysis, 55.5 per cent, of glucose was found. The
advertising for Aphlegmatol appears to be the work of
those ignorant of the English language. These two
preparations appear to be nothing more than concen-
trated solutions of sugar. It is probable that a small
amount of cane sugar might be inverted into glucose
and fructose, but experiments have shown that cane
sugar subcutaneously administered in the small
amounts used in this instance is largely excreted in the
urine unchanged. Less is known about galactose, but
the evidence available would indicate that galactose i&
largely excreted in the urine unchanged when given
subcutaneously. Glucose would be absorbed as such,
and the amounts under consideration, used by the sys-
tem much the same as when given by mouth (Jour. A.
M. A., Aug. 21, 1920, p. 556).
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24
THE PENNSYLVANIA MEDICAL JOURNAL
October, 1920
THE PENNSYLVANIA
Medical Journal
Published monthlr under the supervision of the Publication
Committee of the Trustees of the Medical Society of the State
of Pennsylvania.
Editor
FREDERICK L. VAN SICKLE, M.D Harrlsburg
Aislitent Editor
FRANK F. D. RBCKORD Harrlsburg
AiM0Ut« Editors
JosiPH HcFaxland, M.D Philadelphia
GCOKCK E. PfAHLEa, M.D Philadelphia
Lawunce Litchfieud, M.D Pittsburgh
G«o»OE C. Johnston, M.D Pittsburgh
I. Stewart Roduan, M.D., Philadelphia
John B. McAi.istek, M.D Harrlsburg
Bebnakd J. Mybes, Esq., Lancaator
Pnbllcation Committee
I«A G. ShoehakSk, M.D., Chairman Reading
TuEODoaE B. Appel, M.D Lancaster
Prank C. Hahuond, M.D Philadelphia
All communications relative to exchanges, books for review,
manuscripts, news, advertising and subscription arc to be ad-
dressed to Frederick L. Van Sickle, M.D., Editor, aia N.
Third St., Harrisburg, Pa.
The Societ); does not hold itself responsible for opinions ex-
pressed in original papers, discussions, communications or ad-
vertisements.
Subscription Price — $3.00 per year, in advance.
OCTOBER, 1920
EDITORIALS
A FOREWORD FOR THE NEW JOURNAL
YEAR
With this issue (Volume XXIV, No. 1) be-
gins a new year for the Pennsylvania Med-
ical Journal. With this number also begins
the full control of the journalistic work by the
Publication Committee, and the new Editor.
The editing and publishing will be done in Har-
risburg, Pa.
The past history of the Journal furnishes
a proof of the value of this publication and its
eminent worth to the Medical Society of the
State of Pennsylvania. Its former editor and
publisher. Dr. Cyrus Lee Stevens, whose untir-
ing devotion, whose energy, perseverance and
efficiency have been proved year in and year out
in making this Journal one of the best to be
found in the United States as the official organ
of a state society, cannot receive too much com-
mendation for his service.
This work has builded a monument for Dr.
Stevens, far more enduring than the best of men
in medicine can make during a life time. What-
ever visions the Journal Committee may have
in assuming direction for the coming year, we
feel they can not excel very much that of the
former management. The future of medicine
in this state may bring possibilities for increased
usefulness of this journal; legislative changes
may make an opportunity whereby the Journal
may secure a wider influence than that of the
past ; but a high standard of scientific medicine
must be maintained by this publication if it re-
ceives proper recognition. This can be proved
only by future experience.
During the transition period, while the Jour-
nal was in process of removal from the former
site of publication, the American Medical As-
sociation Press at Chicago, and the management
of the former editor. Dr. Stevens at Athens,
much confusion was bound to take place, and yet
but little interruption occurred in the usual order
of publication. Errors or omissions of any type
should be attributed to the moving of Journal
headquarters.
Such changes as are necessary to conform with
the future plans of the Journd Committee have
been begun, with a hope that the Journal may
create a greater interest. Comment, either fa-
vorable or unfavorable, will be gladly received
by us, so that we may thereby improve each
issue.
In this foreword we bespeak the most earnest
cooperation and assistance by suggestion and ac-
tion of every member of the State Society. We
know personally that but few of the officers of
our Society really know what each issue of the
Journal contains; also we have heard that
many members do not take time to open and
read their Journals, and only by feeling that
this Journal is answering the medical problems
of the members of the State Society can its use-
fulness and success be sustained.
Read the Journal. Offer constructive criti-
cism for the benefit of the Journal Committee
and the Editor.
DR. CYRUS LEE STEVENS
Some men who were born in the year 1851 are
now old. Some are referred to as elderly, while
others belong to the immortals who are and al-
ways will be sixty-five years young. Such an
one is our good friend Dr. Cyrus Lee Stevens.
Although he first saw light in 1851, (and has
been endeavoring to show it to us ever since)
he is to-day the best possible example of the
fallacy of Oslerism.
Any attempt to write an appreciation of our
distinguished brother. Dr. Stevens, is fraught
with difficulty, not because there is nothing good
to be said about him, but because there is so
much to say and so little space in which to ex-
press it, that one is aghast at the possibility of
saying what he should.
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Db. Cybus Lee Stevens
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OCTOBBR, 1920
EDITORIALS
25
Viewing the many-sided activities and suc-
cesses of Dr. Stevens, we are reminded of the
delightful opera, "The Mikado," in which the
versatile and omnipotent Pooh-Bah serves in so
many and so widely differing capacities. Has
any man among us done so many things, profes-
sionally, socially and politically, as Dr. Stevens,
yet has to his credit been master of them all ?
Bom in Stevensville, Pa., in 1851, he has dis-
played much of the same fearless, unconquerable
resolution in his career that his pioneer ances-
tors revealed in their lives when America was in
its early infancy. For Dr. Stevens directly de-
scends from heroic Revolutionary stock.
The fact that his parents chose Cyrus for their
son's name seems almost prophetic. The name
C)rrus is always associated in our mind with
another Cyrus. Like that elder Cyrus, ruler of
the Persian Empire, the triumphant career of
Dr. Cyrus Stevens began with his school days
when he was a prize pupil in the little red school-
house, and continued through his course at La-
fayette College, where he won his A.B. and four
years later his A.M. degrees. Previous to his
college career. Dr. Stevens taught in public and
private schools, and was so successful as a
teacher that he was made principal of the East
Smithfield, Pa., public schools.
During Dr. Stevens' years at Lafayette he
showed such unmistakable signs of literary and
editorial ability that he was made manj^ing edi-
tor of the Lafayette College paper. Showing
thus early the versatility which later rendered
Dr. Stevens' career most unusual, after gradua-
tion from Lafayette he served as tutor in Nat-
ural Science in Parsons College, Iowa. During
these years Dr. Stevens pursued his medical
course. There was no eight-hour law then, nor
has there ever been for Dr. Stevens. The only
eight-hour law he recognized was the one which
operated three times every day. By constant
work and strenuous application to studies and
employment. Dr. Stevens on graduation in medi-
cine was awarded a first prize. As straws show
the way the wind blows, so this early energy,
ambition, and concentration of the student, was
evinced even more strongly in the subsequent
years of Dr. Stevens, the practitioner.
Immediately on graduation, Dr. Stevens vis-
ited the hospitals of Europe, and spent three
years in Turkey, during which time he was Pro-
fessor of Surgery and Obstetrics in the Medi-
cal Department of the Central Turkey College,
at Aintab.
On his return to America in 1885, Dr. Stevens
was made Medical Superintendent of the New
York Medical School and Hospital. Having
seen many sides of the world, he then decided
that Athens, in Pennsylvania, was good enough
for him, and there he practiced medicine with
unqualified success. During his service as mem-
ber of the Legislative Committee of the Medical
Society of Pennsylvania, he was largely instru-
mental in securing the enactment of laws con-
stituting the State Medical Council and Examin-
ing Board in 1893.
The retirement of Dr. Stevens, after twenty-
one years of devoted service as Secretary of the
Medical Society of Pennsylvania, and Editor of
its Journal, is a great loss. How great this loss
is cannot now be estimated. In the years to
come the unselfish sacrifice, the broad visioned
and constructive work done by Dr. Stevens, will
be strengthened and confirmed. The wide scope
of his interest, the kindly genial warmth and
strength of his personality, the efficient and ener-
getic achievements of his finely poised mind, his
unflinching devotion to ideals, civic as well as
medical, his belief in and conviction of the ad-
vantages of organization, have given him an in-
fluence which is wholly exceptional.
The story of Dr. Stevens' life is one of con-
stantly enlarging attainments. This is true not
only of his medical achievements, but also of his
public service. While representing his constitu-
ents as a member of the Pennsylvania State Leg-
islature in 1907 and 1908, he was progressive-
minded in his advocacy of public health meas-
ures and preventive medicine. He was an ar-
dent supporter of the State Department of
Health, and looked after the interests of the
medical profession.
As a member of the Borough Board of Health
(1888-1892), as Surgeon to the Lehigh Valley
Railroad (1889-1893), as Consulting Surgeon to
the Packer Hospital at Sayre, Pa. (1889-1893).
as a member of the Committee on Sanitation of
the Athens Board of Trade since 1891, Dr.
Stevens has rendered services beyond the power
of any ordinary person to estimate. This con-
nection alone formed a record of many years of
faithful and efficient public service. As Medi-
cal Examiner of a number of leading life in-
surance companies Dr. Stevens was convinced
of the deleterious effect of alcohol upon lon-
gevity and physical efficiency. As far back as
1907, when a member of the legislature, he was
an ardent advocate of prohibition. To take such
a stand in what has since come to be known as
"those good old days" was neither pleasant nor
popular.
The social side of Dr. Stevens is shown by
his membership in the Masonic Fraternity. He
is a Past Grand Master in the Independent Or-
der of Odd Fellows, and a member of the Royal
Arcanum. In all these affiliations Dr. Stevens
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26
THE PENNSYLVANIA MEDICAL JOURNAL
October, 1920
has taken a leading place, participating and co-
operating efficiently in all their activities and ac-
complishments.
In his religious faith he is not only a member
of the Presbyterian Church at Athens, biit a
Ruling Elder ; and in his interest in young men
and boys to help them to ideals as high as his
own, he has been active as President of the Y.
M. C. A.
One of his strongest attributes was loyalty.
Dr. Stevens was never a "knocker" in medical
society, and because of his broad and charitable
relations and noble brotherhood in the profes-
sion, we medical men of Pennsylvania are deeply
indebted to him for his years of service in our
behalf.
Dr. Stevens as educator, physician, legislator,
man, humanitarian, and Christian, will serve
throughout his own and succeeding generations
as the model of a steadfast life, lived even in this
chaotic, upside-down, tom-by-many-dissentions
old world of ours. J. B. McA.
IN WH.^T CASES DO PARESIS AND TABES
FOLLOW SYPHILITIC INFECTION?
The war, that interrupted so much useful
work, and distracted attention from so many
important things to its own purposes, seems to
have been responsible for the postponement, for
several years, of an illuminating piece of re-
search work upon syphilis in France, as well as
for its apparent lack of appreciation upon final
publication.
It has long been a matter'of paradoxical clin-
ical observation that severe syphilitic infections
— i. e., those in which a large typical Hunterian
chancre makes its appearance, runs a regular
course and is followed by wide-spread and se-
vere secondaries, and therefore arouses the fear
of nervous tertiary lesions — seldom lead to the
occurrence of either paresis or tabes. Fournier
called attention to this more than ten years ago,
and expressed the opinion "that "general para-
lysis follows in a very regular, quasi constant,
fashion, upon syphilis of apparent benignity."
He even went so far as to suspect that the rea-
son for this was to be found in the fact that the
primary and secondary manifestations were so
mild and so atypical as to pass unobserved or to
be regarded as so trivial, that the treatment was
allowed to lapse.
There may be some truth in this opinion, but
a better explanation now awaits verification.
It will be remembered that the presence of
Treponema pallidum in the brains of paretics
was first detected by Noguchi in 1913. In sev-
enty cases studied by Noguchi and Moore the
organisms were found in twelve. Later Le-
vaditi and Manouelian, using an improved
method, confirmed the observation and increased
the percentage of discovered organisms from
twelve to twenty-four.
Burckner and Galasesco found the rabbit to
be susceptible to syphilitic infection, an enor-
mous multiplication of the specific organisms
taking place when the inoculation was made into
the testis.
In 1913 Levaditi, Marie and Manoueliam suc-
ceeded in infecting a rabbit by injecting its scro-
tum with blood taken from a human being af-
flicted with general paresis, and were engaged in
the comparison of this organism and the lesions
it evoked, with other treponemata taken from
cutaneous, mucous and visceral lesions of hu-
man beings, when the war interrupted.
In an interesting paper Levaditi and Marie
(Annales de I'lnstitut Pasteur, Nov., 1919,
xxxiii, No. 2, page 741 ) give the details of their
experimental and clinical investigations, and
support their conclusions by such an array of
evidence as to leave little doubt of the correct-
ness of their work.
They believe that there are two "strains" of
the Treponema pallidum. The more common in
occurrence, produces the typical Hunterian
chancre, the wide-spread familiar secondaries,
and in the tertiary stage invades the viscera and
bones. To this they give the name "derma-
trophic virus." The second strain consists of
organisms that produce atypical chancres, lead
to unimportant secondaries, and then quickly in-
vade the central nervous system. These they
name "neuratrophic virus."
"The facts shown in the memoir show that
between the treponema of ordinary syphilis, and
the spirochete of the post-syphilitic cerebral and
spinal lesions, such as are obtained from the
blood (and probably also from the brain) there
are striking differences, as well from the bio-
logical point of view, as from the point of view
of the lesions that they occasion in men and
animals. These differences persist, in spite of
a considerable number of passages through the
rabbit and may be summarized thus :
1. In the duration of the period of incubation,
which is a great deal longer in the case of the
neuratrophic virus.
2. In the character of the manifestations pro-
duced in the rabbit : an indurated chancre in the
case of the dermatrophic virus, papulosquamous
lesions in the case of the neuratrophic virus.
3. By the microscopic peculiarities of the le-
sions : a marked affinity for the epithelial tissues
on the part of the neuratrophic virus, vascular
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October, 1920
EDITORIALS
27
and sclerotic alterations being a great deal more
marked in the dermatrophic virus.
4. By the evolution of papulosquamous le-
sions through the increase and dissemination of
the spirochete of general paralysis in the rabbit :
slow evolution, late spontaneous healing*, reap-
pearance after a period sometimes very long.
5. By the pathogenic power of the organism :
marked virulence for the lower monkeys, an-
thropoid apes and man on the part of the derma-
trophic virus; no pathogenisis through cutan-
eous innoculation of the spirochete of general
paresis.
6. Lastly, by the fact that animals healed of
the lesions provoked by the one of the trepone-
mas and which through this fact have acquired
a refractory state as regards that treponema,
continue, in the generality of cases to be recep-
tive for the other spirochete."
It is interesting to note in closing this sum-
mary of the investigation that the virulence of
the dermatrophic virus is entirely unmodified
for monkeys, anthropoid apes and man by pas-
sage through rabbits, while that of the neura-
tropic virus is entirely destroyed.
Through a laboratory accident on the one
hand, and a voluntary sacrifice on the other, they
were able to add the effects of the viruses upon
human beings to their experimental investiga-
tions upon the lower animals. Thus, "a person
among those participating in the investigation
accidentally infected himself by a needle prick,
with the juice expressed from a chancre on a
?;abbit, and containing a great number of mobile
treponema. The innoculation was on the back
of the hand and took place January 7th. On
January 20th, thirteen days afterward, the blood
was Wassermann negative. There was no le-
sion until January 31st, when a slightly ery-
thematous nodule was noted, becoming distinct-
ly papulous by February 7th — ^thirty days after
the accident. The papule indurated slightly and
became covered with scales in the centre. Was-
sermann negative. No enlarged glands, no sec-
ondaries. The lesion preserved the same gen-
eral appearance until the 10th of March, when
it paled. The Wasserman reaction which was
negative on February 24th, became positive on
March 10th. The lesion was shown to be rich
in treponemas. It healed completely March
24th. The case was followed for six months.
No secondaries. The Wassermann remained
positive (last observation June 16th).
This showed that the dermatrophic virus re-
mained virulent for man even after having been
kept growing in rabbits from 1908 to 1914.
Now compare this with the other human obser-
vation made with the neurotrophic virus, which
experiments upon lower animals showed to lose
its virulence : "X — , never having had syphilis
and showing negative Wassermann reaction,
was innoculated by sacrification on the right arm
with a juice rich in tremonemas taken from a
rabbit innoculated for the first time with fresh
human virus. There was no reaction, either
general or local, during long months of observa-
tion and the Wassermann reaction remained
negative after five years." J. Mc. F.
THE PNEUMO-PERITONEAL METHOD OF
X-RAY EXAMINATION
This method of examination has been in use
in America during the past two years, and has
been proved of distinct value in the diagnosis of
intra-abdominal conditions. The lay press now
announces that such a discovery has been made
in Paris, and, like most medical discoveries that
are announced in the lay press, there is given an
undue importance and much inaccurate informa-
tion. It is important, therefore, that the prac-
titioner of medicine be informed as to the actual
facts so that he can readily reply to inquiring
and anxious patients who are ever ready to
grasp at some new discovery, especially if they
think it has been made in Europe, and especially
if it is mysterious and startling. Drs. Stewart
and Stein of New York* deserve most credit for
having developed this method, though they were
not actually the first to have used this procedure.
This method of examination consists of the
introduction into the peritoneal cavity (as pre-
sented by Drs. Stewart and Stein) of oxygen.
The oxygen is taken from an ordinary oxygen
tank, is introduced through a paracentesis needle
which is plunged into the peritoneal cavity below
and slightly to the left of the umbilicus. This
must be done under aseptic precautions and by
one who is familiar with such procedures. The
oxygen is then allowed to flow slowly until there
is some moderate discomfort from abdominal
distention. X-ray plates are then made in vari-
ous positions, but particularly in the positions
which will permit the solid organs, or patholog-
ical tissue, to be uppermost so that they will be
clearly outlined by means of the gas. This in-
volves some discomfort on the part of the pa-
tient, but so far has caused no harm, and it is
generally considered a safe procedure.
This method is especially useful in outlining
the solid organs such as the liver, spleen, kid-
neys, enlarged retro-peritoneal glands, uterus
and ovaries, or any new growth that is located
within the abdomen and that does not involve
I. Journ. Am. Med. Ass., Vol. 75, No. i.
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THE PENNSYLVANIA MEDICAL JOURNAL
October, 1920
the lumen of the gastro-intestinal tract. Infor-
mation with reference to tumors or ulcers with-
in the gastro-intestinal tract can be better dem-
onstrated by means of the opaque meal or
opaque enema. At times valuable information
can be obtained with reference to the gall blad-
der, but even for the demonstration of gall
stones it has not proved of as much value as
other x-ray technique. The lay press gives the
impression that anything affecting the liver can
now be demonstrated. As a matter of fact, only
the size and shape of the liver can be demon-
strated by this method and even this information
as to the size and shape of the liver can generally
be demonstrated by more simple technique. It
is of value in the demonstration of subdiaphrag-
matic abscesses if the patient's condition will
permit the use of this method.
One of the objections to the use of the method
is the slowness with which the oxygen is ab-
sorbed, some of it being demonstrable often at
the end of a week. To overcome this condition,
Stewart has recommended the reintroduction of
the paracentesis needle into the peritoneal cavity,
after the examination has been completed and
the oxygen withdrawn.
More recently Alverez* has recommended the
use of carbon dioxide which is absorbed from
the peritoneal cavity within about half an hour
and requires very quick action on the part of
everyone in order to get the examinations made
before the gas is absorbed. Alvarez believes,
however, that by the use of the carbon dioxide,
because of the quick elimination of the gas, the
method can be used in office examinations in an
x-ray laboratory properly equipped, and in
which good technique and speed has been de-
veloped.
It is important that the general practitioner be
informed upon this subject not only to answer
curious questions on the part of patients and
friends, but that he may advise his patients in-
telligently in the use of these newer methods.
G. E. P.
SIMPLICITY OF MODERN DIETETICS
Allen's work on Diabetes Mellitus, with Jos-
lin's elaboration of the same have done much to
start many doctors in rational feeding. Tradi-
tional books . with foolish diet tables for all
known conditions have done great harm by ob-
scuring the subject of dietetics. That our med-
ical schools still turn out graduates who know
much about the absolutely useless drugs, but
less about food than a girl graduate of a good
2. Col. State Med. Jour., Feb., 1920.
high school, needs no comment. Every physi-
cian should know that man needs, in health or
disease about one gram of protein for every
two pounds of his body weight; that he also
needs eighteen hundred to three thousand calo-
ries to "be supplied by carbohydrates and fats ac-
cording to the work which he has in hand, the
season of the year, and his climatic environ-
ment. The protein is material for building and
repair, the carbohydrates and fat are fuel to
keep the body warm and supply motive power
for muscles and glands; the body also needs
some mineral food but a rational mixed diet
furnishes a sufficient supply of the necessary
mineral elements. Whether we class water as
food or not it is well to emphasize here, the fact
that the most important need of the body in
health and in sickness is the supply of a suffi-
cient amount of water to provide for two to
three pints of urine and one to two pints of
water to be given off by the skin and the lungs
in each twenty- four hours. This will insure to
the organism water enough to help regulate the
body heat, to make possible the chemical reac-
tions of the cell protoplasm and to bring the
reagents for these reactions and dispose of the
waste products of the same.
So much for the diet in health. What is ac-
tually known about diet requirements in disease
is very simple and very interesting. Those who
are not familiar with them should read Profes-
sor Chittenden's "Physiological Economy in
Nutrition," and Lusk's "Science of Nutrition."
Both books are fascinating reading and give
added interest to one's daily work.
In the very acute, virulent, febrile diseases as
"flu," "grip," pneumonia, rheumatic fever, etc.,
the digestion is upset by the onset of the disease
and food is best withheld until the appetite and
a clean tongue indicate that the digestive organs
are ready to negotiate a suitable supply of nour-
ishment. Then the attempt should be made to
supply the needs of a body at rest, choosing
simple, readily digested articles such as por-
ridge, gruels, purees, fish, chops, chicken, beef,
cheese, milk, cream, butter, oil, etc. The needs
for the patient in health should never be lost
sight of for the needs of the sick man are prac-
tically the same as the needs of the well man in
proportion to the amount and kind of work he
has to do. The question is not what is the diet
for this disease but what does this individual
need in the way of building material and fuel
food. When asked the familiar question "Doc-
tor what shall the patient have to eat?" you
should consider first, what a human being of the
size in question needs for the work which this
individual has in hand; second, whether it
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October, 1920
EDITORIALS
29
seems wise to make up this requirement without
the coarser articles of diet; this should be the
case when a sensitive irritable condition of the
digestive organs were indicated by nausea and
vomiting, flatulent distention, colicy pains, or
loose undigested bowel movements with mucus
in the stools ; third, whether the patient in ques-
tion needs laxative or astringent articles of diet.
In the former case the vegetables high in cel-
lulose, the five per cent, and ten per cent, vege-
tables of Joslin's list should be used very largely.
If the digestive organs are irritable the vege-
tables may be given in the form of purees which
can usually be tolerated by the most delicate
stomach. In case there is a tendency for the
food to be hurried through the digestive tract
and passed in an undigested form, in loose bowel
movements, these five per cent, and ten per cent,
vegetables should be omitted and carbohydrates
should be given in the form of zwieback, Hub-
bard's rusk, well toasted white bread, Philadel-
phia pulled bread, — farina, imperial granum,
Cream of Wheat, tapioca, Robinson's barley
flour or other preparation of barley, while pro-
tein is supplied by boiled milk, cream cheese,
egg albumin, etc. Buttermilk should not be
used, but cocoa made with peptonized milk or
boiled milk, should be used freely. In some
cases of diarrhea the various fermented milks
may be tried and often give good results.
Fourth, what special articles are contra-indicated
or need to be taken in minimum or carefully
measured or limited amounts such as carbohy-
drates in diabetes mellitus or other diseases of
the pancreas or in chronic polyarthritis, protein
and sodium chloride in nephritis, the former
when the phthalein return is low and the non-
protein nitrogen in the blood is high, and the lat-
ter when there is general edema and the salt
returii is low, and also in epilepsy the sodium
chloride ration should be limited to the mini-
mum; purin bodies, — meat (which includes fish
and poultry), coffee, tea, chocolate, and aspara-
gus representing the principal ones, — being re-
stricted in gout, — however the diagnosis of gout
should not be made by the general practitioner
without the evidence of toes or tophi, unless
the aid of a laboratory or an experienced cli-
nician can be called upon; food high in oxalic
acid should be omitted from the dietary when
there is evidence of oxaluria, or deposits of oxa-
late in the urinary system; food and particu-
larly water high in lime should be avoided when
the patient has passed calcareous sand, gravel or
calculi ; fat should be limited in diseases of the
liver and pancreas ; no food requiring mastica-
tion can be utilized and such articles may cause
great irritation, in the absence of approximating
molar teeth (the biscuspids are virtually
molars) ; meats and excessive proteins in all
probability are best omitted in gastroduodenal
ulcer or simple hyperchlorhydria. Furthermore
if the patient is already overweight, it must be
borne in mind that he has no surplus of proteins
or building materials stored in his body and that
the daily ration of nitrogenous food must be
supplied, while, on the contrary, the surplus fat
stored in his body may be relied upon to furnish
most of the fuel. It must ever be borne in min-^
however, that the intestines act normally and
efficiently only when supplied with a sufficient
amount of- cellulose to keep them fairly dis-
tended; this means five per cent, and ten per
cent, vegetables in forms which are suitable to
the condition of the patient's digestive organs.
Carry one of Dr. Joslin's pink cards in your
pocket and read it at odd moments until you are
perfectly familiar with it. When a sufficiently
bulky pabulum is supplied, a normal peristalsis
keeps the intestinal contents constantly moving
onward. On the other hand, if the patient is
under weight, while the same amount of protein
is needed as before, carbohydrates and fat
should be furnished to the point of tolerance.
It must always be assumed that the patient is
able to take and digest a sufficient amount of
nourishment until the contrary is proven to be
the case after repeated attempts. The patient's
statements as to his or her ability to digest cer-
tain articles of diet, can not be depended upon.
They must be respectfully and carefully consid-
ered and if need be tested. L. L.
WHOSE TIME?
The following incident will be of interest to those
who are still struggling with the intricacies of train
schedules in relation to New York time:
An American Red Cross officer, who served in the
Italian campaign with the American Army and who
eventually was transferred to the ranks of the Ameri-
can Red Cross, reached his home in Mississippi last
summer while the daylight saving law was in effect
He found one of the old negroes of the town doing a
hacking business with an automobile. The major im-
mediately engaged him for a ride every day. To begin
with he took a drive of twenty miles to view the
scenes of his boyhood.
"Now Uncle Jack," he said, "be back here at four
o'clock and we'll go out again. But be sure to be on
time."
"Yas, suh, I'll sho be there."
The old Uarkie started off and then stopped his car.
"You remember the hour, don't you?" asked the
major.
"Yas, suh. I know you said fo' o'clock. But look
here, boss, does you mean fo' o'clock by God's time or
President Wilson's time?"
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The Medical Society of the State of Pennsylvania
OFFICERS DEPARTMENT
WALTER F. DONALDSON, M.D.
Secretary
8103 Jenkins Arcade BIdg., Pittsburgh, Pa.
CHANGES IN MEMBERSHIP OF COUNTY
SOCIETIES
The following changes have been reported to Sep-
tember 83:
Adams: New Member — Donald B. Coover, Cur-
wensville.
Allegheny: New Member — Henry C. Westervelt,
5306 Westminster Place, Pittsburgh.
Armstrong: New Member — Harry W. Allison,
Kittanning.
Beaver : New Members — Ernest W. Campbell, Mid-
land; James T. Armstrong, Rochester.
Blair: New Members— Roy Deck, 234 N. Duke
St., Lancaster; Carey C. Bradin, Tyrone.
Butler: New Memfr^w— Clarence H. Ketterer, 348
S. Main St., Butler; Ralph Christie, Pctersville.
Cambria: New Members — Harry H. Miller, 245
Ohio St., Johnstown; Winter O. Keffer, Frugality;
Sylvester C. Gearhart, Blandburg.
Clearfield: New Member — William G. Falconer,
Woodland.
Clinton: Removal— Irving O. Mahr from Logan-
ton to Boyertown (Berks Co.).
Crawford: Removal — George W. Ellison from
Meadville to Townville.
Cumberland: B. F. Hunt of Mechanicsburg not a
member, as reported in September Journal.
Delaware: Transfer — Peter M. Keating of West
Chester to Chester County Society.
Erie: New Member — Ray y. Luke, 806 Rankin
Ave., Lawrence Park, Erie.
Fayette: Removal — Andrew G. Opinsky from
Wilkinsburg (Alleg. Co.) to New Kensington (Alleg.
Co.).
Jefferson : Removal — Harry A. O'Neal from Knox-
dale to Brookville.
Lawrence: New Members — James A. Shafer,
Volant; Samuel R. W. McCune, New Castle. Re-
moval—Maur'tct C. James from New Castle to 1313
27th Ave., Columbus, Nebr.
Lebanon : Death — Samuel P. Heilman (Univ. of
Penna., '67) of Lebanon, Sept. 11, aged 78.
Lackawanna: New Members — James J. Dougherty,
Avoca (Luz. Co.) ; Lewis A. Druflfner, Avoca (Luz.
Co.) ; Stanley Winters, Avoca (Luz. Co.).
Lehigh: Death — James H. Lowright (Jeff. Med.
Coll., '80) in Allentown Hospital, Aug. 28, from cere-
bral hemorrhage following overwork.
Luzerne: New Members — Andrew A. Fabian, 137
Wilson St., Larksville; Edward J. Flanagan, 205
Blackman St., Wilkes-Barre ; Harry W. Croop, 234
Rutter Ave., Kingston; Benjamin W. Genung, 203
Wilkes-Barre St., White Haven. Removal— Albert O.
Thomas from Wilkes-Barre to Glen Lyon.
Mercer: Removal — Carl Bailey from Jafliestown to
Sharon.
Montgomery: New Member — Chapin Carpenter,
Wayne. Removals — William H. M. Imhoff from Nor-
ristown to Hillside Home, Clark's Summit; Warren
Z. Anders from Trappe to Collegeville. Death —
Mathias Y. Weber (Univ. of Penna., '81) in Evans-
burg, July 28, from angina pectoris.
Northampton: New Members— P&vd R. Correll,
Easton; Thomas W. Schwab. Bath. Removal— To-
bias U. Uhler from Philadelphia to 54 So. Whitfield
St., Nazareth.
Schuylkill: New Members— Oscar H. Mengel,
Frackville ; Harry W. Bailey, Tamaqua.
Somerset: Removal — Albert F. Keim from Jerome
to Stoyestown.
Tioga: New Member— David A. Patterson, West-
field.
Washington: Removal— Charits T. Graves from
Monongahela to Donora.
Wayne: Removal— Walter R. Krauss from Fair-
view to 1614 N. 16th St., Philadelphia.
Westmoreland : New Member — Robert Miller Coch-
ran, 215% S. Main St, Greensburg.
PAYMENT OF PER CAPITA ASSESSMENT
The following payment of per capita assessment has
been received since August 21 :
8/21
Blair
88
7042
$5.00
Schuylkill
117
7043
5.00
8/31
Beaver
54
7044
5.00
9/4
Clearfield
63
7045
5.00
9/ 7
Tioga
34
7046
5.00
9/ 9
Lawrence
55,
57
7047-7048
10.00
Cambria
126-128
7049-7051
15.00
9/10
Montgomery
138
7052
5.00
9/11
Northampton
131
7053
.5.00
Schuylkill
118
7054
5.00
Blair
89
7055
5.00
9/13
Adams
25
7056
5.00
Luzerne
230
7057
5.00
9/15
Westmoreland
149
7058
5.00
Allegheny
1122
7059
5.00
9/16
Butler
49-50
7060-7061
10.00
9/18
Beaver
55
7062
5.00
Armstrong
62
7063
5.00
Lackawanna
177-
179
7064-7066
15.00
9/20
Northampton
132
7067
5.0O
9/21
Luzerne
231, 232,
234
7068-7070
15.00
9/23
Erie
114
7071
5.00
RESPONSIBILITY
The people of Pennsylvania are confronted
by the continuous attack of ignorance and cu-
pidity upon established medical practice acts.
The bars against the uneducated practitioner of
the healing art were raised through the influence
of well educated physicians, and the continued
safeguarding of the public health properly rests
with the qualified medical men and women of
the state. We should be willing to give service
to the cause, and continually to point the way to
correct diagnosis of disease and injury and to
the correct practice of preventive medicine.
These are the fundamentals in mankind's fight
against sickness. Fads may come and fads may
go, in the treatment of sickness, but diagnosis
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October, 1920
OFFICERS DEPARTMENT
31
and prevention present no new problems in the
larger sense; their need remains the same al-
ways; namely, education.
We trust then that when the members of the
Medical Society of the State of Pennsylvania
are called upon to contribute time or money in
the battle for improved health, they will not be
found wanting. Our opportunity is at hand to
point out to laymen and lawmakers the weakness
of proposed laws for antivaccination and anti-
vivisection, as well as those admitting untrained
healers through the backdoor route, followed by
the drugless cults.
Your opportunity may come at any time to
volunteer guidance to one of the many social
service agencies springing up in every com-
munity. They all revert sooner or later to some
phase of the sickness problem, and almost in-
variably their success or failure depends ulti-
mately upon the services of physicians.
We must meet the trend of the times and no
longer hold back waiting for an invitation to
enter these movements. We by our experience
and teaching created the demand for com-
munity interest in health and sickness, and we
should not fall short of our full responsibility.
Let us be leaders, individually and in groups, in
every movement that requires the seasoned judg-
ment of trained medical men, remembering that
the problem is, as it always has been, how to
manage that all men may have the blessing of
proper care.
MEMBERSHIP
Officers and members of component societies
are reminded that new members enrolled at this
season receive for twelve months' dues the full
benefits of membership in the State Society from
November 1, 1920, to January 1, 1922.
"A physician should associate himself with
medical societies and contribute his time, energy
and means in order that these societies may rep-
resent the ideals of the profession."
"Every physician should aid in safeguarding
the profession against the admission to its ranks
of those who are unfit or unqualified because
deficient either in moral character or education."
MEDICAL DEFENSE
Members threatened by suit for alleged mal-
practice must remember that they should consult
the proper officers of County and State Society
before legal advice is sought. Formal applica-
tion blank, which can be secured either from the
secretary of the county medical society, from
the secretary of the state medical society, or
from the councilor for the district, must be filed
within thirty days after serving of summons.
FREDERICK L. VAN SICKLE. M.D.
Executive Secretary
Harrisburg, Pa.
ECHOES FROM THE SEVENTIETH ANNUAL
SESSION OF THE MEDICAL SOCIETY
OF THE STATE OF PENNSYLVANIA
The Seventieth Annual Session in Pittsburgh
opened under clear skies and fine weather. The
commercial exhibit, which was unusually large
this year, filling every nook and corner of the
spacious corridors and rooms allotted for that
exhibit, offered to the visiting physicians an ar-
ray of articles, both medical, surgical and spe-
cial, rarely found at any state exhibit in so vast
profusion. Exhibitors vied with each other as
to the beauty of their displays, the artistic ar-
rangement of their goods, and each representa-
tive seemed to assume the fraternal spirit, and
less commercialism than has been shown in other
exhibits which we might mention.
The Board of Trustees met promptly at ten
o'clock Monday morning, and transacted the pre-
liminary business' necessary to this session. At
three o'clock the House of Delegates was called
to order by Dr. Cyrus Lee Stevens, of Athens,
when the routine business was presented, the
House adjourning until three o'clock Tuesday
afternoon, meeting again on Wednesday morn-
ing at nine o'clock for the election of officers and
the transaction of other business.
The Scientific Session began on Tuesday
morning with the program which was printed in
the September number of the Journai,, includ-
ing the President's address which appears in this
issue. Dr. Thomas E. Finegan, Superintendent
of the Department of Public Instruction of
Pennsylvania, presented a most interesting ad-
dress on the relation between the physician and
the public schools of the State, which was fol-
lowed with a discussion by Col. Edward Martin,
the Commissioner of Health. Dr. James M.
Anders, Dr. W. Wayne Babcock, and Dr. Rob-
ert A. Keilty followed with papers of unusual
interest.
The afternoon sessions of that day were de-
voted to section work, and but few omissions
from the official program occurred.
Tuesday evening was devoted to a public
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32
THE PENNSYLVANIA MEDICAL JOURNAL
October, 1920
meeting, when Dr. Alfred C. Wood and Dr.
Frederick R. Green discussed Social Insurance
as it pertains to Workmen's Compensation and
Compulsory Health Insurance. Honorable Wil-
liam T. Ramsey, Mayor of Chester, Chairman
of the Commission to Study Compulsory Health
Insurance, was granted the privilege of the floor,
when he recited briefly his experience in study-
ing this problem during a tour through the Brit-
ish Isles as the representative of the Commission.
The program was concluded by an address by
Dr. E. A. Peterson of Washington, on the work
of the Red Cross and its relation to the phy-
sician.
Wednesday's program included some of the
most interesting papers of the session, beginning
with the general meeting at 9 A. M., with papers
as per the official program, and followed by the
other sections in the afternoon.
The House of Delegates met promptly at nine
o'clock on Wednesday morning, when the offi-
cers were elected whose names appear upon the
officers' page of this Journal. The Section Of-
ficers and Chairmen of Committees also appear
for the fiscal year of 1920-1921.
Several amendments were presented to the
House and acted on at this session. Some of
these amendments created animated discussion,
but were finally adopted as presented or as
amended. The recommendations from the vari-
ous committees were presented, discussed and
generally adopted.
The scientific program for Wednesday was
carried out as presented in the official program.
These papers were of high character, and gen-
eral discussions followed.
The social affair Wednesday evening was a
decided success, and reflects great credit on the
Committee on Arrangements having the matter
in charge. A large number of physicians, their
wives and invited guests, were in the hall and
participated in the dancing and good cheer that
followed.
Thursday morning the various sections held
their meetings, all well attended, and this was
followed by the joint meeting with the Inter-
state Association of Anesthetists in the after-
noon, which was largely devoted to anesthesia.
This was an especially important session, at
which papers of great interest were presented
by prominent men in the profession specializing
in anesthesia.
The House of Delegates held its final meeting
in the afternoon, at which the business not al-
ready transacted was taken up and finally dis-
posed of.
What the session lacked in numbers was made
up by the enthusiasm of those present.
All present look forward with much interest
to the next session to be held in Philadelphia. A
record-breaking meeting is expected. The r^s-
tration list of the Pittsburgh meeting was an evi-
dence of the interest among the members of the
society and totaled 1,122.
The following report was received too late to ap-
pear in the report of special committees of September
issue :
Report of Henry Beates, Jr., M.D., Chairman
United States Pharmacopceial Association
Mr. President and Fellow Members:
Your committee representing the Medical Society
of the State of Pennsylvania at the 1920 session of
the United States Pharmacoporial Association held at
Washington, D. C, begs leave to report that it was
present during the meetings. The committee elected
Dr. Henry Beates chairman.
The convention enacted measures that maintained
the standard of the Pharmacopoeia, which serves as a
model for almost all the pharmacopoeias of the world.
Representation on the Revision Committee by manu-
facturing concerns of questionable reputation was
prevented and the official character of the Pharma-
copoeia maintained.
Your chairman was appointed by the convention,
chairman of the Nominating Committee_ of the
Pharmacopoeia! Convention, and it is gratifying to re-
port that Uie business was transacted with a unanimity
of purpose and spirit of good fellowship that finds the
pharmaceutical and medical members on the best of
terms and eager to achieve the ends in view with
celerity and thoroughness.
Respectfully submitted,
Adolph Koenig,
Wm. DuFFiELD Robinson,
Henry Beates, Jr., Chairman.
Following is an extract from Editorial Notes and
Comment, American Druggist, July, 1920:
Of the recently selected committee of fifty for the
revision of the U. S. Pharmacopoeia analysis shows it
to include seventeen physicians and thirty-three phar-
macists. Most of the physicians are in active practice
of their profession, while of the pharmacists but
three, if we are correct, operate drug stores, the other
thirty being teachers, research chemists or in related
lines. The committee appears to be very well bal-
anced, indeed, not from the standpoint of geographi-
cal distribution, but because of the attainments and ex-
perience of its members, who are eminently fitted for
the task they are called upon to discharge.
DIAGNOSIS.
Do not "jump"; a "shot" at a diagnosis is most
often fatal to the marksman.
Never be ashamed to confess, "I don't know"; but
be ashamed to have to confess, "I have not examined."
Be thorough. Remember no fact about the patient
is without possible importance. Collect all your data
before making any diagnosis.
Of two probable diagnoses, ceteris paribus, choose
the commoner. Strive to be exact A diagnosis must
sometimes be only a balance of probabilities; but do
not shirk the responsibility of making that balance.
Remember the "man who never makes mistakes never
makes anything." — Golden Rules of Medical Practice.
From the Journal of The Arkansas Medical Society,
August, 1920. . . .
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County Medical Societies
REPORTERS OF COUNTY SOCIETIES:
Adams — Henry Stewart, M.D., Gettysburg.
Allegheny — Paul Titus, M.D., Pittsburgh.
Akmstbonc — Jay B. F. Wyant, M.D., Kittanning.
Beavek— Fred B. Wilson, M.D., Beaver.
Bedford — N. A. Timmins, M.D.. Bedford.
Berks — Clara Shetter-Keiscr, M.D., Reading.
Blair — James S. Taylor, M.D., Altoona.
Bradford — C. L. Stevens, M.D.. Athens.
Bucks — Anthony F. Myers. M.D.. Blooming Glen.
Butler — L. Leo Doane, M.D., Butler.
Cambria — Frank G. Scharmann, M.D., Johnstown,
Carbon — Jacob A. Trexler, M.D., Lehighton.
Center — James L. Seibert, M.D., Bellefonte.
Chester — Henry Pleasants, Jr., M.D., West Chester.
Clarion — Sylvester J. Lackey. M.D., Clarion.
Clearfield — J. Hayes Woolridge, M.D., Clearfield.
Clinton — R. B. Watson, M.D., Lock Haven.
Columbia — Luther B. Kline. M.D., Catawissa.
Crawford — Cornelius C. LafFer. M.D.. Meadville.
Cumberland— ^Calvin R. Rickenbaugh, M.D., Carlisle.
Dauphin — Marion W. Einrich. M.D., Harrisburg.
Delaware — George B. Siekel, M.D., Chester.
El.K — Samuel G. Logan, M.D., Ridgway.
Erie— J. Burkett Howe, M.D.. Erie.
Fayette— George H. Hess. M.D.. Uniontown.
Franklin — John J. Coffman, M.D.. Scotland,
Greene — Thomas B. Hill. M.D.. Waynesburg.
Huntingdon — -John M. Beck, M.D., Alexandria.
Indiana — Alexander H. Stewart, M.D., Indiana.
Jefferson — John H. Murray, M.D., Punxsutawney.
Juniata — Isaac G. Headings. M.D., McAlisterville.
Lackawanna — Harry W. Albertson, M.D., Scranton,
Lancaster — Waller D. Blankenship, M.D., Lancaster.
Lawrence — William A. Womcr, M.D., New Castle.
Lebanon — Samuel P. Heilman. M.D., Lebanon.
Lehigh — Martin S. Kleckner, M.D., Allentown.
Luzerne — Peter P. Mayock, M.D., WilkesBarre.
Lycoming — Wesley F. Kunkle, M.D., Williamsport.
McKean — James Johnston, M.D.. Bradford.
Mercer — M. Edith MacBride, M.D., Sharon.
Mifflin — Frederick A. Rupp, M.D., Lewistown.
Monroe — Charles S. Logan, M.D., Stroudsburg.
Montgomery — Benjamin F. Hublcy. M. D., Norristown.
Montour — Cameron Shultz, M.D., Danville.
Northampton — W. Gilbert Tillman, M.D., Easton.
Northumberland — Charles H. Swcnk, M.D., Sunbury.
Perry — Maurice I. Stein, M.D., New Bloomfield.
Philadelphia — Samuel McClary, 3d, M.D., Philadelphia.
Potter — Robert B. Knight, M.D., Coudersport.
Schuylkill — George O. O. Santee, M.D.. Cressona.
Snyder— Percy E. Whiffcn, M.D., McClure.
Somerset — H. Clay McKinley, M.D., Meycrsdale.
Sullivan— Carl M. Bradford, M.D.. Forksville.
Susquehanna — H. D. Washburn, M.D., Susquehanna.
Tioga— Lloyd G. Cole, M.D., Blossburg.
Union — William E. Metzgar, M.D., Allenwood, R. D. 2.
Venango — John F. Davis, M.D., Oil City.
Warren— M. V. Ball, M.D., Warren.
Washington — Homer P. Prowitt, M.D.. Washington.
Wayne — Sarah Allen Bang, M.D.. South Canaan.
Westmoreland — Wilder J. Walker, M.D., Greensburg.
Wyoming — Herbert L. McKown, M.D., Tunkhannock,
York— Nathan C. Wallace, M.D., Dover.
OCTOBER, 1920
COUNTY SOCIETY REPORTS
BERKS— AUGUST AND SEPTEMBER
At the August meeting of the Berks County Society
Dr. C. J. Dietrich, of Reading, read an interesting ac-
count of a case of Cardiospasm, outlining the symp-
toms and treatment from the first visit, until a cure
was effected. We quote extracts from Dr. Dietrich's
paper: "The first symptom Mrs. H. noticed was diffi-
culty in swallowing. This gradually became worse
until she found herself unable to swallow. Follow-
ing this regurgitation appeared, sometimes being the
contents of the oesophagus and at other times includ-
ing stomach contents. At times she had been unable
to get anything into the stomach for a period of two
days, her weight decreasing about fifty pounds? * * *
Patient was placed on 1/250 Hyoscin Hydrobromide
and 1/200 Atrophin Sulphate, to be taken one hour
before meals, * * * Diagnosis was Cardiospasm with
dilation and gastrostenosis. Patient was referred to
Dr, Chevalier Jackson for treatment and examination.
Dr. Jackson's findings were oesophageal walls coated
with thick, pasty material, furred in appearance, with
no actual ulceration visible, but with tighter spasmodic
closure at the hiatus. Dr. Jackson's treatment con-
sisted in daily lavage for a period of three weeks.
He then dilated thtf stricture daily for a week follow-
ing. * * * I saw patient about a month later, and
while she still is compelled to eat slowly, she now eats
anything without difficulty, is gaining in weight and
feeling fine."
Dr. G. I. Winston, of Reading, read an instructive
paper on the Vegetative Nerve System, in which he
classified the nerve system into
I. Cerebro-spinal, composed of brain, spinal cord,
spinal and cranial nerves. This is the system over
which we have control, and the nerves terminate in
straited muscle fibres or skeletal muscles.
II. The Sympathetic, or Vegetative nerve system,
over which we have no control, composed of a num-
ber of ganglia situated on either side of the spinal
column, head, face, thorax, abdomen and pelvis. All
these ganglia are connected with an elaborate system
of intercomravmicating nerves, many of which are con-
nected with the cerebro-spinal system. Many of these
ganglia supply innervation to the blood vessels, heart,
glands and viscera, causing them to increase in force,
to contract, relax, etc.
VAGATONIA
By this term we mean a neurosis in which there is
hypertonicity of the vagus nerve and evidence of in-
creased innervations of the organs controlled by it
Gastro intestinal symptoms are most common and
consist of hypertonia in the musculature of stomach
and intestines, causing spastic constipation, tender pal-
pable colon, a tightly contracted external sphincter,
abdominal pain and tenderness, which may be mis-
taken for colicystitis, appendicitis, or gastric lesions.
Pylorospasm, bronchial asthma, bradycardia are more
of the symptoms. Symptoms the opposite of these
may be due to a disturbance of the sympathetic sys-
tem, or sympatheticotonia.
At the September meeting Dr. Grim read an excel-
lent paper on the clinical diagnosis of syphilis, while
Dr. F. J. Gable discussed the treatment of syphilis.
Dr. Gable stated that "during our military service we
found twenty-eight per cent, of the American Army
in one of the stages of syphilis. Nearly the same per
cent, was found in the Canadian and British Armies.
In the Canadian Army, after thorough treatment, they
could answer for only seven per cent, of absolute
cures, while the American Army found fifty per cent.
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THE PENNSYLVANIA MEDICAL JOURNAL
October, 1920
could be cured." Dr. Grim urged the necessity for
prompt diagnosis and treatment, stating that, if taken
early enough, the disease could be entirely cured. Dis-
cussion was opened by Dr. Wm. Bertolet on cardio-
renal syphilis, followed by Dr. J. Stockier on syphilis
of the nose and throat, and Dr. Wm. Leiser, 3rd, on
syphilis of the eye.
C1.ARA Shetter Keiser, Reporter.
B UCKS— SEPTEMB ER
Physicians of lower Bucks County were guests at
the home of Dr. William C. LeCompte. Officers were
chosen as follows: President, Dr. Frank Lehman;
secretary, Dr. Howard Pursell; treasurer. Dr. James
Collins.
CENTRAL PENNSYLVANIA— SEPTEMBER
The Central Pennsylvania Medical Association held
its annual meeting at Tyrone, on Wednesday, Septem-
ber 8th, in the Y. M. C. A. building. This associa-
tion was unique in its inception and this uniqueness is
continued in the fact that there are no officers, no
dues — ^nothing but this annual get-together meeting of
all the members of the following County Societies:
Blair, Bedford, Clinton, Clearfield, Cambria, Hunting-
don, MifHin, and Centre. Ninety-two members an-
swered to roll call, and the speakers of the day re-
ceived a most cordial welcome from a very deceptive
audience. Dr. W. F. Donaldson, of Pittsburgh, Secre-
tary of the State Society, was introduced, and pre-
sented a most timely paper on "Our Duty to the Pub-
lic Health." Dr. Donaldson very clearly brought home
to us our failings in this line of medical work. He an-
swered in part the reasons for the upstart of the many
and various cults; he showed the medical and surgi-
cal industrial possibilities, also those of prenatal care;
he emphasized the possibilities and means of help that
medical men, individually and collectively, could ren-
der to the public. Even though free discussion was
not aroused during the meeting, the reporter has
heard many of his colleagues conversing on just the
topics Dr. Donaldson brought to his hearers.
Dr. E. W. Meredith of Pittsburgh, presented a
beautiful paper on "Some Surgical Conditions of the
Abdomen." Time alone limited the discussion of his
thoroughly enjoyed presentation, and many interesting
phases of surgery and post-operative care were
brought out of the woods and talked over. The field
of gall-bladder surgery seemed to evoke the frankest
discussion. The question of the Fowler position in
peritonitis, was another subject which was most
heartily reviewed. The making of surgical patients
comfortable, and the care prior to operation and post-
operatively was the mainspring of the majority of the
discussions.
After the scientific programme was completed, the
members adjourned to the banquet hall and did jus-
tice to a masterpiece menu delivered by the Civic Club
of Tyrone, to the strains of one of the cleverest jazz
orchestras in the state. The members can scarcely
wait for 1921 to come, so we can get together again.
James S. Taylor, Reporter for Blair Co.
Following a short business meeting, Dr. Edward
Kerr gave- a clinic of cases in the Chester County
Hospital, after first giving a general outline of the
system adopted by his staff in the handling o£ patients
sent by other physicians. Free cases are referred to
any one of the three surgeons. Dr. Kerr, Dr. Wood-
ward or Dr. Davis, with the plan of having the assist-
ant surgeons operating on alternate days. Pay cases
may be referred also to any one oi the three physi-
cians on duty.
The first case shown was one of multiple tumors of
the face and body in a colored child. The tumors re-
sembled gummata but as the Wasserman tests have
been negative, and the child has shown no improve-
ment on mixed treatment the diagnosis of syphilis did
not seem justified. Suggestions as to treatment were
asked from members of the Society. Dr. Kerr then
showed a series of interesting cases, reports and speci-
mens of acute abdominal condition, including intus-
susception of ileum into ileum in a child ; a case of
acute intestinal obstruction from tlie incarceration of
eight inches of ileum in the abdominal wall; a con-
valescent patient who had been operated upon for an
acute ileus from strangulation of the bowel with in-
testinal adhesions. A resection of three feet of the
bowel had been done successfully.
An unusual specimen of double pus tubes removed
was shown.
A case of extra-uterine pregnancy with a hemo-
globin of 20 per cent, operated on by Dr. Woodward
was also reported.
Dr. Kerr then gave a talk on the operative treat-
ment of prostatic-hypertrophy with demonstration of
an original method of keeping the bladder dry during
the interval between the operations of cystotomy and
the removal of the prostate.
Another case presentation was that of femoral
hernia of the bladder in a man. The patient had en-
tirely recovered and was about to leave the hospital.
Dr. U. G. Gilford gave a medical clinic on cases ia
the hospital with particular reference to cardiac and
renal disease. He called attention to the fact that the
Phenol-sulpho-nephthalein test for kidney function de-
pended as much upon the condition of the circulation
as upon the renal efficiency. Under normal conditions
65 per cent, of the phthalein should be eliminated
within two hours. This assumes that th« heart and
the kidneys are both normal.
Dr. Gifford then discussed kidney disease, showing
the difference in clinical symptomatology between true
nephritis, "nephrosis," or kidney irritation, and hyper-
tension kidney, illustrating many points by cases or
case reports. One of the cases of hypertension
showed a systolic blood pressure of 320 mm. on ad-
mission to the hospital. This case was particularly in-
teresting in view of the fact that the blood urea was
only 40 mg. per 100 cc. Another very instructive case
was that of a young man who had been under obser-
vation in the hospital for several months suffering
from all of the symptoms of true renal disease, but
who had practically entirely recovered following ton-
sillotomy.
CHESTER— AUGUST
The regular monthly meeting of the Chester County
Medical Society was held at the Chester County Hos-
pital, Tuesday, August 17th, with President W. Wel-
lington Woodward in the chair.
CHESTER— SEPTEM B ER
^he regular monthly meeting of the Chester County
Medical Society was held at the Chester County Hos-
pital on Tuesday, September 21, 1920, with President
W. Wellington Woodward in the chair.
Dr. Thomas G. Aiken, of Berwyn, addressed the So-
ciety on the subject of Bronchial Asthma, giving a
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COUNTY MEDICAL SOCIETIES
35
resume of the etiology, pathology, symptomatology,
and treatment of this condition.
Dr. Aiken stated that in all probability bronchial
asthma is invariably due to an anaphylactic reaction
to some protein, whether in the form of bacterial
product, ingested food, or the pollen of plants coming
in contact with the mucous membranes of the nose and
throat. The determination of an individual's sensitive-
ness to certain proteins is often a difficult matter to de-
termine, and necessitates a complete history and gen-
eral study of the case. The testing of the patient for
anaphylactic skin reactions has done much to simplify
the diagnosis of difficult cases. The examination of
the urine in all cases of asthma is of great importance
in order to determine the function efficiency of the
kidneys, and also to determine the extent of the
toxaemia which is always present in these cases.
Dr. Aiken is of the opinion that most of the so-
called colds at certain seasons of the year, particu-
larly the fall and spring, are in reality forms of hay
fever or asthma, and are mild anaphylactic reactions
of the patient to certain proteins of plants. He said
that in many instances wheat produced a marked re-
action in susceptible individuals^ and the abstinence
from wheat foods in any form prevented the recur-
rence of the attacks.
In discussing the treatment of the acute attacks of
bronchial asthma Dr. Aiken called attention to the
value of prophylactic doses of the extract from the
plant or .food to which the patient was susceptible.
These prophylactic measures should be begun, if pos-
sible, several weeks prior to the probable onset of the
attack. Atropine, or atropine and morphine hypo-
dermically are of great value in the acute stages. The
thorough examination of the patient for evidence of
focal infection is of course imperative.
Dr. Aiken's paper was discussed by Drs. Sharpless,
Margolies, Patrick, Davis, Klevan and Pleasants. Dr.
Sharpless cited an interesting instance of a patient
who reacted to so many of the Allergen tests that the
series showed as one large wheal. He advised, there-
fore, that in making the skin tests sufficient ^pace be
allowed between the scarifications.
Dr. Davis gave his experiences with a new proprie-
tary remedy which is evidently intended for use in
such cases of asthma as are known to have no idio-
sjTicrasy towards the iodides as it is used intraven-
ously. The cases cited were very interesting, and cer-
tainly suggest the possibilities of success along these
lines.
Several of the members present gave their experi-
ences with the hypodermatic use of Adrenalin Chlo-
ridel-1000 solution in the treatment of the acute cases.
There seems to be no strong contra-indication to the
use of this drug in doses of from five to fifteen
minims. In some instances a marked fall of blood
pressure followed the injection. This seems to be
contrary to the teachings of physiologists in regard to
the vasoconstrictor action of Adrenalin, but is easily
explained by the fact that in some cases the high
blood pressure is due to the tremendous strain of the
patient to get his breath, and the relief of this strain
is immediately followed by a drop in pressure.
Henry Pleasants, Jr.
CHESTER-MONTGOMERY— AUGUST
The following is clipped from the Bucks County
Medical Monthly. The editor regrets that he did not
receive a full report of this interesting meeting, and
hopes that he will not be so neglected in the future.
The report of the address g^ven at the recent Valley
Forge meeting of the Chester-Montgomery County
Societies, is so well stated that we abstract it from the
Chester County Society Reporter.
Commander W. S. Bainbridge, U. S. N., gave an in-
spiring talk on lessons of the Great War. Dr. Bain-
bridge, who is now Professor of Surgery at Columbia
University, captivated his hearers by his keen humor
and observations. His work in Germany, France and
Austria prior to the entrance of the United States
into the war had given him a wonderful insight into
actual conditions at that time and enabled him to give
a clear outline of the progress that had been made in
medicine and surgery during the past four or five
years. He cited thirty-one lessons which had been
taught during the war, including the Carrell-Dakin
treatment of wounds; the general use of antitetanic
serum; the excision of the path of a missile through
the flesh; the removal of periosteum above the sawn
bone in amputations; the "ether-coctail" oral anes-
thesia; the excision of scar tissue in all cases of
osteomyelitis; the early operative treatment of pene-
trating wounds of the abdomen; the early diagnosis
and treatment of gas-gangrene and a host of other
equally important lessons.
In conclusion he gave a dramatic account of an
interview he had with a general of the German Gen-
eral Office relative to the ultimate outcome of the war.
This interview had taken place at a time when the
fortunes of the war seemed to be all in favor of Ger-
many. The question was asked of the German officer
what would happen in the event of the tide of fortune
turning, and the defeat of Germany imminent. The
reply was that before German soil was scarred, there
would be an armistice; that after the armistice the
enemies of Germany would be thrown into a state of
social and industrial unrest that had never before been
known; that differences would spring up between the
enemies of Germany which would dissolve their allied
power; and that finally, at the psychological moment
the apparently disrupted Germany would suddenly
crystallize into the strongest world power that had
ever been known which would crush all her enemies
completely. Dr. Bainbridge concluded by drawing the
attention of the members to the fulfillment of many
of these prophecies and the great danger to the world
of the ultimate fulfillment of the last, unless there was
an exhibition of unselfish, whole-hearted patriotism
on the part of every man, woman and child in the
country. Dr. Henry Peasants, Jr., Reporter.
FOURTH CENSORIAL DISTRICT— AUGUST
On August 19, 1920, the Fourth Censorial District of
Pennsylvania State Medical Society held its annual
meeting at Mt. Gretna, Pa. The meeting was well at-
tended, there were good speeches, and to cap the cli-
max those present enjoyed a splendid feast. On this
occasion the Poet Laureate of the Susquehanna, Dr.
Hugh Hamilton, gave us a treat in the form of his
newest poem.
ON THE HILLS OF CONEWAGO*
By Hugh Hamilton, M.D.
Harrisburg, Pa.
GEOLOGICAL
Just where we're sitting this day.
The warm, tropic Gulf Stream did flow;
Dropt huge boulders, 'long its way.
On the Hills of Conewago!*
•Pronounced "Con^e-wah-go."
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THE PENNSYLVANIA MEDICAL JOURNAL October, 1920
With Cedar seeds, and "Gneissic" rock.
From "Ice Bergs," that on it did go ;
'Till "New Red" silt them did block.
On the Hills of Conewago !
TOPOGRAPHICAI,
Now, adds beauty to the view,
Charming seen from the window;
O'er things so old, yet so new,
On the Hills of Conewago I
LEGENDARY
From these high hills, in deep dells.
Shrill wild Indian yells, did echo!
Listen? If they the Story tell?
Of a Tribe: "Conewago!"
SOCIAL
Use stolen hours of brief leisure,
To grasp rich moments as they go ;
Hoard, Friendship's golden treasure!
On the Hills of Conewago !
Let THAT, then be the greeting.
Never to be forgotten though;
Of the Fourth Censor'l Meeting,
On the Hills of Conewago !
FRANKLIN— AUGUST AND SEPTEMBER
The meeting in August at Mont Alto Sanatorium
was a real treat to those who were in attendance. The
evening was rather inclement but the afternoon ses-
sion in the "White Pine Grove," with the papers of
Drs. Sowell, Everhart ahd Lee were well worth the
effort to be present from the farthest point. The sup-
per was quite interesting and appetizing.
The demonstration of the treatment of bums by the
aid of moving pictures is a great advantage. The
method of dressing and removing these, together with
the appearance of the results, is quite remarkable.
The meeting at Blue Ridge Summit, at the summer
home of Dr. and Mrs. A. Barr Snively, was a "red
letter day" in the Society's history. The day was a
perfect one in temperature and brightness. The place
of meeting, ideal. The program of addresses — Drs.
Appel, Van Sickle and Bagley — was quite interesting
and instructive. Every one of the seventy and more
in attendance enjoyed the occasion sincerely.
LUZERNE— SEPTEMBER
The first meeting of the fall term of the Luzerne
County Medical Society was held in the society build-
ing September 1, 1980, at 8 : 30 P. M.
The essayist of the evening was Dr. A. W. Grover
of Kingston, Pa., who read a paper on "Fractures of
the Skull with Special Reference to Treatment"
Lantern slide demonstrations of the roentgen-ray
findings in many of his cases were well illustrated and
explained by Dr. Ruth M. Lance, of Dorrenceton.
The essayist made a plea for early operative inter-
ference as affording the greatest hope for the patient.
The greatest dangers are not hemorrhage and shock
but increased intracranial pressure and infection.
Pressure from concealed hemorrhage is the most fre-
quent cause of death. In fifty-five cases observed by
the essayist at the Nesbitt West Side Hospital the
mortality with operation was 25%, and without opera-
tion was 64%. Complete case histories and records of
five most interesting cases were read.
In summarizing he said fractures of the skull are
always serious. There is never any fracture so mild
that we can relax diligence and none so severe as to
be absolutely hopeless. The greatest danger is in-
creased intracranial pressure and early operation af-
fords the best prognosis.
The piiper was discussed by Drs. Prevost, Fisher,
Rumbaugh and Dinkelspiel.
At the second meeting in September, Wednesday,
the 15th, a venereal disease symposium was given by
the members of the Dispensary No. 1 Pennsylvania
State Department of Health.
Dr. C. H. Miner, of Wilkcs-Barre, State Medical
Director for Luzerne 'County, outlined the state and
national program for the prevention and spread of
venereal diseases. He especially emphasized the fact
that it was not the policy of the State to treat all
patients suffering from venereal disease but rather to
see that they are treated.
In pursuing this policy venereal disease clinics are
being established in every hospital in Luzerne County
for the treatment of cases who can afford to pay
something for their treatment but who are unable to
pay a physician's fee. Patients who can pay a fee
are referred to them and none but the absolute charity
cases will be treated at the state dispensary. The
physicians were especially urged to report their de-
linquents to the state clinic in order that all. patients
may be properly cared for and treated until cured.
Dr. Walter L. Lynn read a history of the work ac-
complished by G. U. Clinic No. 1 since it was estab-
lished in August, 1918. The educational, legislative
and medical accomplishments that were cited by the
essayist made it most apparent to every one that a
V. D. clinic is a vital necessity for our community.
A symposium on syphilis terminated the program.
Dr. Cyrus Jacobsky discussed etiology and symp-
tomatology. Dr. E. W. Bixby, pathology, and Dr.
Peter P. Mayock, prognosis and treatment. "The papers
were discussed by Drs. Schappert, Mengel and W. J.
Davis, and the discussion closed by Drs. Miner and
Mayock. Peter P. Mayock, Reporter.
LYCOMING— AUGUST
The annual outing of the Society was held at Elk
Lake, Sullivan Co., Friday, August 13th, and was a
grand success, a large proportion of the members be-
ing in attendance and enjoying to the fullest extent the
beautiful scenery, as well as the delightful hospitality
of Dr. Chaapel and his wife. The dinner served was
elaborate and the members who were fortunate
enough to be present voted it one of the finest they
ever had the privilege of enjoying.
NORTHAMPTON— SEPTEMBER
The Medical Society of Northampton County held
its first meeting since the summer vacation on Sep-
tember 17th at Seip's Cafe in Easton.
Committees were appointed to draw up resolutions
on the deaths of Drs. S. D. Shimer, of Easton, and
Thos. Cope, of Nazareth.
Dr. George Wilson, Instructor in the Department
of Neurology of the University of Pennsylvania, read
a paper on "Diagnosis of Some of the More Common
Diseases of the Nervous System," which brought
forth a spirited discussion.
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October, 1920
COUNTY MEDICAL SOCIETIES
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The next meeting of the society will be held on the
89th of OctoBfer in conjunction with the Lehigh County
Society at the Rittersville State Hospital.
Following the meeting dinner was served in the
dining hall. W. Gilbert Tiuman, Reporter.
NORTH PENN CLINICAL SOCIETY-
AUGUST
The North Penn Clinical Society has been rejuven-
ated, a revived spirit instilled' and a determined incli-
nation to attain a useful old age, has imbued the or-
ganization with a renewed lease of usefulness. Lay-
ing work aside for part of the day, the members re-
cently decided to have an outing to which the wives
were to be invited and their entertainment be made a
feature of the day.
The committee oppointed at the last meeting, Drs.
Huff and Paulus, had done their part well, and thus
on the 29th of Jime, the doctors with their good wives
at their side, smote dull care a hard whack and headed
their cars for Point Pleasant, where Host Thompson
received his guests gracefully and the occasion for a
lot of good things for the Mrives was on. Oh, the
waffles the chef sent in — waffles "food fit for ye epi-
curean gods," made to perfection — and two helpings
at that ! O, boy, it was good to be there !
Dr. Rahn was the only brave member of the party
who donned a bathing suit and took to the water, as
in a manner bom. But for him to get back to the
hotel was another story— with the extra "padding"
soaked off, the sharp crushed stones played havoc
with his feet Poor Rahn I But, as Dr. Weierback
commented, "What else could be expected as a result
of an "annual job" I
While it was a hot day, the women were all con-
tentment and smiles; their beaming countenances
emanated the rays of happiness that were shining
through. There were old and young present; the
bunch mixed elegantly. Even flat tires failed to
dampen the sociability of the occasion; "gas" was
plentiful and cheap. The afternoon passed rapidly ; it
was a day "off" and that meant a whole lot to the
ever kindly, humane bunch of doctors and their wives
that left the Point at five, tired but happy.— Ahthonv
F. Myers, in the Bucks County Medical Monthly.
NORTHWESTERN PENNSYLVANIA— SEP-
TEMBER
At the instance of the Erie County Medical Society,
and especially the Corry members, a meeting of four
cotmty organizations, namely, Erie, Warren, Venango,
and Crawford, was held September 16th, at Corry,
and was addressed by Dr. Crile of Cleveland. About
a hundred and twenty-five physicians were present.
Dr. Crile took as his subject some phases of ab-
dominal surgery. As the result of an examination of
the records of 14,000 abdominal operations, he' felt
free to say that a woman who had borne children and
who was probably suffering nerve exhaustion and
complained of pain, might be considered a neuras-
thenic, but was not a fit subject for an exploratory
operation; neither should an operation be performed
for adhesions when there were no other lesions diag-
nosible. He stated that floating organs and displace-
ments of organs, unless causing considerable pain, sel-
dom were benefited by surgical intervention. Lane's
colectomy for intestinal stasis was an operation that
he considered unjustifiable. Ulcer of the stomach
should be given the benefit of medical treatment first.
then possibly surgical help, followed up by prolonged
medical care. Gall bladders, unless markedly diseased,
should be drained rather than excised. Dr. Crile
stated that, positive as he was about surgical inter-
vention in some things, he was equally positive as to
the result of his experience in refraining from some
operations in the group of cases enumerated.
As a technical point he brought out that persons
with diseased or disturbed ftmction of the liver
should be carefully handled during a surgical opera-
tion. The anesthesia must be short, analgesia rather
than anesthesia being used wherever possible, artificial
heat being supplied during and after the operation,
and plenty of water given by mouth, rectum and skin,
before and after. The liver is intimately associated
with the brain cells ; anything that lowers heat or af-
fects the liver cells will act on the brain cells, caus-
ing stupor and death. Patients often, after operations
about the liver, or who have liver disease and are
operated on, fail to recover, even when the tempera-
ture chart for the few days, seems to indicate a fa-
vorable termination. By using the precautions de-
scribed, much better results have been obtained with
such patients.
The talk was a most helpful one. If it could be
brought home more forcibly, especially to the young
surgeon, it would undoubtedly greatly diminish the
amoimt of unnecessary mutilation of women, which
started far back in the '80's, when ovariotomy was the
fashion, and which continues to the present day in the
excising of gall bladders, appendices, tonsils, etc., for
the relief of a group of symptoms that are probably
of the mind rather than of any one organ.
After the meeting a buffet Itmcheon was tendered
the visiting physicians. Warren County was repre-
sented by nearly half of its members — twenty-five
in all.
SOMERSET— SEPTEMBER
The Somerset County Medical Society met in Sep-
tember session at Somerset on the 21st inst. with the
best attendance in quite a while — just one-third of the
membership being present. This in itself was inspir-
ing after the miserable failure in attendance at the
"outing" meeting at Markelton in July.
Some members met at this meeting who had not met
before^ some were present who had not been to a
meeting since they began to get gray, and this was
gratifying. This was a good time to tell the mem-
bers that they would miss a good thing if they did not
attend the State Society meeting at Pittsburgh, Octo-
ber 4-7, as the Secretary had also stated in The Call.
The paper by Dr. C. W. Frantz was well worth the
while to attend, his subject being The Significance of
Hypogastric Pain. Dr. C. F. Speicher's talk on The
Tonsil as a Source of Infection was very good. Both
subjects were well discussed and we are sure that no
one present is sorry for the time spent at that meeting.
Dr. Lloyd Albert Heikes, of Boswell, was mustered
in as a new member and several blank applications
were requested so that we are anticipating more acces-
sions soon. H. C. McKiNLEY, Reporter.
SUSQUEHANNA— SEPTEMBER
The meeting of the Susquehaima County Medical
Society, which was held at Hallstead, was well at-
tended. The meeting was called to order by the presi-
dent and the main topic for discussion was Compul-
sory Health Insurance. A most excellent paper was
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THE PENNSYLVANIA MEDICAL JOURNAL
October, 1920
presented by Dr. E. R. Gardner of Montrose, which
gave some of the pros and cons for health insurance.
After this was heard the meeting was opened to gen-
eral discussion. It was voted to have reprints made
of this paper and to have it published in a number of
the local papers throughout the county. The society
voted unanimously to oppose the health insurance bill,
believing it will ultimately prove detrimental to coun-
try, patient, and physician.
The remainder of the time was taken up by reports
of unusual cases. - The more important being a case of
supernumerary ovary in a woman of 30 years of age;
adenoma of testicle, which had undergone marked de-
generation, in a child of 18 months, and a case of
metritis in a girl of 17 years of age, which had ail the
appearances of a gravid uterus of five months, com-
plicating an appendectomy for acute appendicitis, the
uterus gradually returning to its normal size after the
removal of the appendix.
H. D. Washburn, M.D., Reporter.
WASHINGTON— SEPTEMBER
The September meeting of the Washington County
Medical Society which took the place of the annual
outing was held upon the spacious grounds of the
Pennsylvania Training School, Morganza, Pa., Tues-
day, September 14, 1920.
The members and their guests, who included the
families of the members, nurses, the County Commis-
sioners and candidates for State Assembly, partook of
a bounteous luncheon which was generously supple-
mented by sweet milk, buttermilk, ice cream and coffee
through the kindness of Superintendent W. F. Penn.
The music furnished by the Training School Band
was of a high order of excellence and was greatly ap-
preciated.
Following a brief business meeting the scientific
program was replaced by the dedication and unveil-
ing of the Physicians' Memorial Tablet. This beau-
tiful piece of bronze surmounted by a spread eagle
and containing the names of all the physicians in the
county who served in any capacity during the World
War, is the gift of the County Society to the com-
munity and will be given a place of honor in the
rotunda of the courthouse.
The following program was carried out:
Report of Bronze Tablet Committee — Dr. J. B. Mc-
Murray, Washington.
Address by Congressman Henry W. Temple and un-
veiling of tablet.
Receiving the Tablet— Chaplain H. A. Riddle, West
Alexander.
Recitation — "In Flanders' Field" — Miss Marguerite
O'Brien, Wheeling, W. Va.
Toasts :
Our Nurses — Dr. E. M. Hazlett, Washington.
Our County Society— Dr. C. T. Dodd, Washington.
The Medical Society of the State of Pennsylvania —
Dr. Walter F. Donaldson, Pittsburgh.
Our Army — Dr. A. E. Thompson, Washington.
Our Flag — Dr. J. N. Sprowls, Claysville.
The Pennsylvania Training School — Superintendent
W. F. Penn.
The speakers were all well chosen and their efforts
elicited well merited applause. This meeting certainly
marks an epoch in the life of our society and one to
which we can refer with pride.
H. P. Prowitt, Reporter.
YORK— JULY
VERBUM SAPIENTI SUFFICIAT
At a regular meeting of the York Cotmty Medical
Society held on Thursday, July 1, 1980, the Committee
on Public Policy and Legislation was instructed by a
unanimous vote to interview each candidate for the 1^-
islature from York County and to receive in writing
his attitude towards the subject of Compulsory Health
Insurance. The committee got in touch with every
candidate, and held personal conferences with all ex-
cept one. The meetings were very cordial and the re-
sults obtained were highly satisfactory to the com-
mittee. The candidates and the committee exchanged
their views, and the former were eager to receive both
the detailed information and the attitude of the medi-
cal profession concerning the subject of Compulsory
Health Insurance. The pernicious effect such legisla-
tion would have upon both the medical profession and
the communities in which it might become effective
was carefully explained to them. The committee has
absolute assurance that the following candidates, if
elected, will oppose any and all forms of Compulsory
Health Insurance, viz: Walter R. Stout (1st District),
John May (2d District), Thomas E. Brooks (3d Dis-
trict), J. M. Flinchbaugh (3d District), John R. Bit-
tinger (4th District), and B. L. Breneman (4th Dis-
trict). C. E. Cook (2d District) has not yet been
heard from by the committee at this writing and Rob-
ert S. Spangler (1st District), while not pledging him-
self to oppose Compulsory Health Insurance, prom-
ised to be "fair" to the medical profession.
Excerpts from the "Report of the Health Insur-
ance Commission to the General Assembly of the
Commonwealth of Pennsylvania," January, 1919, state :
"Most employees are unable to save toward emer-
gencies. The result is that many of them fail to re-
ceive medical care of any sort and that many more do
not receive care until the illness is past the stage when
it could be quickly remedied."
"Approximately a fourth of those actually disabled
by illness never receive medical care, and a larger per-
centage of those ill but trying to work are without
attention."
"Half sick men are struggling to keep at work be-
cause they cannot afford to be ill."
The committee believes there never was a time
when wage earners made as much money, lived as
comfortably, dressed as well, enjoyed as many lux-
uries, and were as able to pay for medical services as
in the present day. The committee believes there
never was a time when the wage earners received as
skillful and efficient medical care in private practice,
in hospital, and in dispensary as at the present time.
The committee believes that if any wage earners or
poor patients do not receive proper and efficient medi-
cal care in case of illness it is due to their own delib-
erate neglect.
The committee begs to report that 100% of the re-
plies to a questionnaire sent to every member of this
society in York County are to the effect that the state-
ment in the report of the Health Insurance Commis-
sion that "approximately a fourth of those actually
disabled by illness never receive medical care, etc,
etc.," is at variance with fact. The committee feels
that the whole report of the Health Insurance Com-
mission lacks evidence of specific personal investiga-
tion and deals too much in generalizations and specu-
lations for unchallenged acceptance, and would advise
all members of the medical profession to make a care-
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October, 1920
STATE NEWS ITEMS
39
ivl study of this report of the Health Insurance Com-
mission.
On page 244 of the report of the Health Insurance
Commission we learn that "various plans for State
Insurance have been proposed in this country, differing
somewhat in the manner and type of benefits provided.
The most comprehensive proposals aim to insure all
employed persons against sickness and accident not
covered by Workmen's Compensation Acts, including
the necessary supplies and hospital treatment, extend-
ing this care to the worker's dependents. It is pro-
posed to conduct the system under state supervision
and to support it by contributions from the employees,
employers and the community (including doctors, of
course,) in various proportions."
On page 239, of the same report, we read that "the
British Medical Association made an investigation of
the situation. Their report showed that the usual
method of payment was by capitation, resulting often
in inadequate payment for excessive work and poor
medical return to the patient. The average fee ob-
tained per visit was about 21 cents."
As stated in the July, 1980, issue of the Illinois
Medical Journal, page 36, the "unanimous condemna-
tion of Health Insurance by the American Medical
Association at New Orleans does not indicate that the
subject is worthy of no further attention. We showed
in our. last issue that substitutes even worse than the
original scheme are being extensively propagandized at
the present time. In New York State several bills
equally visionary, and some more vicious have already
been put forward; it behooves the profession to be
alert to dangerous legislation."
The committee urges every physician to "be alert"
at all times and to study this most vital subject as
. carefully as possible. The report of the Health In-
surance Commission of Pennsylvania, January, 1919,
can be obtained gratis from J. L. L. Kuhn (Printer to
the Commonwealth), Harrisburg, Penna.
Dr. G. E. HoLZAPPtE, Chairman;
Dr. Julius H. C>)mrob,
Dr. H. M. AixEman,
Committee on Public Policy and Legislation.
STATE NEWS ITEMS
The Editor is in receipt of a letter from Dr. W. E.
Egbert, Secretary of the Delaware County Society,
from which the following is extracted :
"Jar up the reporters. Get them on the job. They
should tend to this news item stuff, and get more
newsy reading in the Pennsylvania Journal each
month. We just had a star number to-night by Dr. G.
Victor Janvier, entitled 'Browsing in the Obstetrical
and Gynecological Meadows of New York City.' This
talk would be highly interesting to every medical man
in Pennsylvania, and should have been taken verbatim
by some good stenographer. Get after these reporters,
therefore, and ss>ve an already over-worked secretary
some little worry. Thanks ! Time, 12 : 30 A. M."
To all of which the Editor says a fervent Amen!
DEATHS
Dr. Benjamin F. BaER, of Philadelphia, died Sep-
tember 11, 1920.
The Father of Dr. Charles P. Large, Meyersdale,
passed away on Friday morninjr, September 10th. His
body was taken to Philadelphia for interment. Dr.
Large has the sympathy of all in Ws bereavement.
Mrs. Alice Laughlin Gilliford, aged 65, widow of
Dr. R. H. Gilliford and a well-known resident of Pitts-
burgh, died at the home of her sister, Mrs, James
West, Long Beach, Cal. The body will be brought East
for burial in Pittsburgh. Mrs. Gilliford was born in
East Liverpool, Ohio, and had lived at 1220 Fayette
Street, Northside, for years. She was widely known in
club circles.
DRr George A. Parker, Sr., died at his home in
Southampton, on Saturday morning, July 24, 1920, fol-
lowing an illness of six months. He was in active
practice until six months ago.
Dr. Parker was bom November 2, 1853, at Trenton,
N. J., and graduated in fhe Medical Department of the
University of Pennsylvania, in 1875. Soon after grad-
uation, he located at Southampton. He was a mem-
ber of both the County and State Medical Societies.
Dr. John Irving Van Wert died in New York City
on July 25, 1920. Dr. Van Wert was the son of Wil-
liam A. and Sarah Clarke Van Wert, born at White
Lake, N. Y., on July 5, 1865. He was educated at the
University of Michigan and the Bellevue Medical Col-
lege. He spent several years in further study at the
Polyclinic hospitals in New York and Philadelphia.
He then came to Pennsylvania and located in Patton,
where he practiced his profession until failing health
compelled him to abandon his work.
Dr. Van Wert was vice-president of the Grange Na-
tional Bank of Patton, a member of the Medical So-
ciety of the State of Pennsylvania, and the American
Medical Association, the Masons, the Knights of
Pythias, and the Odd Fellows.
Dr. Reuben H. Andrews, for more than thirty
years owner and editor of the Medical Summary, died
on Friday night at his home, 2321 Park Avenue, Phila-
delphia, after a long illness. He was 70 years old.
Dr. Andrews was born at Hilltown, Pa., on Janu-
ary 20, 1850. He taught school at Upper Sellersyille,
Pa., to earn enough to study medicine at the Univer-
sity of Pennsylvania, from which he was graduated in
1874. He began to practice medicine at Kulpsville,
Montgomery (bounty.
In 1876 he moved to Lansdale, Pa., and in 1881 he
became proprietor of the Lansdale^ Reporter, a daily
newspaper, but continued to practice medicine. He
sold the paper in 1884 and went to Philadelphia in 1885
to establish the Medical Summary.
He remained the active editor and publisher until
illness forced him to retire. In 1890 he retired from
the active practice of medicine to devote his entire
time to his medical publication.
Dr. Andrews is survived by his widow, Mrs. Mary
A. Andrews, and three daughters, Mrs. Florence New-
man, Dr. Louise Andrews Black and Mrs. Beatrice L.
Aarons. The funeral will be held from his home on
Tuesday afternoon. Interment will be at Laurel Hill
cemetery.
items
Dr. Carl J. Bailey, of Jamestown, has moved to
Sharon, Pa.
Dr. J. C. Secor of Westfield, has been appointed
local surgeon to the New York Central Railroad.
Born— to Dr. and Mrs. W. E. Egbert, Chester, Pa.,
a son, September 16, 1920.
Born to Dr. and Mrs. Alpheus McKibben, Pitts-
burgh, July 20, 1920, a daughter, Juliet Nancy.
Dr. William LeRoy Kiester has been appointed an
assistant in the State clinic at Reading.
Dr. J. Marshall Sterling, 812 S. Third St., Phila-
delphia, died at the Mt. Sinai Hospital, having been
very seriously ill since the first of the year.
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THE PENNSYLVANIA MEDICAL JOURNAL
October, 1920
Dr. H. I. Klofp, of the State Hospital at Allentown,
attended the State Convention of Therapists at Phila-
delphia and spoke on state work.
The Armstrong County Medicai Society consists
of every physician in Armstrong County and every
member has paid his dues for 1920.
Miss Ruth Phiixipy of Carlisle, entertained re-
cently in honor of Miss Margaret Brenneman, who
soon is to become the bride of Dr. W. T. Phillipy, a
popular member of the Cumberland County Society.
For Violating the Quarantine Law, Lewis Mc-
Clain of Liberty Township, Adams County, was fined
$50 and costs, August 21. The defendant took his son
to a picnic when he was just recovering from diph-
theria and a week before quarantine was lifted.
Dr. Leman D. Cruice, of Philadelphia, has been
appointed physician in charge of the infirmary, cor-
rection farm and girls' home, Warrensville, Ohio, suc-
ceeding Dr. John McCleary, resigned to study tropical
diseases in India.
Dr. and Mrs. John J. Coffman, Scotland, will en-
joy a winter spent with their son, in Reading. In Dr.
Cofftnan's absence. Dr. Samuel D. Shull, N. Main St,
Chambersburg, will have charge of the work of the
Secretary, of the Franklin County Society.
Dr. W. W. Richardson, Medical Director of the
Mercer Sanitarium, Mercer, Pa., and family have
moved to Erie, Pa., where Dr. Richardson is engaged
in practicing neurology. He will spend two days of
each week at the Mercer Sanitarium.
Dr. W. T. McMillan of Meyersdale, has disposed
of his practice and real estate to Dr. C. C. Glass, late
of Pittsburgh, who has taken possession and is now
in active practice. Dr. McMillan goes to Los Angeles,
California, for his health.-
Representatives from Nine Counties met at Al-
toona September 21st to prepare for the Christmas
seal sale under the Pennsylvania Tuberculosis So-
ciety. Dr. W. G. TurnbuU, medical director of the
Pennsylvania Tuberculosis Sanitarium, Cresson, spoke.
The Hospital Site Committee of Waynesboro has
been authorized and directed to conduct a referendum
on the question of site and to adopt such plan for
same as they shall elect. This was the action taken
at a recent public mass meeting.
M. D. Greenfield, Charleroi, who is said to^ have
been convicted of practicing drugless therapy without
a certificate, appeared before the court August 23, and
was sentenced to pay a fine of $25 and costs. It is
said that Greenfield is a graduate of a chiropractic in-
stitution. •
Through the Untiring Efforts of the Rev. Dr.
Carothers and others, a hospital has been established
in Westfield, which supplies a long-felt want in the
Cowanesque Valley. The building contains twenty
beds, and is well supplied with instruments, electric
lights, and other equipment that goes to make up a
modem institution.
Mayor William T. Ramsey returned to Chester,
September 1st, after a two months' visit to the British
Isles, where he studied compulsory insurance laws.
He was sent abroad by the commonwealth and will
report his findings to Governor Sproul. He visited
France, Belgium and Holland after the completion of
his official studies.
Dr. Howard L. Hull of Camp Hill, Pa., has re-
signed his position as Chief Medical Inspector of the
State Health Department in charge of the Division of
Communicable Diseases to accept an appointment as
Passed Assistant Surgeon, United States Public
Health Service Reserve. Dr. Hull has been assigned
to temporary duty at Hospital No. 41, New Haven,
Conn.
The Seventeenth Annual Meeting of the Cum-
berland Valley Medical Association was held in Car-
lisle, Pa., September 2, under the presidency of Dr.
David W. Van Camp, Plainfield, Pa. The following
officers were elected : President, Dr. James B. Amber-
Mowery, Mechanicsburg, Pa.; Vice Presidents, Wil-
liam D. Campbell, Hagerstown, Md., and Thomas H.
Gilland, Greencastle, Pa. ; Secretary, Dr. John J. Coff-
man, Scotland, Pa. (reelected), and Treasurer, Dr.
John K. Gordon, Chambersburg, Pa.
The Pennsylvania Delegation to the Fifteenth
International Congress Against Alcoholism will in-
clude : Dr. Hobart Amory Hare, Philadelphia ; Mrs.
Joseph M. Gazzman, Philadelphia ; the Rev. J. K. Mc-
Clurkin, Pittsburgh; Senator Plymouth W. Snyder,
Hollidaysburg; Miss Rebecca N. Roads, Belief onte;
Professor W. A. Elliott, Meadville; Dr. Homer W.
Tope, Philadelphia; Harry M. Chalfant, Narberth;
Dr. Lydia Cogill, Philadelphia; Dr. Ernest LePlace,
Philadelphia; Dr. E. E. Montgomery, Philadelphia,
and Calvin M. Smith, Philadelphia.
The State Department of Health has announced
appointment of the following physicians as medical
inspectors of schools to fill vacancies : Dr. Herman H.
Farkas, Paradise and Heidelberg Townships, York
County; Dr. George B. Perry, Fawn Grove Borough,
York County ; Dr. W. H. Smithson, Cross Roads Bor-
ough and East Hopewell Township, York County ; Dr.
N. A. Dombert, Evansborough Borough and Forward
Township, Butler County; Dr. W. G. Gilmore, Emlen-
ton Borough, Richland and Scrubgrass Townships,
Venango Coimty ; Dr. John L. Lalley, East and West
Mead, Vernon Townships, Crawford County.
The Health Colony Club of Pittsburgh will hold
its president's reception in the Hotel Chatham, Octo-
ber 7, with the president, Mrs. James Ward, Jr., as
guest of honor. Mrs. John R. Johnston and Mrs.
Charles S. Miller have charge of the program, which
will include the president's address and a musicale.
This club has done notable service in providing tents
for tuberculosis patients from Pittsburgh while they
were waiting to be admitted to the sanitarium at
Cresson, Pa., which has never been able to accommo-
date all of those seeking admission. "The Health
Colony Club has also established a diet kitchen at the
sanitarium for which it expects to soon erect a per-
manent building.
Auditor General Charles A. Snyder has been
chosen as one of the trustees of the new hospital at
Pottsville. The institution has been named tiie "A.
C. Miliken Open Hospital," bearing the name of
one of Pottsville's wealthiest and most philanthropic
residents. Nearly 300 women have united as an aux-
iliary, and officers have been chosen as follows:
President, Mrs. J. Barlow Cullom; first vice-presi-
dent, Mrs. H. O. Bechtel, wife of President Judge
Bechtel, of the Schuylkill County courts: second vice-
president. Miss Sarah Ball, of Minersville; secretary.
Miss Annie Boyer; assistant secretaries, Mrs. Ruth
Sapper Snyder and Miss Annie Reilly, treasurer. Mrs.
A. W. Schalck; Publicity Committee, Mrs. Robert
Braun and Mrs. J. O. Carlin.
The National Anesthesia Society held its first
annual meeting at Pittsburgh, October 4-8, 1920, with
headquarters at the William Penn Hotel. The meet-
ing was in conjunction with the Interstate Anaesthet-
ists Society, the Western Pennsylvania Odontological
Society, and the Medical Society of the State of Penn-
sylvania.
One of the special features was the awarding of
prizes aggregating $200 for the best papers on original
research in anaesthesia presented to the members of
the society and to alt members of the allied societies
meeting at the same time.
An attractive program of entertainment was pro-
vided to supplement the business sessions.
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October, 1920
GENERAL NEWS ITEMS
41
Sale of "Meoicines" Heavily Charged with alcohol
for the purpose of intoxication was declared recently
by Dr. Edward Martin, State Health Conunissioner,
to be in violation of the Brooks license law. The com-
missioner directed Dr. Thomas S. Blair, chief of the
Bureau of State Drug Control, to lay all evidence ob-
tained of such sales before the district attorneys of
the various counties. A number of offenders have
been convicted in the courts of the state for the sale
of Jamaica ginger containing a high percentage of al-
cohol for the purpose of inducing intoxication and not
for its proper medicinal use. The recent death of a
man in York from alleged imbibing of one of these
heavily charged "medicines" has aroused the health
department to the danger which attends their promis-
cuous sale as a beverage.
•
At a Luncheon September 22d at the William Penn
Hotel, plans and progress of the extension fimd com-
mittee of the Public Health Nursing Association of
Pittsburgh were reported by Chairman D. L. Gillespie
and Director A. C. Estes. A movement to secure
$100,000 for the extension has been under considera-
tion since the establishment of the association in 1919,
when necessary funds were secured by private con-
tribution and through gifts of the Red Cross.
The association is the only organization of its kind
in Pittsburgh or Allegheny County, its establishment
combining the forces of a number of small organiza-
tions and enlarging the service, at the same time be-
coming part of a large national organization with
branches throughout the country.
"The need for public health nursing has never been
so pronounced, nor is there a section of the country
that requires it more than the Pittsburgh district,"
said a member of the Executive Committee. The peo-
ple of Pittsburgh should be more fully acquainted
with the scope and character of the services which
our body is rendering and is equipped to give. It is
not only handling a vast number of charity cases of
infections, contagious diseases, as well as maternity
cases, incurable and aged patients, but one of the most
valuable points of the work is in the prevention and
elimination of disease through prompt and thorough
treatment at the source. _ The public health nurses are
visiting on average of nine families a day, caring for
the sick, instructing in hygiene, and aiding in the en-
forcement of health ordinances."
At the Fifty-seventh Session of the Homeo-
pathic Medical Society of the State of Pennsylvania,
held at Harrisburg September 21st to 23d, the principal
topics for consideration were Sanitary Science, Child
Hygiene and Compulsory Health Insurance. Speakers
on the latter subject were Dr. William M. Hillegas,
Philadelphia, on "What is State Health Insurance?"
Dr. Clarence Bartlett on "Its Effect on Medical Edu-
cation and on the Practice of Medicine," Dr. F. L.
Van Sickle, Executive Secretary of the Medical So-
ciety of the State of Pennsylvania, on "Health Insur-
ance Especially in Relation to its Effects on the Com-
munity." These papers were followed by a report
from Mayor William T. Ramsey, of Chester, chairman
of a commission which has just finished an inquiry
into the results of such laws in England. Mayor Ram-
sey asked the Society to withhold action in the matter
until they received the full report of the commission.
Notwithstanding this report a resolution was intro-
duced by Dr. C. Harlan Wells, of Philadelphia, and
adopted unanimously. The resolution reads as fol-
lows:
"Resolved, That the members of the Homeopathic
Medical Society of the State of Pennsylvania believe
the enactment of any measure for compulsory health
insurance would be imposing a useless and unneces-
sary financial burden on the citizens of this Common-
wealth, and would result in inefficient medical service
to industrial workers and would lower the present
high standards of medical education and medical prac-
tice."
Four members of the commission were present when
the action was taken. They were Mayor William T.
Ramsey, chairman; Dr. C. Oram Ring, Dr. Francis
J. Patterson and Dr. Summerfield J. Miller.
Dr. George W. Hartman, Harrisburg, was elected
president, and Dr. J. M. Kenworthy, Philadelphia, sec-
retary.
' vacation notes
Dr. and Mrs. J. P. Strickler, of Scottdale, spent
several weeks at Lake Chautauqua.
Dr. Harvey M. Becker, Sunbury, has returned from
a month's sojourn in the Poconos.
Dr. James N. Richards, Fallsington, is spending the
summer in the western part of the state.
Dr. George Morris Dorrance has returned to his
home, 2025 Walnut Street, Philadelphia, from a tour
through Canada.
Dr. and Mrs. Alfred E. Fretz, Sellersville, spent a
well earned vacation in the Poconos, making a two
weeks' rounds by auto.
Dr. Clay H. Weimer, Shamokin, has purchased a
cottage at Mt. Gretna, and enjoys the week-ends with
his family, who are spending the summer there.
Dr. Fred P. Steck, Shamokin, is enjoying a six
weeks' fishing trip in the Black Hills of South Dakota.
On his way home he expects to visit the Mayo clinics.
Dr. and Mrs. W. L. Estes, Jr., have returned to
their home in South Bethlehem from a month's holi-
day spent in the New England States.
Dr. and Mrs. George Fales Baker, of Old Oaks,
Rosemont, who have been occupying their camp at
Paul Smiths, in the Adirondacks, returned Septem-
ber 23.
Dr. and Mrs. George H. Haas, of Allentown, are
the guests of the former's brother. Dr. James A.
Haas, 115 South Street. Dr. G. H. Haas attended
the convention of the Homeopathic Society.
Dr. and Mrs. William J. Wilkinson, of Grand
View Hospital, Bucks County, spent the last half of
August on a vacation trip through the northern coun-
try by auto.
Dr. Bruce Lichty, Meyersdale, has returned from
a jaunt into the Adirondacks, which has put the glow
of health in his countenance; looks as if he gained a
thousand pounds 1
Dr. Leon S. Gans, Director of the G. U. Division
of the Department of Health, who has been spending
a month in Maine, has returned to Harrisburg and re-
sumed his work in the Department.
Dr. AtiD Mrs. Howard Fordb Hansell, who spent
the summer abroad and who have since their return
to this country been staying at the Ambassador, Atlan-
tic City, have returned to their home at Seventeenth
and Walnut Streets, Philadelphia.
GENERAL NEWS ITEMS
Announcement has been made of the death of
Professor Felix Guyon, a former president of the
Paris Academy of Medicine and head of the Hopital
Necker. He was known especially for his work on the
diesases of the urinogenital organs.
During the Year, Mr. John D. Rockefeller gave an
additional $20,000,000 to the general education board
to be used in improving medical education in the
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TMlE PENNSYLVANIA MEDICAL JOURNAL October. 1920
United States; the income and principle to be dis-
tributed within the next filty years.
Oregon has Become Famous for production of
cascara bark. The gathering of this bark centers
about Roseburg, whence it is shipped by the carload
to the Eastern markets. Its demand is such that this
has become a profitable enterprise.
_ The Hollister- Wilson Laboratories have discon-
tinued theold name, and are now known as the Wilson
Laboratories, thus making clear the connection with
Wilson and Company and insuring to the medical pro-
fession the sarne^ high standard of products and im-
varying dependability.
The Southern Medical Association Meeting has
been compelled to change its date of meeting, owing to
conflict of dates with the fall racing in Louisville,
which would have made hotel accommodations doubt-
ful for all attending physicians. The time for the
meeting is announced as November 15 to 18.
Dr. L. Duncan Bulkley, of New York, has an-
nounced his retirement from the active practice of
dermatology and will devote his attention to consul-
tation practice in the same and to the treatment of
cancer. Dr. Clark, formerly associated with him, will
take up the active work.
The Objects of the Medical Association, as out-
lined in the quarterly, are to strengthen and coordinate
the medical forces of the country and to collaborate
with doctors outside Palestine; to give the medical
work a national as well as a humane value; to pre-
pare a native soil for Jewish scientists ; and to help in
the creation of the Hebrew University.
Palestine's First Medical Journal, Harefooah,
(Medicine), has just made its appearance, published by
the Jewish Medical Association of Palestine. _ The
journal is a quarterly and its first issue is dedicated
to the memory of the Jewish physicians and nurSfes,
who "laid down their lives in the years of upheaval in
the Holy Land."
The Consulting Staff to cooperate with the ex-
ecutive ofHcer of the Massachusetts-Halifax Health
Commission, Dr. Franklin B. Royer, formerly of the
Pennsylvania Department of Health, has been ap-
pointed as follows: Col. John Stewart, Drs. Frank
Woodbury, Arthur Birt, George M. Campbell, Samuel
J. McLennan and R. Evatt Mathers.
The Executive Committee of the American Red
Cross has decided to discontinue the Red Cross Maga-
zine with the October issue, on account of the in-
creased cost of publication and especially of paper.
The publishers stand ready to refund to those sub-
scribers who will not receive the full number of is-
sues to which they are entitled, the pro rata- amount
of their subscription.
Quack Medicine Seized. — Last month the Federal
agents seized two shipments of medicine in Seattle
which failed to conform to the Federal Food and
Drugs Act. This is part of the nation-wide attempt
to stop the sale of fraudulent remedies and those
which make extravagant curative claims. These medi-
cines were claimed to be mislabeled as to their curative
and therapeutic effects.
Activities at the Walter Reed Hospital, Wash-
ington, will shortly be shown in moving pictures
through the efforts of the bureau of the Potomac Di-
vision, American Red Cross. The film was taken in
cooperation with Surg. Gen. Merritte W. Ireland and
shows the work at the hospital for the wounded sol-
diers from a physical, educational and recreational
standpoint. . Other films are to be released in the
future.
The Supreme Court has affirmed the decision of
the Montgomery Circuit Court, which was adverse to
the claims of Dr. Thomas D. Parke, Birmingham, and
other physicians of Jefferson County, that the legis-
lature exceeded its authority in delegating health work
to the Alabama Medical Association. The Associa-
tion will, therefore, continue to name the State Board
of Health and be the general authority for the en-
forcement of all State laws regarding health and sani-
tation.
Physicians of the Cincinnati Health Depart-
ment found 34,064 school children in need of some
form of medical treatment during the last school year,
according to a report recently published. Out of this
total 11,249 children recovered from the physical de-
fects from which they were suffering; 1,491 either
refused treatment, wiUidrew from treatment after it
was started, or left the city, and 31,324 cases are still
pending. The statistics cover both the public and
parochial schools, 114 in number.
The Trustees of the University of Alabama have
ordered the removal of the Medical School from Mo-
bile to Tuscaloosa, as this school failed to obtain a
class A rating with the Council on Medical Education
of the American Medical Association. The Univer-
sity is establishing what will be practically a new
medical school. During 1920-1921 only the work of
the freshman year will be given and in the following
session two years' work will be given. The clinical
courses will not be offered until such time as the Uni-
versity feels that they can be established on a high
plane.
It has been Reported in The British Medical Jour-
nal that professors of the Paris Faculty of Medicine
have been placed in two classes according to their
seniority, those in the first class receiving a salary of
25,000 francs, and those in the second class a salary
of 23,000 francs. By a recent ministerial decree Pro-
fessors Richet. Pouchet, Hutinel, De' Lapersome, Gil-
bert, Roger, Nicolas, Ribemont-Dessaignes, Qu^nu,
Prenant, Widal, Chauffard, and Weiss have been put
in the first class, and Professors Delbet, Marfan, Hart-
mann. Bar, Marie, Borca, Teissier, Desgres, Lejars,
Achard, Robin, Legueu, Letulle, Couvelaire, Camot,
Besancon, Vaquez, Dupre and Jeanselme in the second
class.
As A Memorial to the late Major General William
C. Gorgas, former Surgeon General of the United
States Army, it has been proposed that an interna-
tional institute for research in tropical diseases be es-
tablished at Panama. Panama has been chosen as the
location for the proposed memorial because of the fact
that General Gorgas' most noteworthy health work
was accomplished in that country. It is hoped that
the sanitary work so far advanced during the lifetime
of General Gorgas may be continued by means of
study made possible by such an institute. It has been
announced that the Panama Government is willing to
donate the St. Thomas Hospital for the use of the in-
stitute.
During the Great War, Uruguay stood staunchly
with the United States, and her president, Senor Bal-
tasar Brum, a brilliant yofing statesman, who is well
known in diplomatic circles in Washington, and the
able foreign minister made decisions which will be
permanent additions to international law; in sub-
stance, first, that a republic fighting for her sovereign
rights is not a belligerent and has the right of asylum
and protection from all republics, and second, that
when the United States is forced into war to protect
her rights she is protecting the rights of all republics,
and ail republics become parties to the conflict. Uru-
guay promptly followed the United States in declar-
ing war on the Central Powers.— Wm. J. Mayo, Jour.
A. M. A., 8-28-20.
The American Society for Control of Cancer an-
nounces that appropriation of $225,000 for 2% grams
of radium has been made a fact. Any citizen of the
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October, 1920
CURRENT MEDICAL TOPICS
43
United States may avail himself gratuitously after Oc-
tober 15th of treatment, but preference will naturally
be accorded citizens of New York. The first gram is
now in the vaults at Buffalo, and was brought 8,900
miles across the continent in the form of 125 tons of
Colorado camotite to the plant at Orange, N. J., where
it was extracted. This is said to be the first pur-
chase of radium by any state and marks a step of ad-
vancement in the treatment of cancer by this method,
which is now admitted by authorities as the most effi-
cient means yet attained.
Answering Inquiries from the Ohio State Board
of Optometry relative to interpretation of sections of
the optometry act, Attorney General Price has ren-
dered an opinion in which the following rulings are
set forth:
1. "Peddling" as used in the act includes practicing
of optometry from door to door, but not the soliciting
of patients to be treated.
8. Nonresidents not possessing required educational
qualifications are not eligible to take the standard ex-
amination, but those who have practiced for two years
prior to passage of the act may take the limited ex-
amination.
3. Physicians practicing under state license are ex-
empt from the provisions of the act and may adver-
tise themselves as optometrists.
An Analysis of the Infant Death Records in
Massachusetts for the past year has been made by a
special commission' on maternity benefits. The report
shows that ten thousand and fifty-three children under
one year of age died in this state during 1919; more
than fifteen hundred of these deaths occurred before
the infants had reached the age of one day. Statistics
show that one person in every ten dies in early infancy
in Massachusetts. In New Zealand, only one in twent/
is lost, while the latest statistics from Russia report
that one person in four dies in infancy in that country.
The death rate is higher among male babies than
among females, 5,670 of the former, and 4,383 of the
latter, being the toUls for last year. The causes of
infant deaths in Massachusetts during 1919 are as fol-
lows: Congenital debility, prematurity, icterus, and
sclerema, 2,041 ; malformations, 661 ; accidents of
labor, 799; respiratory diseases (bronchitis, broncho-
pneumonia, etc.), 1,321; intestinal diseases, 1,394; all
other causes, 2,633.
Dr. John Henry Carstens, President of the De-
troit College of Medicine and Surgery, and a former
President of the Michigan State Medical Society,
passed away at his home in Detroit, August 7, 1980.
He is survived by his widow and the following chil-
dren: Misses Edith and Mildred Carstens, Mrs. L. J.
Hirschman, and Dr. Henry Carstens.
Dr. Carstens was one of the most widely known
physicians, not only in Michigan, but throughout the
United States. For many years he was a constant at-
tendant of the American Medical Association, Missis-
sippi Valley Medical Association, Congress on Medical
Education and other medical societies. He was a
public-spirited citizen and a competent physician.
In the Issue of the New York Times for August
8th, it was stated that the Department of Health called
attention to the decision of the Nebraska Supreme
Court to the effect that a physician is not_ compelled to
maintain secrecy in the case of communicable disease
when the health of other persons is endangered by so
doing. In the case referred to, the Court granted a
verdict in favor of the physician who, after advising
the patient to remove himself from contact with other
persons and to isolate himself, warnedan exposed per-
son of the danger. The following opinion was issued
by the Court:
"In making such disclosure a physician must also be
governed by the rules as to qualifiedly privileged
communications in slander and libel cases. He must
prove that a disclosure was necessary to prevent
spread of disease ; that the commtmication was to one
who, it was reasonable to suppose, might otherwise
be exposed, and that he himself acted in entire good
faith, with reasonable grounds for his diagnosis and
without malice."
Children Born Out of Wedlock may receive pro-
tection of uniform laws. The National Conference of
Commissioners on Uniform State Laws at its annual
meeting held in St. Louis, August 19, adopted a reso-
lution to include this subject in its program. At the
present time, Minnesota affords a greater amount of
protection to children bom out of wedlock than does
any other state. In most of the states, legislation for the
protection of children of illegitimate birth is archaic.
Following regional conferences held last February in
Chicago and New York to consider standards which
should govern legislation, a committee representing both
conferences was appointed by the Children's Bureau
of the United States Department of Labor to draft a
memorandum embodying the principles agreed on in
the resolution of the two conferences and to act in an
advisory capacity to the bureau on this subject. A syl-
labus of propositions to serve as a basis for a pro-
gram for illegitimacy legislation was drafted by Prof.
Ernest Freund of Chicago and approved with certain
amendments by the committee. This syllabus is in-
cluded in a puplication of the bureau now in press.
CURRENT MEDICAL TOPICS
How about the candidate for the legislature? Have
you been to see him? Have you talked constructive
medical legislation with him? It would be wise for
you to pay him a friendly visit and have a good heart-
to-heart talk with him along progressive lines. Vari-
ous forms of medical and health legislation will be
presented, some wise and some of a vicious type, and
it is up to the doctor to show to the candidate the
true condition of affairs. — From the Bucks County
Medical Monthly, August, 1920.
A suspended member has only himself to blame. In
failing to pay his or her dues is the cause of the sus-
pension and being dropped from the roll. It is, how-
ever, not a proper way to get out of the Society. The
honest and honorable course is to resign at the end of
the year paid for, if a member does not care to con-
tinue his membership. But a medical life is a con-
tinuous course of education. An education which
comes from mingling and study with his fellow prac-
titioners.— Franklin County Call and Roster, July,
1920.
An endowment fund for the County Medical Society
would be a beneficent object. A number of societies
have such a fund. In the past history of our Society,
a number of members have died who left considerable
estates where a porticn could have been left for
such a fund and where such benefactions would not
have been missed by the surviving part of the family.
Such gifts should be so secured or placed that the So-
ciety could get only the interest or dividend. Such
donation could be made to revert to the heirs or to
some charitable cause in the discontinuance of the So-
ciety.—fro»fe/i>» County Call and Roster, September,
1920.
A committee of the National Civic Federation,
headed by \yarren S. Stone, chief of the Brotherhood
of Locomotive Engineers, as a guarantee that the in-
terest of the workingmen should not be neglected, has
reported against the plan of compulsory state health
insurance, and will submit its findings to such legisla-
tures as are now in session with this project before
them.
The chief of the Locomotive Engineers is a repre-
sentative of the more conservative element of trade
unionism, but the report which he sponsors is none the
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"^HE PENNSYLVANIA MEDICAL JOURNAL October, 1920
less significant for that fact, in its reminder that there
is much of the so-called "labor" legislation annually
or biennially brought to the mill, but is not entitled to
that label by reason of a general endorsement even by
organized unions. — Northumberland County Medical
Society Notes, Aug. 31, 1920.
Generally the recognition of benefactors comes tar-
dily. It takes a long time to obtain the full perspec-
tive, to bring into the proper relief those who really
serve their time and deserve gratitude at first of their
contemporaries and at last of posterity. Often we are
too near the great and the good to recognize in the
correct dimensions the greatness and the goodness.
It is true of families, we did not appreciate father
and mother till we lost them. Now we say when we
can no longer tell them, how kind and generous, and
long suffering they were with us. The praise or
fame worth while will come unsought. Those whose
deliberate aim is the mere glory, rarely win the selfish,
ruthless crown they seek. The love and the gratitude
of the race comes to those who quietly and contentedly
labor in their place and let the reward take care of
itself. — From Dr. F. U. Ferguson, Gallitzin, Pa., in
The Medical Comment, Cambria County, Sept. 4, 1920.
The entry of the selective service men into the
United States Army brought before us more vividly
than ever before the prevalence of venereal disease
among our young men. Five-sixth of the total num-
ber of cases occurring in the soldiers were brought in
from civilian life. The venereal rate per thousand
from the city of Johnstown was 4,94, or out of every
one thousand men who left here for the camps, five
had some form of venereal disease. The venereal dis-
ease constituted the greatest cause of disability in the
army. It was more crippling than bullets.
The United States Public Health Service has been
waging an intensive campaign against this menace.
They have established their forces in every part of
this country. The state health departments have been
asked for their aid, but still further recruits are
needed. The civilian communities have been respon-
sible for the spread of this disease. _ Practically all
cases are contracted within communities over which
civil authorities have control. The army has done
more than its share in the fight of wiping out venereal
disease. We must continue the attack with vigor.
Our city will be watched by the nation at large. — The
Medical Comment, Cambria County, Sept. 4, 1920.
The following advertisernent inserted in newspapers
by a female chiropractor will be read with great inter-
est by our strictly scientific members, as it clearly ex-
plains the cause of all diseases and tells how to restore
health in every case.
PINCHED NERVES
"Pinched nerves are the cause of disease. The con-
dition is caused by a misplacement of the small bones
(vertebrae) of the spine. _ The vital force is thus pre-
vented from flowing uninterruptedly to the various
organs and disease ensues. Chiropractic spinal ad-
justments given by a competent chiropractor, with the
bare hands only, put the bones back in place, the pinch-
ing is relieved and the vital force flows to the various
organs. Health is then the result. Consultation and
spinal analysis free."
Motion pictures^ are being used by the British Royal
Society of Medicine to demonstrate surgical, medical
and dental manipulations. Complicated surgery and
nervous diseases have been successfully studied by
motion pictures.
The records of the Mary M. Packer Hospital at
Sunbury, just compiled from May 1, 1920, to August
31, 1920, show that during that time one hundred and
nine operations were performed and out of that num-
ber no deaths occurred. The institution can justly
feel proud of this record and the surgeons deserve
great credit for their untiring efforts in relieving suf-
fering humanity and for their faithful attention to the
needs of the institution.
"CRITICISM"
Some wonder why such a thing as Compulsory
Health Insurance should be proposed. Personally we
don't.
With nearly every eye man claiming that blindness
is universal, every ear man that deafness is ditto,
every throat man itching to dig out every tonsil, and
some going so far as to hold that any tonsil is a sick
tonsil, every nerve man telling us we are all crazy,
and every other D. F. telling us that every door knob
reeks with germs, is there any wonder that the Health
Commission took us as a class at our word, and rushed
to the preservation of the public? In the face of such
pessimistic testimony someone had to suffer for the
general good, so why not the doctor? He is just nat-
urally the easiest proposition in the world. He is the
safest goat yoii can find.
Some time ago it was claimed that a certain state-
ment unjustly criticized a nearby government hospital.
In the indignation of the moment a special committee
was appointed to investigate the truthfuhiess of the
charges that justice might be done a worthy officer.
Did the committee ever act? No.; they will not,
either, for the hospital is now closed.
Just such things as that put us at the mercy of any
class or cult that cares to take a jab at us. As a
whole the profession is like the proverbial month of
March!— TAe Bulletin of the York County Medical
Society, July 1, 1920.
A NEW MENACE
The construction of the various new roads through-
out the county has lead to the development of a new
public health menace. The laborers who have been
employed on these roads have been housed in camps
in various localities throughout the county. In many
cases these camps are located on the various water-
sheds. As the sanitary precautions taken are of the
crudest type, a very serious source of pollution of the
water supply has developed. The attention of Dr. W.
E. Matthews, the County Medical Director, was called
to this condition some time ago. After a thorough in-
spection the following nuisances were discovered:
1. A camp on the watershed that drains into the
reservoir that supplies Ebensburg. This is located
along the nfw road being built between Ebensburg
and Carrolltown. Open water-closets and all sorts of
refuse and g^arbage about the place.
2. Open outside toilets on the Leidy farm above
Conemaugh that drain into the Salt Lick reservoir
that supplies Johnstown with water. A lumber camp
was also located on this same watershed.
3. A camp located on the watershed of the Mill-
creek reservoir near the Graystone Country Club.
This also supplies the city of Johnstown.
The State Health Department got to work on this
at once. At the present time Inspector Awl is here
and is making a thorough inspection of all the water-
sheds in this county. Sanitary Engineer Fortinbaugh
spent several days going over the situation in this
vicinity and ordered all the nuisances abated. The
complete eradication of all the sources of pollution is
of the utmost importance. The control of typhoid
fever depends a great deal upon a clean water supply.
Our water at present is excellent and it must be
kept so.
Every physician should be on the lookout for any
condition that may prove a menace to the health of
the community. The source of every case of typhoid
fever should be traced out with a vengeance. At the
present time there are only three cases of typhoid
fever in the county outside of the city of Johnstown.
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October, 1920
BOOK REVIEW
45
This is a fact that we should be proud of. Not so
many years ago at this time we would have several
hundred cases scattered throughout our county. The
strict enforcement of the ordinary laws of sanitation
have accomplished wonders in the control of this one
disease. Much of the credit belongs to the doctor. —
The Medical Comment, Cambria County, Sept. 4, 1920.
BOOKS RECEIVED
THE DOCTOR'S OFFICE
To para phase an old proverb — a doctor may be
known by the office he keeps. The first requisite of a
doctor's office is that it shall be equipped with every-
thing that he can legitimately use in the practice of
his profession. The equipment of course depends on
the sort of work he does. The specialist has to have
more apparatus of various kinds than a man in general
practice. We have seen some offices so filled up with
machinery that there was very little room for the
desk, and we have noticed that the offices of the best
doctors have very little of this sort of thing. A little
apparatus intelligently used is much better than a
great deal that is placed in the office to impress the
minds of patients. A doctor's office, if he expects to
attract the best class of patients, must be clean, and
if possible, in good order. Dirt and disorder are often
associated but not always. The former is much more
objectionable.
Should a doctor's diploma and his license from the
State Board of Examiners be displayed in his office?
We can imagine circumstances in which this is proper
but in this neighborhood these are unnecessary and
an array of sdch documents suggests vain glory.
There will be plenty of medical books in the office of
an up-to-date doctor. A few good books well read
are of more use than an extensive collection that re-
mains on the shelves.
A doctor's office is a place of business and should
look like one. Luxuriously upholstered chairs, etc.,
are out of place. We heard of one professional man
who had the front legs of the chairs in his office cut
short so as to make them as uncomfortable as pos-
sible and_ thus discourage an unnecessary prolongation
of his client's visit. We should not be obliged to re-
sort to such an expedient as this but should be able
when the visit is through to get the patient on what
Dr. Holmes called the "inclined plane of conversa-
tion," which leads them courteously but expeditiously
to the front door. Pictures of storks and skulls and
the like so abundantly supplied to us as advertisements
by drug houses are very objectionable. The same may
be said of photographs of operations in which the
doctor appears dressed in an operating gown and
gloves and wielding a scalpel or saw. If there must
be pictures in the office let them be good ones, prefer-
ably engravings, of men famous in medicine or allied
sciences. Whatever may be said of the office we
think that the waiting room should have in it as little
tc suggest medical procedure as possible. Here
books, pictures, magazines and other objects that will
interest the patient and divert his mind are in place;
for_"Anoci-association" is useful in medicine as well
as in surgery. A tactful office assistant or stenog-
rapher can often mitigate the mental discomfort of
patients waiting to see the doctor.
All physician's offices should be equipped to do sim-
ple laboratory tests. _ How much of this work should
be done by the physician himself or under his imme-
diate direction will depend on circumstances. A good
hospital offers the best means of getting laboratory
work done in the most satisfactory manner. If this is
not available, a trained man can do this work for a
number of physicians. In only exceptional cases, we
think, should a physician attempt the more elaborate
laboratory procedures in his own office.
All of these things, however, are only accessories ;
it is the skill, the earnestness and the personality of
the doctor that produce results. — The Medical Re-
porter, Chester County, September, 1920.
Books received are acknowledged in this column,
and such acknowledgment must be regarded as a suffi-
cient return for the courtesy of the sender. Selec-
tions will be made for review in the interests of our
readers and as space permits.
Operative Gynecology. By Harry Sturgeon Cros-
sen, M.D., F.A.C.S., Assistant in Gynecology, Wash-
ington University Medical School; 2d Edition. 834
original illustrations. C. V. Mosby Company, St.
Louis, 1920. Cloth, $10.00.
High Frequency Apparatus; Design, Construc-
tion AND Practical Application (2d Edition Revised
and Enlarged). By Thomas Stanley Curtis, author of
"Construction of Induction Coils and Transformers,"
"Model Submarine with Wireless Control," etc. 275
pages, with 150 illustrations. New York : Norman W.
Henley Publishing Company, 1920. Cloth, $3.00.
_ A Short History of Nursing, from the earliest
time to the present day, by Lavinia L. Dock, R.N., Sec-
retary, International Council of Nurses, in collabora-
tion with Isabel Maitland Stewart, A.M., R.N., Assist-
ant Professor, Department of Nursing and Health,
Teachers College, Columbia University, New York.
G. P. Putnam's Sons, New York and London. The
Knickerbocker Press. Price $3.50.
BOOK REVIEW
GEORGE MILLER STERNBERG: A Biography.
By his Wife, Martha L. Sternberg. Pages 332, with
illustrations. Chicago: American Medical Asso-
ciation, 1920. Cloth, $5.00.
The American Medical Association has done well in
departing from its set policy of not publishing miscel-
laneous books in order that it might place permanently
on record the pioneer work of General Sternberg.
Mrs. Sternberg in this labor of love for the memory
of her husband has written historical facts in a style
more interesting and charming than the better novels
of the day. The name of Dr. Sternberg immediately
calls to mind one of the great episodes in the history
of medicine, that of the conquest of yellow fever, in
the successive stages of which three medical officers
of the United States Army, Drs. Sternberg, Reed and
Gorgas, may be said to have played the leading role.
Dr. Sternberg entered the army in 1861 as surgeon
with the Union forces, and served^ throughout the
Civil War and in the Indian campaigns, notably the
Nez Perces War, a vivid account of which is ren-
dered in his biography. In the course of his tours of
duty at eastern and southern military posts, he ac-
quired valuable experience in combating cholera and
yellow fever, and his expert advice was frequently in
request when these diseases threatened to invade the
country in epidemic form. He was the pioneer in
bacteriology in the United States ; he discovered the
pneumococcus in 1880, and was the first in this coun-
try to dernonstrate the organisms of malaria, cholera
and tuberculosis. The practice of modem disinfec-
tion is based on Dr. Sternberg's researches on the
value of commercial disinfectants, which work he
started in 1878 at an isolated frontier army post.
Under the same inauspicious surroundings he also in-
vented a heat regulator, modified and elaborated forms
of which are to-day in general use for the thermostatic
control of heating apparatus.
As Surgeon General he directed the medical activi-
ties of the army during the Spanish-American War,
founded the army medical school, organized the nurse
corps and the dental corps, and established many mili-
tary hospitals throughout the United States, including
the tuberculosis hospital at Fort Bayard. By the es-
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The PENNSYLVANIA MEDICAL JOURNAL
October, 1920
tablishment of laboratories and by personal encourage-
ment he inspirod medical officers of the army to en-
gage in research, to the development of which he had
spent the best years of his life. Many scientific inves-
tigations were conducted during his term as Surgeon
General, the most important of which related to tropi-
cal diseases, typhoid fever and yellow fever. During
the Spanish-American War he recommended the ap-
pointment of the Typhoid Fever Board composed of
Majors Walter Reed, Victor C. Vaughan and Edward
O. Shakespeare, and suggested the searching investi-
gation of typhoid fever in the military camps which
led to the formulation of adequate measures of pre-
vention.
From his first experience with yellow fever at Gov-
ernor's Island, New York Harbor, Dr. Sternberg's in-
terest in the subject never flagged. He fought several
epidemics of the disease in the cities and military posts
along our coast and himself suffered a severe attack
of the disease. He was a member of the first Havana
Yellow Fever Commission, the appointment of which
was the immediate outcome of the wide prevalence
and great mortality of yellow fever in 1878, and he
made exhaustive studies of the disease in Cuba,
Mexico, Brazil and other tropical countries. One of
the most brilliant discoveries in the history of medi-
cine resulted from his appointment of the Yellow
Fever Board, under Major Walter Reed, in May, 1900,
which by human experimentation proved conclusively
that yellow fever is transmitted by mosquitoes. The
practical application of this discovery resulted in the
eradication of yellow fever from Havana and con-
tributed to the successful building of the Panarna
Canal. After his retirement from the army, he did
much to improve housing conditions among the labor-
ing classes in Washington, and toward the prevention
of tuberculosis. He was the author of a manual of
bacteriology and of several other works on special
topics, notably on malaria, immunity, serum therapy
and infection. He had been highly honored during his
lifetime, and was president of the American Medical
Association and of many other scientific societies.
C. L. S.
AMERICAN PROCTOLOGIC SOCIETY
Twenty-first Annual Meeting, Memphis, Tenn.,
Aprii, 28-23, 1920
Abstract
WHEN GREEK MEETS ALBANIAN
"When is the Greek cobbler not a Greek cobbler?"
"When he is an Albanian cobbler."
The above conundrum offers an interesting sidelight
on the psychology of the alien in our midst, recently
discovered by an American Red Cross nurse. In the
course of her relief work in southern Albania she was
astonished at the number of young men of that coun-
try who spoke English. Upon inquiry she learned that
nearly all had been living in America for the past five
years. They had returned to their homeland after the
armistice to take unto themselves wives, after which
they expected to go back to "God's country."
"But," she protested to one benedict, "What do you
do in the United States? Where do you and your
countrymen keep themselves? Until I came overseas
I don't think I ever saw an Albanian."
"Sure-Mike, you've seen them, lady," was the re-
joinder. "In America already are more than 18,000
Albanians. Much work for all in New England mak-
ing shoes. Much more have own biz ; — what you call
cobblers."
"But why do you call yourselves Greek?" persisted
the puzzled Red Cross woman.
"You not see, lady?" Obviously the young man was
disappointed at his questioner's lack of perspicacity.
"All rest of United States just like you. Never hear
of Albania untila da war. Everybody chewa da rag
so much evera time we spika it. So we just say 'from
Greece.' Save alia da fool questions. Why not? —
We maka da shoes just as good Greek or Albanian,
don't we ? You betcha life ! If not believe, aska da
boss. He knows. And anyhow, what-da-Hell maka
da difference hbw we calla ourself, when alia be
Americans soon?"
Presidential Address
Cooperation and Coordination
collier f. martin, m.d.
Philadelphia, Pa.
The writer traced the development of proctology
from the time over twenty years ago, when it was
largely in the hands of advertising quacks, up to the
present, when it has become a well recognized spe-
cialty. He showed the influence on this developnfent
which has been exercised by the American Proctologic
Society and its founders, particularly Dr. Joseph M.
Mathews, until recently of Louisville, Ky. He said
that the society had gone along conservatively, in the
past, bust must now face and do its part in the great
expansion of specialism which has followed the war.
For enlarging its scope of work, the writer recom-
mended the following:
1. The clinical program should be made an annual
feature of the meetings.
2. The society should continue to hold its meeting
in the week preceding the A. M. A.
3. It may soon be necessary to enlarge its fellow-
ship, but the society should do so conservatively.
4. The fellows should be encouraged to read papers
before local societies.
5. Reprints of such papers should be sent to all
fellows.
6. There should be some method of interchange of
ideas between meetings.
7. Effort should be made to secure the establishment
of courses in proctology in every medical school.
8. The society might endorse certain textbooks for
use in such teaching.
9. A committee might be appointed to cooperate
with other societies for the suppression of quacks and
quack remedies.
10. The efficiency of the society mainly rests on the
secretary, but he should be aided in every possible
way by every fellow.
THE RECTO-VAGINAL SEPTUM IN
PROC 'OLOGY
DESCUM C. MCKENNEY, M.D., F.A.C.S.
Buffalo, N. Y.
The writer made a plea for the more careful ex-
amination of the anorecto-vaginal septum by the proc-
tologist, and of the rectimi by the genecologist, so that
rectal disease and damaged septum, when associated,
may receive at one and the same time, when possible,
the necessary surgical attention. He described the
anatomy and functions of the levator ani muscle, the
pelvic fascia and other important structures which
form the septum, the rectocele, and other pathological
results of damage to those structures, and the inter-
ference with the performance and regularity of de-
fecation and other symptoms which result from the
damage.
In reference to the treatment, he considered the as-
sociation of damaged septum with rectal pathology, as
hemorrhoids and fistula, with vaginal pathology, as
lacterated cervix and cystocele, and summarized the
principles of septal repair as; the separation and ele-
vation of the posterior vaginal mucous membrance
from the rectum as far up as the cul de sac, if neces-
sary; the infolding of the rectal wall and the main-
tenance of it in this position by bringing together above
the fold the recto-vaginal layer of pelvic fascia; the
formation of a new perineal body by bringing together
from either side the edges of the levator ani muscle,
and other immediately associated structures; the ob-
literation of all dead space; the trimming away of
redundant vaginal mucous membrane, and the closure
of the wound.
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The Pennsylvania Medical Journal
Owned, Controlled and Published by the Medical Society of the State of Pennsylvania
Issued monthly under the supervision of the Publication Committee
Volume XXIV
NuiiBE« a.
212 North Third St., Harrisburg, Pa., November, 1920
Sobsckiptiok:
$3.00 Per Yeak
ADDRESS
PREPARATION FOR THE GROUP
SYSTEM OF MEDICINE*
M. HOWARD FUSSELL, M.D.
PHILADELPHIA
In searching for material for this address the
chairman has been led by his experiences in
teaching and in practice, to wonder what is to
become of all the men and women who take up
the practice of medicine as a livelihood. How
are we to apply all the recent discoveries in
methods of diagnosis and their application to the
cure and prevention of disease.
Surely the aim and desire of all men and
women who study medicine in order to practice
its application must be to prevent and to cure
disease. Those who have spent their lives in
the practice of medicine certainly must realize
that the profession is not one which of itself
allows a man to amass a fortune. For much of
our work we never desire or expect to obtain re-
muneration. Charlatans there are whose chief
aim is the making of money, and they may suc-
ceed. Some by extraordinarily great fees suc-
ceed in becoming coniiortably well off, but
riches as viewed to-day do not come from the
practice of medicine alone. This thought should
be presented to those who contemplate the study
of our profession. They should open their eyes
and have altruism and not riches as their goal.
In his presidential address before the Associa-
tion of American Physicians, May, 1920, Her-
mann Biggs presented one of the most recent
and thoughtful articles that has been published
in medical literature. His paper, dealing with a
plan to make practfcal use of all the recent
methods, was based upon his wide experience as
Commissioner of Health of the State of New
York. This experience led him to present to the
Senate of New York a bill which was aimed to
make the "Group System" of medical practice
a state institution under state control and run by
state finances. The bill failed in passage, but
the idea lives.
In his comments on the bill he points to the
Mayo's Clinic at Rochester as the greatest prac-
*The Chainnan's Address delivered before the Section on
Medicine of the Medical Society of the State of Pennsxlvania,
PittsboTch Session, October s, 1930.
tical result of "Group Medicine" in the world,
which embraces more than i6o physicians in its
staff and attends to the wants of from 60,000 to
70,000 sick individuals.
Incident to the accuracy of the group idea as
practiced at Rochester, Dr. Biggs did not men-
tion the financial results of this method as
practiced by the Mayo group. It is common
knowledge that the Rochester physicians have
gained much material wealth, that they are using
the major part of that wealth in disseminating
knowledge gained by their methods, and have
become world philanthropists.
Dr. Biggs points out the well-known fact that
the necessities surrounding men and women who
prepare themselves for the practice of medicine
involve great financial outlay, and these necessi-
ties do liot enable a man or woman to make a
living for self or family until they are in the
neighborhood of 30 years of age. His desire is
to make the recent discoveries available for all,
and to make the practice of medicine worth
while to the practitioner.
All these things are true. The idea of "Group
Medicine" is ideal. As yet, however, it is in the
formative stage, only a few Rochesters exist. It
will be better for all when the group idea is uni-
versally adopted, and we must all work for that
result; but until then what of the men and
women who are now practicing medicine?
What of the hundreds yearly added to their
number ? What of the wonderful advancement
in everything pertaining to the practice of medi-
cine? What of all the advance in diagnosis and
treatment ? How are we to conduct our profes-
sion as it exists to-day and will continue to exist
for many decades ? In answer to this question
several facts must be taken into consideration.
As is well known the science of medicine has
progressed by leaps and bounds in these last
forty years. New sciences have sprung into ex-
istence— bacteriology, roentgenology, serology,
modern surgery, modern therapeutics are liter-
ally new methods of diagnosis and treatment.
No individual can hope to have more than a
working knowledge of them. It is necessary to
use all" of these new specialties if our patients
are to be well treated. How can this be done
to-day, while men of the vision of the Mayo's,
the Biggs' and the Baldy's, the Christians are
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48
THE PENNSYLVANIA MEDICAL JOURNAL November, 1920
pointing the way to "group medicine"? Three
means are at hand :
1. Daily constant use of diagnostic and thera-
peutic means inherent in ourselves.
2. Increased knowledge of the specialties, ob-
tained by reading and observation and attend-
ance at meetings of medical societies.
3. Improvement of our local hospitals, so that
each may be a true "group" center.
USE OF ORDINARY DIAGNOSTIC AND THERAPEUTIC
. METHODS
I have had the privilege of addressing this and
other societies upon the necessity of the prac-
ticing physician availing himself of all of the
modem means of diagnosis before advising any
treatment, becoming familiar with and practic-
ing modem therapeutics. The time has passed
in which such diagnoses as "stomach trouble,"
"heart condition," "asthma," etc., etc., will stand.
These are ancient and useless. Every practic-
ing physician must recognize that the knowledge
which he obtained in lecture, quizz, demonstra-
tion, laboratory and wards, supplies him with
the tools for making a diagnosis, that without a'
diagnosis everything is hit or miss, and that
diagnosis is the most difficult of arts, notwith-
standing* the helps that the specialties afford us.
When a physician is called to a patient, these
things are necessary :
If the case is an emergency, attempt to relieve
that which is threatening life or giving distress.
After the emergency is over, study the case.
The youngest physician has been trained in
the elements of making a diagnosis. Daily use
in every case will make us all experts.
First, a history.
Second, a physical examination from head to
foot with patient stripped.
Third, the daily use of a laboratory in his of-
fice.
These all of us have, all of us can use, and by
their use most of the cases can be solved and
properly treated. If the number of patients we
have to attend precludes this intensive study of
every case, then one of two helps we MUST
HAVE if we are to do honest work — a well
trained assistant, or our patients in a well
equipped hospital. We owe our patients this in
all our cases.
If we have taken care in the observation of
the cases we must recognize that most of the
conditions we treat are end results, which could
have been prevented by early diagnosis, by in-
tensive study, by preventive medicine. Preven-
tative medicine will in time make t)rphoid fever,
diphtheria, syphilis, tuberculosis, as rare as
smallpox. Early diagnosis will save thousands
of lives in diphtheria, in tuberculosis, in en-
docarditis, in nephritis, in carcinoma. Intensive
study will make early diagnoses possible. It
does not avail for us to know a case of diph-
theria when the toxin has been active for days,
or a case of nephritis which has been active for
weeks, or a case of locomotor ataxia in the late
stages. The time to do good is before these end
results have occurred. The greatest of these
three essentials is Diagnosis.
KNOWLEDGE OP THE SPECIALTIES
It is impossible for all of us to become spe-
cialists. Each speciality needs a lifetime spent
in its acquisition. Every internist, every sur-
geon, every family doctor, however, owes it to
himself and to his patients to have enough
knowledge of each speciality that he may intel-
ligently refer his patients to the x-ray man, to
the bacteriologist, to the eye, ear and nose man,
and not only refer them but interpret the report
of the specialist's investigations.
I do not believe that any physician or surgeon
is doing his duty to his patients if he does not
have enough knowledge of the specialties to in-
telligently determine, with the aid of the spe-
cialist, whether the findings of the latter are the
cause, the result, or are independent of the
symptoms complained of. We do not have the
right to make mere reference bureaus of our-
selves. To this end the physician in each re-
ferred case should, when practicable, talk with
his consulting specialist, and when possible see
the x-ray pictures, the culture, the operation,
etc., etc. I know this is a big program, but it
will pay in knowledge, in safety to the patient,
in remuneration to the physician. The methods
to be used that we may thus become perpetual
students of medicine are :
First. Reading — not only the things in which
we are most interested, but a glance at least at
what is doing in the specialities. A good plan
is to have at hand a joumal of each of the spe-
cialties, as well as a general journal, such as the
Joumal of the American. Medical Association
and The Pennsylvania Medical Journal.
If we read these journals we can at least have
an inkling of what is going on in the medical
world.
Second. As I have intimated, when possible
follow your referred case to the x-ray, to the
laboratory, to the surgeon. This also takes time,
but it pays.
Third. There is not in the whole realm of
medicine such an educator as the medical so-
ciety. Attend all the meetings possible. Take
part in the meetings. All of us have something
to impart. This is comparatively easy for the
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November, 1920
GROUP SYSTEM OF MEDICINE— FUSSELL
49
man who lives in the city. I take my hat off to
the country members who attend meetings,
often miles away from their residences, and
which can be reached only at the expense of
much time and trouble.
IMPROVEMENT OF OUR LOCAL HOSPITALS
A few years ago the Bureau of Medical Edu-
cation and Licensure of Pennsylvania announced
that every recent graduate in medicine should
spend at least one year as an interne in a hos-
pital before he could appear before the Bureau
for examination for a license which would give
him the right to practice medicine.
Soon the hospitals in the state were divided
into accepted and not accepted hospitals. The
accepted hospitals were those which the Bureau
believed after inspection were able and willing
by equipment, by organization, and by the char-
acter of the medical staff, to give an adequate
training to the candidate for a license to practice
medicine.
This division of the hospitals raised a storm
of protest against the ruling, and particularly
against the chairman of the Board, Dr. J. M.
Baldy. Some of us thought the chairman was
foolish, that it was impossible for small hos-
pitals because of lack of funds and of equip-
ment, to raise their standards, but Baldy's views
were much broader than ours. We soon found
that we are daily realizing more fully that the
d^[ree of excellence upon which Baldy insisted,
not only allowed us to train residents for prac-
tice, but what is much more important in my
mind, so raised the standards of the hospitals
that they are becoming real "group" centers.
To these centers physicians of the neighbor-
hood may take their patients, study them by the
help of the staff, make a reliable diagnosis, and
fix upon a real treatment, which will raise the
case from a troublesome problem to a problem
studied and solved, with the patient restored tp
health, benefitted, or pronounced incurable, thus
eliminating any avoidable guess work.
Thus, gentlemen, if we who are connected
with one or more hospitals will take an interest
in them, will see that every case coming to us,
either in the ward or to the dispensary or
brought to us by the family physician to study
with him, is adequately cared for, then we will
.see that Baldy has pointed the way. We have
the means at our command — to use all of the
advances in medicine, to advance ourselves men-
tally, medically, financially, to get ourselves out
of the rut. Every physician can be a copartner
in this work, help his patients, help himself, and
not have a tendency to look upon a hospital as a
place where his patients go and are forever lost
to view. The family physician who has always
held the highest position in the world, the high-
est I believe without exception of all the profes-
sions, has at hand the means of increasing the
value of his work. As a means to an end, he
can use his daily routine to improve it, and to
help himself and others, by
First — Studying his cases thoroughly through
every means at hand.
Second — Continued study of medicine in the
broadest sense.
Third — The upbuilding of present hospitals,
and where necessary, establishment of others, on
lines of greatest efficiency.
Make the hospital a veritable medical research
center.
ORIGINAL ARTICLES
PRACTICAL POINTS IN HEART
DIAGNOSES*
S. CALVIN SMITH. S.M., M.D.
PHII,ADei.PHIA
Introduction. — ^We are living in an age when
the spirit of Scientific Investigation dominates
the Field of Medicine. Laboratory findings and
instrumental methods of examination have, in
the minds of some physicians, taken first place
in the diagnosis of disease. The study of heart
affections more than any other branch of medi-
cine, has recently received a tremendous impetus
as a result of the lately introduced instrumental
methods of examination. There is danger that
we of to-day may fall into the error of placing
too much dependence upon pulse tracings or
upon the striking revelations of the electrocar-
diograph, just as our forbears fell into the error
of placing too much reliance upon the stetho-
scope, in the early history of that invention. Or
we may duplicate with the electrocardiograph
the later-day mistakes which were made when
the blood pressure apparatus came into vogue
and by a too liberal interpretation of instru-
mental findings, bring not only disappointment •
to ourselves but also bring discredit to a valua-
ble method of clinical heart examination.
One cannot lose sight of the fact that labora-
tory and instrumental examinations must ever
be secondary in importance to clinical findings ;
and clinical findings consist of much more than
the mere detection of physical signs. A diag-
nosis of heart disease that is based solely upon
'Read before tbe Section on Medicine of the Medical Society
of the State of Pennsjlvania, Pittsburgh Session, October $,
1930.
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50
\^ THE PENNSYLVANIA MEDICAL JOURNAL
November, 1920
any ingtriimpnta^**WiS£p^M- ftvaj>wnaHnfi is aS
likely to prove erroneous as is an opinion based
solely upon the presence or absence of physical
signs. The true significance of instrumental ex-
aminations and of physical signs is to be found
in their correlation with other testimony of heart
disease, such as is furnished by a study of
( 1 ) Family history,
(2) Personal history,
(3) Presenting symptoms,
(4) Rate response to exercise.
together with these factors in cardiac diagnosis,
one should weigh the evidence afforded by the
clinical laboratory and when forming final judg-
ment upon a heart affection, constantly bear in
mind three fundamental concepts, viz :
( 1 ) The heart can be influenced by the same
factors which induce disturbances and altera-
tions in other structures of the body, however
remote ;
(2) Heart affections are rarely primary;
(3) It is not possible in study or in treatment,
to dissociate the circulatory system from other
systems of the body, such as the nervous, ali-
mentary, glandular, respiratory, excretory and
muscular systems.
It is the purpose of this paper to blend fa-
miliar and somewhat neglected methods of in-
quiry with the more recent procedures, in a
systematic search for early evidence of heart
affections. First in importance is
HISTORY
History can be conveniently divided into
(a) Family history,
(b) Previous personal history,
(c) History of present illness.
Family History may be of much cardiac sig-
nificance when it reveals a tendency towards af-
fections of the nervous system. It suggests a
search for the frequent underlying systemic in-
fection, syphilis, which may have been trans-
mitted or acquired by association. It also shows
a predilection to cardiac neuroses in the present
patient, through inherited nerve weakness. A
family history of hyperthyroidism would have
•a similar significance. Cancer or tuberculosis
in parents frequently render the parents consti-
tutionally inferior and may cause the offspring
to enter upon life with lessened powers of re-
sistance,— and as a consequence, exhibit a heart
which is distinctly burdened by an ordinary ex-
istence which imposes no strain whatever on
those with the heritage of heart-muscle strength.
Senile conception on the part of parents may
likewise influence the offspring. The same ob-
servation applies to any condition or infection
which would deplete parental physical reserve —
hence it is well to inquire into the health of par-
ents several months prior to and at the time of
the patient's birth.
Previous Personal History. — The patient in
recounting his history may dispose of certain
infections which at times seriously affect the
heart by employing the blanket term "all the
usual diseases of childhood." That these in-
fections are not such harmless accompaniments
of childhood as the laity indulgently believe, is
shown by clinical and cardiographic investiga-
tions which have been conducted at the Phila-
delphia Hospital for Contagious Diseases during
the past several months. For example, even
uncomplicated measles and whooping cough will
at sometime during their course, induce heart
disturbances in the majority of cases, — disturb-
ances which could readily result in definite heart
affections should after care be neglected.
It is important, from a cardiac standpoint to
know the duration of convalescence from any
infection, as well from the infections of child-
hood as from infections of later years. Too
often the period of absolute rest in bed termi-
nates when the acute symptoms subside, and the
child is permitted to indulge its natural inclina-
tion to activity without restraint. As a result,
convalescence is retarded and the child is "sick-
ly"" for a considerable time following the infec-
tion ; it is then that initial damage to the heart
often takes place, perhaps to be strikingly re-
vealed only when the demands of rapid maturity
are later on thrown upon strained heart struc-
ture, during the adolescent period.
Focal Infections. — The broad conception of
heart disorders requires that they be regarded,
for the most part, as disturbances secondary to
infective processes elsewhere within the body.
With this thought in mind, the patient's history
should be thoroughly searched in order to un-
cover (i) "local" infections (a term formerly
applied to diseases which were then believed to
be localized in certain structures of the body,
such as typhoid fever and pneumonia) ; (2)
systemic infections (such as syphilis or tuber-
culosis), and also (3) focal infectimis.
Whether other definite cause be determined or
not, focal infections should be uncompromis-
ingly searched for in all patients with circula-
tory disturbance. The focus may be found in
teeth, in tonsils, perhaps in discharging ears, oc-
casionally in suppurative infection of the sinuses
or gall bladder. Indeed, the improvement in
cardio-circulatory defects which follows the ex-
traction of infected teeth, which nevertheless
were symptom-free, is often amazing ; pulse ir-
regularities and tumultuous heart action quite
disappear, the transverse diameter of the heart
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November, 1920
HEART DIAGNOSIS— SMITH
51
may distinctly lessen in size and symtoms of
circulatory embarrassment frequently abate.
The same observations apply, in varying degree,
to foci of suppuration which have their focus
elsewhere in the body.
Operations and their details come in for close
scrutiny when considering the previous history
of a patient. If the operation were for the cor-
rection of injuries it is well to know whether
the wound was infected and the time required
for healing. If the operation were for the relief
of inflammation or for the evacuation of pus,
the physician should know the duration of symp-
toms prior to operation, the nature of the opera-
tion, the time required for convalescence and
whether or not the operation were successful,
vis: did it relieve the symptoms and have they
at any time since recurred? A history of re-
peated operations on the same organ, or various
operations on a series of organs, will excite the
suspicion that the successive infections own as a
common source a hidden focus not as yet dis-
covered, probably still active, and likely affect-
ing the heart.
Occupation. — Occupation which entails phys-
ical effort in excess of that which an inferior
constitution can withstand, imposes a burden on
the heart muscle. Sedentary occupations, with
their lack of sufficient physical exercise, may be
responsible for lack of heart muscle tone and,
when such a person undertakes unusual exer-
tion, disturbances referable to the heart may
ensue. Employment which necessitates pro-
longed and continued mental effort or intense
metal concentration continued over a period of
time may be reflected in the heart's action.
Those who work with chemicals, in dye stuffs,
or in vitiated atmospheres, often show constitu-
tional effects from their employment which de-
range the heart's action. Persons whose occu-
pations necessitate continued physical exertion
may show no effect of such exercise when they
are engaged in their employment; but if they
change their occupation to a life of physical in-
activity, heart symptoms may ensue in conse-
quence of relaxed tonicity of heart muscle.
Anxiety, nervousness or driving the human ma-
chinery at high speed may bring on marked
alterations in the nerve balance of the person so
harassed, and cardiac irregularities result.
Habits. — It is amazing how many patients
drink insufficiently of water and as a result have
defective elimination. Eating habits, such as
improper mas'tication and the bolting of food
may cause intestinal derangements. Constipa-
tion and resultant intestinal putrefactive changes
are frequently the only ascertainable cause of
cardiac symptoms. The habitual use of drugs.
including the purpose for which they are used,
as well as the amount and frequency of alcoholic
beverages should be noted. The sex relation of
the patient, whether there be abstinence, ex-
cesses or perversions are frequently responsible
for a chain of neurotic manifestations. The
physician may overlook such causes unless he
definitely inquires into the sex life of his pa-
tients.
Social State. — If the patient be married, one
should know the number of pregnancies which
have resulted from the union; the number of
children born at full term ; the age of such chil-
dren ; their state of health both at the time of
birth and at the time the inquiry is made. It is
well known that a history of miscarriages or the
presence of stigmata in children may point to
the necessity of having a Wassermann blood test
or spinal fluid examination made in order to de-
termine the syphilitic origin of cardiovascular
symptoms.
EARLY PRESENTING SYMPTOMS OF HEART
AFFECTIONS
There is a group of complaints with which
many patients present themselves that are most
suggestive of early heart affections. Certainly
they bespeak the heart muscle fatigue which
usually precedes cardiocirculatory breakdowns.
As indicative of the order of frequency and the
relative importance of these earlier presenting
symptoms, the following table is presented :
TABLE NO. I
Incidents of Early Presenting Symptoms in 500
Consecutive Rejections from Military
Service*
Limitations on Sudden Physical Effort 70-S%
Precordial pain 68.2%
Giddiness 66.6%
Palpitation 664%
Coiigh 344%
Dyspnea 31-4%
Fainting 29-5%
Edema 7.8%
These figures were gathered from a group of
young men but recently drafted from civil life,
who had physical breakdowns of varying degree
during their first few weeks of training at a mil-
itary camp. It is significant that precordial pain,
giddiness and palpitation were present in two
out of three recruits ; cough, dyspnea and faint-
ing were symptoms in one out of three. Only
one out of every fourteen had edema, for the
reason that edema is one of the later symptoms
of heart affections, and these were early cases.
We may now briefly discuss these and other
presenting symptoms.
•From "Heart Affections: Their Recognition and Treatment"
by the writer. Reprinted by permission of The F. A. Davis
Co., Publishers, Philadelphia.
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52
THE PENNSYLVANIA MEDICAL JOURNAL November, 1920
(i) Inability to perform customary tasks
without distress was the dominant symptom in
this group of men. It was the reason for the
majority of them being referred to the cardio-
vascular board — ^and hence it is above all the
most important presenting symptom. (See
table No. 2.) The men "broke" under drills,
marches and especially under sudden bursts of
running; they were unable to withstand a de-
gree of physical effort which imposed no hard-
ship on hundreds of others. The routine of
military life uncovered heart affections which
were not revealed when the man was first re-
cruited from civil life. After the first cardiac
break a few were unable to perform even the
simple act of climbing stairs or bending to lace
shoes, without symptoms of distress.
(2) Precordial oppression and pain were
present in 76% of the men with mitral lesions ;
in 72% of those with cardiac enlargement (the
cause of which was not always demonstrable) ;
52% of early aortic lesions complained of pain.
Hence precordial oppression or pain is an early
and important symptom of cardiovascular affec-
tions, often of myocardial significance, and
should never be lightly passed over without a
thorough search for its cause.
Precordial hyperasthesia — tenderness of the
pedoral muscles — might be mentioned in this
connection. It is a sign that is not unusual in
cardiac conditions, and is elicited by grasping
the upper border of the pectoralis major muscle.
It is often found in cardiac neuroses.
(3) Giddiness — ^vertigo or dizziness — was
present in 71.5% of the men with mitral lesions ;
in 66.9% of those with cardiac enlargement and
in 58.8% of early aortic lesions.
(4) Palpitation — ^by which I mean a periodic
rapidity of heart rate of which the patient is un-
comfortably'conscious — was present in 67.5% of
mitral lesions; in 69.1% of cases of cardiac en-
largement and in 47% of the aortic lesions on
the series.
(5) Cough. — Of the mitral lesions found
among the 500 cases which form the bases of
this discussion, 35.7% had cough not due to
obvious cause; 38.3% of the cases of cardiac
enlargement presented this symptom, as did also
23.5% of the aortic lesions.
(6) Dyspnea was present irt 37.7% of the
mitral lesions, in 26.3% of the cases of cardiac
enlargement and in 35.2% of the aortic lesions
in this series.
(7) Fainting, as a presenting symptom, in the
above table shows an interesting discrepancy be-
tween a mitral lesion incidence of 27.1% and an
aortic incidence of 5.8%.
TABLE NO. 2
Percentage of Early Limitations on Effort in
500 Consecutive Rejections from
Military Service
DIAGNOSIS.
OlTtI Occupation
on Enllatment,
Unable to
Withstand
Military
Service.
Mitral LealODi,
Cardiac Enlargement (trans-
verse diameter averaging
M.« O. M.)
Nniro-Circulatory Astbenia .
Tachycardia (cause undem-
onstrable)
Myocarditis
Thyrotoxicosis
Aortic Lesions
Totals 600131.0
I I I
1S7».S31.2 19.1 20.3 69.1
13129
86 37.
1
49 30,
25 30,
17|27,
0 31.
«30.
o'is.
.5140.
o'a).
131.
2!31.2
2 20.2
20.0
22.8
36.0
24.2
8.3
11.7
6.0
8.5
8.0
17.1
54.llOi.g
53
r.e
71
8t
0180
4 44.
,4.')3.0
sios.o
,0 44.0
,2 24.2
11.4 55.170.6 49.7
EXERCISE TEST
When examining a patient who is suspected
of having early heart damage, it is well to en-
quire into the question of the heart's response
to exercise. It is by an exercise test that one
may arrive at an estimate of the heart's capacity
for work, and from such a test deduce signifi-
cant facts which are a basis for forming an
opinion as to the degree of efficiency of the heart
muscle.
The purpose of exercising such a person is to
raise the heart rate, by moderate effort, to a
point approximately 40 beats in excess of the
preexercise rate. In individuals of mature years
Digitized by
Cnoogle
November, 1920
HEART DIAGNOSIS— DISCUSSION
53
this may be accomplished by bending move-
ments; the patient stands in the erect posture
with the arms over the head and touches the
floor from ten to twenty times in rhythmical
bending movements. With younger adults,
more vigorous exercise will be required, such as
hopping loo times on one foot. The selection
of an appropriate exercise test for a given pa-
tient must rest with the judgment of the exam-
ining physician. No test is universally applica-
ble.
No matter whether the individual's pulse rate
be 72 or 90 before exercise, if an increase in
rate of approximately 40 beats is secured, it will
usually be found that the unaffected heart will
return to its preexercise rate within two minutes
following the exertion. There are exceptions to
this rule, which exceptions are found in men of
athletic tendencies or in those who lead strenu-
ous physical lives ; in such persons the heart rate
may increase very little after the usual exercise
test ; it will be necessary to double the amount
of exercise to estimate the response of such a
heart. Again, there are persons who are unable
to finish any exercise test, however mild it be,
on account of inherent weakness of the heart
muscle ; in persons of this g^oup it is unwise to
continue the exercise test. The respiratory rate
is usually between 24 and 32 immediately fol-
lowing exercise in unaffected hearts but returns
to normal within two minutes.
Affected hearts will usually mount to a higher
rate than 40 beats a minute following exercise ;
and it is characteristic of both neurocirculatory
asthenia and myocardial affections that the rate
remains disproportionately high and does not
return to the preexercise rate for several min-
utes following exercise. The respiratory rate
also remains elevated and dyspnea, of varying
degrees, is usually present in affected hearts.
INSTRUMENTAL AIDS IN DIAGNOSIS
It is not possible in the limited time at our
disposal to fully appraise the value of such in-
strumental aids in cardiac diagnosis as the
stethoscope, blood-pressure apparatus, x-ray,
polygraph and electrocardiograph. No matter
what their comparative values be, their diagnos-
tic values assume correct proportion only when
correlated with clinical evidence of heart affec-
tions. For example, to attempt to appraise
heart structure by simply having listened to the
sound which its action produces ; or to make a
diagnosis of valvular disease by the use of the
stethoscope alone, is hazardous and illogical.
By the same analysis, to attempt to arrive at an
estimate of heart muscle efficiency merely by
reading the scale of a blood pressure apparatus ;
or to attempt to mathematically juggle these
readings into terms of heart muscle efficiency, is
to lay one's self open to monumental error.
Many pulse arrhythmias are clarified by the use
of the polygraph ; and yet the physician cannot
arrive at a clinically satisfactory diagnosis nor
can he approximate the prognosis in a case with
any degree of certainty from a study of poly-
graphic tracings alone. The electrocardiograph
is invaluable in differentiating certain heart ir-
regularities ; and by the study of a set of curves
repeated at proper intervals and under varying
conditions of rest and exercise, one can often
deduce whether or not the heart muscle is af«-
fected and whether or not the cardiac lesion is
progressive. But the electrocardiograph cannot
be considered the one solitary and indispensable
factor in cardiac diagnosis, any more than one
would attribute such significance to the opthal-
moscope, stethoscope, blood pressure apparatus
or polygraph.
The physician who arrives at a clinically sat-
isfactory diagnosis of heart affections is the
physician who properly correlates the evidence
obtained by a study of the history ; the present-
ing symptoms; the rate response to exercise;
and the physical findings of the patient, with
laboratory evidence and with the testimony af-
forded by modem instrumental methods of
heart examination.
DISCUSSION
Dr. William H. Mbrcur, Pittsburgh : Mr. Chair-
man and Members of the Medical Section: I can
hardly say too much in opening the discussion on this
paper of Dr. Smith's, because it is of great importance.
All modem science is making great advances in the
prevention and cure of preventable diseases, but heart
diseases continue to increase almost constantly. All
the advances which have been made in regard to tuber-
culosis, and the advances made in infectious diseases
by means of health agencies, seem not to have been
able to check the advance of cardiac conditions. In
my opinion, and it is now extended over quite a num-
ber of years, heart diseases are more and more com-
mon and are not being practically arrested compared
with other diseases.
I think Dr. Smith is to be especially coniplimented
Digitized by '
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yGoogle
54
THE PENNSYLVANIA MEDICAL JOURNAL Novembbr. 1920
on two features of his paper, although I would com-
mend everyone he has made. In the first place, the
paper is carefully written, and second, it is carefully
thought out. A paper like that cannot be assimilated
by the audience after hearing it once.
One of the courtesies extended to a man who dis-
cusses a paper is to have a copy of the paper sent to
him in advance, so that he can read it. I read the
paper over carefully three times before I felt, as he
read it to you, I had assimilated the points he made.
I was very much impressed In reading it with the
remark that studying a subject is entirely different
from assimilating it. Hundreds of fellows study all
their lives, and never learn anything. The difference
between studying and assimilating is great, conse-
quently I would advise all those who are interested in
doing the best heart work they are capable of for their
patients, to read this paper when it is published, or to
get a reprint of it and study and assimilate it. Noth-
ing will help them more than that.
Dr. Smith in his paper has very well emphasized
some of the chief points, and it is not necessary for me
to lay any more stress in the discussion on some of the
points that impressed me more than any of the rest.
However, I wish to emphasize one or two points which
appear to me to be of special value.
The first point he made rather late in the paper was
the modern idea of laying so much stress on instru-
mental diagnosis of heart disease, the electrocardio-
graph and the stethoscope, and all those things. There
is no doubt the younger members of the profession
are making a great mistake of neglecting the old, well-
tried methods, and in laying too much stress on in-
strumental methods. The older physicians did not
have any of these modern laboratory aids, and yet in
a great many cases, if you read their contributions,
they made a great many better diagnoses than we
make to-day.
One other point I think the paper illustrates, with-
out going into it at length, was the point I heard only
on Sunday, made by a man in speaking about educa-
tion, and this applies to medical education as well as
to anything else, namely, there are so many men who
try to instruct the medical profession, they try to test
out their audiences either in speaking or in writing by
getting off half-baked ideas concerning which they do
not come to any conclusion themselves, hence it is a
waste of our time to listen to what they have to say,
and of their time.
Dr. Smith has given us well matured conclusions,
largely based on facts, and not on fancy, and I would
recommend them freely.
There were two or three other points, such as a
careful history and especially the question of focal
infection, which I would like to say more about, but
as my time is up, I will leave them to the subsequent
speakers.
Dr. J. M. Anders, Philadelphia: It seems to me,
what was- said in regard to the diagnostic study of in-
dividual cases is of special value and of great im-
portance. I think some of my colleagues sitting near
me recall the day when the masters in the art of diag-
nosis attempted to interpret obscure cardiac cases after
a single superficial physical examination of the heart,
and I can quite as easily recall the fact that this simple
and superficial method met frequently with failure as
shown by the revelations and observations made at
the dead house. It is true, as Dr. Smith has intimated,
we cannot disassociate cardiac affections from the dis-
eases of other systems and organs of the body. While
this may be said of other systems and organs of the
body, it is especially true of cardiac affections, that we
must apply a thorough and systematic method referred
to by the Chairman of the Section a moment ago, and
again emphasized by Dr. Smith in his paper. That
method embraces a careful anamnesis, a careful record
of the presenting symptoms and of the physical signs
repeatedly elicited, and thorough laboratory studies of
the case. This is the only way, it seems to me, to make
an absolute diagnosis, and there should always be in-
cluded in the diagnosis the leading etiological factors
and associated conditions. I take it, it is a reflection
on our methods rather than on our diagnostic acumen
that we so often fail to recognize such simple asso-
ciated conditions as renal insufficiency, as hydro-
thorax, and the like, when they occur in connection
with cardiac diseases. The arrythmias, myocarditis,
in connection with the acute infections, especially ty-
phoid fever, acute articular rheumatism, diphtheria,
and the like, as well as chronic myocardial diseases of
toxic origin, all require this thorough, systematic
method as laid down by Dr. Smith for their correct
solution and interpretation. We are, thanks to the
more modern scientific methods, beginning to distin-
guish between the lesions of the conducting media of
the heart and myocarditis as they occur both in acute
and chronic affections of the heart, and I wish to say,
in concluding niy brief remarks, that, it seems to me,
we as practitioners of medicine should realize the im-
portance of making thorough studies of our cardiac
cases, and if this be found impracticable at home, we
always have an opportunity to send our patients to an
expert diagnostician with the facilities for studying
and reporting.
Dr. Amos W. Colcord, Clairton: I wish to say a
few words from the standpoint of an industrial sur-
geon on cardiac diseases. This is a much neglected
field, and should be emphasized a good deal more than
it is in examining men engaged in the different in-
dustries.
During the last six years, I have examined a gpreat
many men who are engaged in the different industries,
and I confess I have been guilty of neglect in this
respect.
We owe a debt of gratitude to Sir James Mackenzie,
of England, for emphasizing four points in the diag-
nosis and handling of cardiac cases. First, the relative
importance of heart murmurs, the physical findings,
et cetera. Second, the great importance of a careful
history and the presenting symptoms in heart cases.
Third, the fact that we can detect early the signs of
heart failure, and fourth, by so regulating the life of
the patient that we can prolong his life and increase
his years of efficiency. It is right here that we can
drive the nail, and we as industrial surgeons must
take advantage of the great advances in cardiac dis-
eases. By making more thorough examinations of
our heart cases, by estimating the patient's margin of
resistance, and how his heart will act under stress, we
can find out in six or ten minutes by making a careful
examination whether the patient has a subnormal
heart and can have him come back for repeated exami-
nations. The patient should be placed in a position
where his heart is subjected to the least stress, and we
should watch him for the effect of the work on his
heart. I believe if we will do that in the thousands of
cases that come to us, we can materially increase the
efficiency of the men in our industries, we can pro-
long their lives, and their years of work.
Dr. S. Stalberg: I think the subject of Dr. Smith's
paper is of great importance. There is no question
that the work on electrocardiographic, etc., diagnosis
Digitized by
mic, etc., diagnosi
LiOogle
November, 1920
BLOOD PRESSURE APPARATUS^HEIN
55
of heart disease is not only important, but has just
begun, and is opening very important and very inter-
esting vistas in this field of diagnosis.
There was one point in Dr. Smith's paper in which
I was especially interested, and that was the so-called
exercise test or the examination of heart sufficiency
by means of standard exercises. I first became inter-
ested in the subject in the heart ward of one of the
army base hospitals ; the tests which we applied there
were a whole lot like the one Dr. Smith mentions. The
ward specially consisted of cases of neurocirculatory
asthenia — cases for the most part in which there was
no demonstrable organic cardiac condition. In those
cases for various reasons, whether the predominant
feature was myogenic or neurologic, the men were
not able to respond to the exercise tests normally;
they were, as Dr. Smith says, men who had broken
down in the course of their military training.
With the hopping test on the left foot, we found
that in practically all the cases these men in the first
place had a rather rapid heart beat, and in the second
place their response was poor. The rate of increase
after exercises was greater than normal, and it took
them a greater time to return to normal, which in
healthy individuals should be two minutes. The great
majority of them were eventually discharged as unfit
for military duty.
Since my discharge from the army I have used this
test. Not all of us can avail ourselves of the electro-
diogram, polygraph, etc., but we can ail employ the
exercise test, and in my opinion it is one of the most
important tests in diagnosing the sufficiency of the
heart After all, in the last analysis, to my mind, the
important thing is the sufficiency of the heart muscle
itself.
One point, I believe mentioned by Dr. Kohlman, was
heart murmurs. Many people maintain that heart mur-
murs, especially systolic apical murmurs, mean noth-
ing. I believe unless it is a functional murmur it
means a good deal. Endocarditis leads to myocardial
degeneration.
There is one question I would like to ask Dr.
Smith, and that is, what his experience or opinion is
with regard to determining the relative measurement
of the heart with regard to the measurement of the
chest Just before I was discharged from the army it
occurred to us not only to measure the dimensions of
the heart but also to measure it with regard to the
figure of the patient that is, taking into consideration
both the height of the patient and the measurement
of his chest wall; but the investigations were not
pursued. Some work along these lines has since been
done by French authors.
Dr. Smith, closing: In reply to Dr. Stahlberg's
query as to the relative measurement of the transverse
diameter of the heart as compared to that of the chest ;
I do not believe any definite, absolute ratio exists.
Some of the x-ray experts who have devised tables on
this subject have recently told me that further obser-
vations proved such tables inaccurate. I think we
should consider the general conformity of the chest
wall and the influence which the' type of chest may
have on the contained organs. The heart diameters
should be measured from the midsternal line, so many
centimeters to the right of that line in the fourth in-
terspace and so many centimeters to the left of that
line in the fifth interspace ; adding these gives us the
total transverse diameter of the heart. In a group of
2,215 men, the average transverse percussion diameter
was 12^ centimeters, but one has always, in an indi-
tndual case, to consider whether he is dealing with an
elongated chest or a short narrow chest ; and, by em-
ploying the sense of comparison deduce whether these
measurements, whatever they are, constitute cardiac
enlargement for the individual. A transverse diameter
of 13H centimeters might constitute marked cardiac
enlargement in a slender young girl, — yet in a broad
chested robust youth such measurements would be well
within the individuals' normal physiologic limits.
ERRORS AND OVERSIGHTS RESULT-
ING FROM THE USE OF THE BLOOD
PRESSURE APPARATUS*
GORDON E. HEIN, M.D.
WTTSBURGH
The object of this communication is to em-
phasize again a few of the more common errors
resulting from the routine use, and in one in-
stance from the lack of use of the sphygmoma-
nometer. We do not intend to discuss the value
of the blood pressure instrument, nor the mul-
tiple uses to which it is put, but wish to point
out a few clinical observations made during
study of cardiac cases. Patients who have
been given various drugs because of arterial
hypertension without adequate search for the
conditions causing or associated with the in-
creased blood pressure are not uncommon.
Probably more frequent are the cases in which
the height of the mercury column was considered
the index of progress or retrogression of patho-
logical processes in which insufficient attention
had been given to normal or temporary varia-
tions. Again, one sees patients with a low emo-
tional threshold concerning whom a single
observation caused an entirely errcmeous impres-
sion, which was not corrected later by subse-
quent examinations. On the contrary, without
the sphygmomanometer conditions are over-
looked which would have been suggested by its
routine use. This is true especially of pulsus
alternans, which while it must be sought for,
may be detected frequently, when present, with
the expenditure of very little time and a little
care.
Case after case is encountered in which de-
tection of an increased systolic tension was con-
sidered the end point in an examination and was
considered the basis for drug treatment, with-
out further search for the underlying causes.
Without doubt, the heart at the time was doing
more than the normal amount of work, but the
finding of hypertension "per se" should be a
g^ide to direct the course of inquiry rather than
an indication for exhibition drugs intended to
'Read before the Section on Medicine of the Medical Society
of the State of Pennqrlvania, Pittsburgh Session. October $,
1920.
Digitized by
Cjoogle
56
THE PENNSYLVANIA MEDICAL JOURNAL November, 1920
lower blood pressure. Nor is such treatment
always without danger. Cases are on record
where collapse has followed the administration
of as small a dose as i/ioo gr. of nitroglycerine,
(i) Patients who are subjectively worse after
such treatment are by no means uncommon.
Conversely a high blood pressure may lead
immediately to the inference that the patient
has renal insufficiency. While it is true that
hypertension is frequently associated with renal
and arterial disease it still remains to be proved
that in all cases hypertension is a result rather
than a concomitant or an etiologic factor in the
production of the nephritis or arterial sclerosis.
When one considers the multiplicity of factors
at work maintaining an adequate arterial ten-
sion; the efficiency of the cardiac muscle and
valves, the condition of arteries, arterioles, capil-
laries and veins, the condition of the nervous
system, renal system, gastro-intestinal system,
and all factors which in turn modify the few
mentioned, the futility of placing the responsi-
bility for changes in blood pressure on one par-
ticular factor or organ is clearly evident.
In the search for conditions which are asso-
ciated frequently with arterial hypertension the
state of the kidneys and vascular system deserve
an important place, but not to the exclusion of
other considerations. To mention a few such
conditions as familiar hypertension, noted by
Dana (2) ; the hypertension occurring during
and after the menopause in some women (3) ;
the effect of constipation, of obesity, of exercise,
of. eating and especially the result of emotion
must be bom in mind. Moschowitz (4) has
emphasized the last in the description of the
type he found most frequently showing hyper-
tension ; "The patients are overweight and
sometimes even obese. The neck is short, the
muscles are soft, their bodily movements are
sluggish, their carriage and walk are ungraceful
and they lack the spring and elan of the former
athlete. Psychically, these people are tense;
they pursue their vocation with tremendous
seriousness and worry over trivialities
Phlegm and hypertension are in my experience
antagonistic."
The role of mental reactions in producing
both fleeting and more constant changes in ar-
terial tension, is, I believe frequently underesti-
mated. Many of the so-called tests for cardiac
efficiency are tests of vasomotor control and re-
flect the response of the nervous system to
stimuli and not the condition of the heart
muscle.
Because of response of the vasomotor mech-
anism to emotion single observations are often
of very little value. The pressure obtained in
the office and for the first time in the hospital is
usually higher than later determinations. Those
who served on draft boards or who worked on
cardio-vascular boards during the recent war
were no doubt struck by the marked changes
which may occur in tension within very short
periods of time. I have observed the systolic
pressure drop from 170 mm. to 120 mm. within
20 minutes. It may take weeks or longer. Dur-
ing a routine examination of officers for over-
seas service one physician was found to have a
systolic pressure of 180 mm. He insisted that
an error had been made since he had been taking
his own pressure repeatedly for several years
in the course of investigations on arterial ten-
sion. He was finally convinced that the obser-
vation was correct, but was assured that proba-
bly the condition was temporary, and was the
result of the strain under which he was living.
He returned daily, requesting subsequent exami-
nations and at the end of ten days his systolic
pressure had gradually decreased to 140 mm.
During subsequent examinations for a period of
a month it remained at approximately this level.
Often in a hospital a vicious circle is pro-
duced in a neurotic patient who is made aware
of deviations from the normal of his or her ar-
terial tension. The examinations are closely
observed by them and entirely unwarranted con-
clusions are drawn. It is often, I believe a bad
policy to tell a patient anything about his blood
pressure. It may be necessary in some cases to
warn people of unnecessary dangers which
they are being exposed to, but sometimes harm
rather than good results.
This instability of vasomotor control is the
element which makes the Goetsch test difficult
of interpretation in many cases. We feel that a
control series of observations after the injection
of 7J^ m. of sterile water should be used in each
case in which the test was made. The effect of
adrenalin on some patients with arterial hyper-
tension as demonstrated by O'Hare ( i ) , should
not be neglected. He concludes that "the ves-
sels are especially sensitive to the intra-muscular
injection of adrenalin, a markedrise in pressure
taking place immediately after its injection."
He reported only ten cases in which it was used,
nine of which gave a typical reaction. The rise
was so marked in two cases that he was un-
willing to try the test on more patients. Inci-
dentally it may be noted that the response to the
same stimulus is not always the same. Recently
the arterial tensions of eight medical students
were observed prior to and following a 20-
minute oral quiz. In three the systolic pressure
was increased 1 5 mm. after the 20-minute period
while in another it dropped 10 mm. under simi-
Digitized by VjOOQIC
November, 1920
BLOOD PRESSURE APPARATUS— HEIN
57
lar conditions. O'Hare has noted changes of
34 nun. in systolic and 24 mm. in diastolic pres-
sure following the discussion with the patients
of the subject of their blood pressure.
Basing deductions as to physical improvement
or decline on a finding as variable as the arterial
tension frequently leads to error. Recently I
had the opportunity of observing the progress
of two patients, both of whom had cardio-renal-
vascular disease. Exitus in each case was
caused by a terminal broncho-pneumonia. In
one patient the systolic blood pressure rose
slowly ; in the other it dropped. The interpre-
tation that one patient was improving because of
a decrease in arterial tension, or that the other
was retrogressing would not be justified by the
outcome.
The same reserve should be maintained in in-
terpreting formulae such as that of Gibson, (5)
who states that "when the arterial pressure ex-
pressed in millimeters of mercury does not fall
below the pulse rate, expressed in beats per
minute, the fact may be taken as of excellent
augury, while the converse is equally true."
Tice (5) observed that in 31 cases the rule held
in 64.5%. This leaves 35.5% or over 1/3 in
which the rule was in error.
Newburgh and Minot (6) state that Gibson's
rule held in but 43% of cases observed by them
and concluded that blood pressure measure-
ments cannot be used as a basis for treatment.
A rule which is erroneous in almost 50% of the
instances in which it is applied can be of little
value in a given case.
Determining a normal systolic pressure by
methods such as adding .5 mm. to 120 mm. for
each year after the twenty-first and similar
formulae probably results more often in a wrong
than a correct impression. The normal limits
for an individual cannot be expressed in half or
single millimeters of pressure but considerable
latitude must be provided. A rigid rule may be
satisfactory to an examiner for an insurance
company. He may realize that people with good
expectations for prolonged life are included
among the people rejected. The physician's
problem is the individual and the diagnosis of
disease where none exists is a serious injustice.
The discovery of a systolic blood pressure of
145 mm. in a man of 24 years of age demands
further examination, but in itself does not con-
stitute evidence upon which definite deductions
may be based. It is part of a picture and as
such must blend with the rest to produce a fin-
ished work. It is by no means rare to observe
individuals doing their daily work and living
normal lives with arterial tension above the level
which is ordinarily found in people of similar
age. Conversely patients with definite cardiac
disease often have arterial pressure closely ap-
proximating the normal.
Mrs. B., aged 50, had no enlargement of the
heart, no murmurs, no ankle oedema, no en-
larged liver and a blood pressure of 128 mm.
systolic and 80 diastolic.
Autopsy revealed a heart weighing 170 grams
showing marked fibrous degeneration of the
myocardium.
Mrs. E. M. S., aged 50 years, died five days
following operation for cholelithiasis. Exami-
nation of heart before surgical intervention re-
vealed distant heart tones, no enlargement nor
murmurs. Blood pressure observations made
during operation were :
At beginning: Systolic: Diastolic:
140 mm. 84 mm.
In 20 minutes 140 mm. 96 mm.
In 30 minutes 120 mm. 78 mm.
In 45 minutes no mm. 78 mm.
After operation 1 18 mm. So mm.
At autopsy fibrous myocardial degeneration
was found. Heart valves were negative. Heart
weight was 210 grams.
The blood pressure may be high in patients
with failing hearts. I have within the past six
months seen a patient with marked dyspnea,
oedema of the ankles, enlarged liver, and pulsus
altemans with a blood pressure of 240 mm.
systolic, and 132 mm. diastolic.
Use of aneroid sphygmomanometers has in-
creased greatly because of ease in employing
them. But, whereas a mercury instrument nec-
essarily registers accurately the aneroid instru-
ment should be frequently checked to see that it
is functionating properly. Recently I examined
5 aneroid sphygmomanometers in daily use in a
hospital. It can be seen by the following table
thiat one of the five was accurate although two
did not deviate from normal to a marked degree.
Mercury
Column. Sphygmomanometer.
No. I No. 2 No. 3 No. 4 No. S
O mm. O mm. O' mm. O mm. O mm. O mm.
40 40 41 42 38 40
60 60 63 60 57 61
100 100 100 98 94 104
120 120 118 120 114 127
200 200 198 ao6 194 215
250 250 244 256 24s 264
In the case of the other two the error was
greater. A patient with a systolic pressure of
130 mm. according to one instrument would
show 143 mm. with the other or an individual
with 120 mm. systolic pressure would have only
107 mm. with the other sphygmomanometer.
As the pressure rose the error was increased.
In no way do I wish to disclaim the valuable
information which is obtained from the routine
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58
THE PENNSYLVANIA MEDICAL JOURNAL November, 1920
use of the sphygmomanometer, but merely wish
to point out the need of reserve in interpreting
observations and the need of caution in deter-
mining the underlying etiologic factors when
deviations from normal are found. Every pa-
tient is an individual and as an individual he
must be considered.
There is one use of the sphygmomanometer
which to me seems to have been insufficiently
emphasized. I refer to the detection of pulsus
altemans by the cuff method. In 1915 Herrick
(7) demonstrated that by carefully adjusting
the pressure in the cuff of the sphygmomanome-
ter slightly below the systolic level in a given
case of pulsus altemans, the pulse rate could be
halved. Every other beat is weaker and only
the stronger pulse waves come through, while
the weaker impulses are completely obstructed.
At this pressure also the oscillations of the mer-
cury column are alternately higher and lower.
In most patients in whom continuous altera-
tion of the pulse could be demonstrated by the
sphygmograph we were able to show alteration
by the cuff method. Frequently we have dis-
covered alteration by means of the sphygmoma-
nometer, later corroborating it by an arterio-
gram. Pulsus altemans occurring but for one
or two cycles, after a premature beat is discov-
ered usually only by graphic methods.
The frequency with which pulsus altemans
occurs and the definite aid it renders in prog-
nosis place it among the signs which are too im-
portant to be neglected. Windle (8) found
pulsus altemans in 30.5% of 202 patients having
arterio-sclerosis. White (9) places the inci-
dence about the same, having demonstrated it in
23.6% of 300 patients with cardio-vascular dis-
ease. Gordinier ( 10) states that he agrees with
MacKenzie and Windle in giving it third place
among pulse irregularities.
The grave significance of the finding has been
emphasized frequently. MacKenzie (11) states
that his rtsults agree with those of Windle the
majority of whose patients with pulsus altemans
died within two years of its detection. Hart
(12) knows of no case of continuous alteration
"in which death has been delayed more than two
years." Patients exhibiting the phenomonen do
not have always symptoms referable to the
heart. Windle (13) reports one case in which
the patient had no heart symptoms nor dyspnea
until four months after the detection of the
pulsus altemans. The search for such a valua-
ble sign for prognosis should be routine, espe-
cially so, since it may be performed in a few
minutes at the bedside. Nevertheless, here too,
caution must be used in interpreting findings.
Regularly recurring premature beats ; auricular
flutter with alternating periods of more or less
marked heart block ; and even cases of auricu-
lar fibrillation may present alternately strong
and weak pulse waves which may appear so ap-
parently regular that without graphic aid they
would be considered pulsus altemans. In doubt-
ful cases the sphymograph or similar instru-
ments should be resorted to for final decision,
but nevertheless the sphygmomanometer has its
place at the bedside in first suggesting the pres-
ence of an alternation.
SUMMARY
Interpretation of blood pressure observations
requires caution. Opportunities for error
abound. Changes produced by vasomotor in-
stability as a result of emotion or mental activ-
ity, especially, are apt to create wrong impres-
sions. A wide limit for normal is necessary for
both systolic and diastolic pressure.
A vicious circle may be produced in a neurotic
patient who is informed of deviations from nor-
mal in his or her arterial tension.
Single blood pressure estimations often are
valueless.
Aneroid sphygmomanometers require re-
peated checking to insure confidence in their ac-
curacy.
Increased or decreased blood pressure must
be considered signs, not clinical entities. Per se
they do not demand drug treatment always.
Danger may attend lowering hypertension.
Pulsus altemans is too infrequently sought
for. Its presence often may be detected by the
cuff method, and its prognostic value is g^eat.
When found in the manner described by Her-
rick it should be corroborated by a graphic
method.
I wish to thank Dr. Heard for his assistance
and for the privilege of observing his cases.
(i) James P. O'Hare, Vascular Reactions in Vascular hyper-
tension; Am. Jour, of Med. Sc. CLIX. 369, March, 1920.
(2) Harold W. Dana, Theories Regarding Blood Pressure;
Jour. A. M. A. 72: 1432, May 17, 1919.
(3) A. H. Hopkins, Climacteric Hypertension: A Study ol
High Blood-Pressure During and Following the Menopause, Am.
Jour, of Med. Sc. CLVII: 826, June, 1919.
_ (4) Eli Moschowitz, Hypertension; — Its Significance, Rela-
tion to Arterio-Sclerosis and Nephritis and Etiology. Am.
Jour, of Med. Sc. CLVIII: 668, November, 1919.
(s) Quoted by Frederick Tice, The Blood Pressure in Pneu-
monia; Am. Jour, of Med. Sc. CLII:ai, July, 1916.
(6) A. H. Newburgh and Geo. R. Minot; The Blood Pres-
sure in Pneumonia; Arch, of Int Medicine, 14: 48, July 15,
1914.
(7) Herrick, James B., Jour. A. M. A. LXIV: 739, February,
I9J5-
(8) J. D. Windle, Quart. Jour, of Med. 6: July, 1913.
(9) White, Paul D.. Quoted by Cabot-Physical Diagnosis
♦P-i 14. Wm. Wood & Co., New York, 1919.
(10) H. C. Gordinier; Pulsus Altemans, Am. Jour. Med.
Sc. CXLIV: 174, February, 1915.
(11) MacKenzie: Diseases of the Heart: P-26o 3d Ed. Ox-
ford iJniversity Press, London 1918. ■
(12) T. Stuart Hart; The Diagnosis and Treatment of Ab-
normalities of Myocardial Function P-198, Rebman Co., New
York, 19 1 7.
(13) J. D. Windle, Quarterly Journal of Medicine, 10:275,
July, 1 91 7.
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November, 1920
AURICULAR FIBRILLATION— HEARD
59
DISCUSSION
Dr. Andrew P. D'Zmura : Mr. Chairman and Gen-
tlemen: Several years ago Mackenzie in a letter to
the Lancet concerning the value of a certain blood
pressure formula then somewhat in vogue, stated that
just as valuable information could be gained from it
as could be derived of the respiratory function by
measuring the nasal orifices. This picturesque hyper-
bole was probably intended to emphasize the fact that
the blood pressure is only one factor in the main-
tenance of an efficient circulation and that one cannot
draw any broad conclusions as to the status of the
circulation from the blood pressure findings alone.
No hard and fast rules can be formulated ; no very
close classifications can be made. It is possible to
make interesting comments with regard to blood pres-
sure in general but every individual must set his own
standard. We cannot draw any conclusions from an
isolated observation because there are so many fac-
tors which disturb it: repeated observations must be
made.
Take the matter of emotion. Dr. Hein mentioned
the case of the students taking an oral quiz. I can
cite the case of patients visiting the dentist. They
react in different ways. One patient may respond by
having an initial rise of 30 or 40 mm. If the dentist
has treated him kindly and he has not suffered too
mtKh there is a drop to the normal level after leaving
the chair. If on the other hand, the patient is still
angry with the dentist, the blood pressure remains up
to approximately the increased level for some time.
To illustrate: a man with a systolic pressure of 175,
taken before going into the dentist's chair, had a rise
to 220 during the extraction of some badly decayed
roots because anaesthesia was none too good and he
was hurt. His pressure remained over 200 during
several hours subsequent observation.
Emotion can also be shown to have its part in the
supposedly accurate information which can be gained
from effort tests; these when taken alone, may also
be nothing but a test of vasomotor response and the
status of the circulation as a whole cannot be deter-
mined from them alone. They have not been stand-
ardized sufficiently for us to do that. Especially when
we are considering N.C.A. or whatever one may call
it — ^we certainly can not ascribe the most important
part of the circulatory phenomena to the heart or any
other single factor while we are still uncertain as to
the real causation of this condition.
Every once in a while physicians, particularly sur-
geons and anesthetists, rediscover the supposition that
a systolic blood pressure of 120 and a diastolic of 80
are optimal regardless of the many other factors which
go to make up the state of comparative health. Im-
mediately the magic of figures is invoked and we have
the birth of another formula which attempts to assess
the circulation as a whole by considering but one fac-
tor in the maintenance of an efficient circulation and
that an extremely variable one.
The object of Dr. Hein's paper wsts not to say that
blood pressure determinations are of no value. It
was to point out many pitfalls and the futility of at-
tempting to make blood pressure findings tell the en-
tire story. Sometimes they do; very much more
frequently we believe that it is necessary to determine
many other factors before a conclusion about the effi-
ciency of the circulation can be drawn.
Dr. Hein, closing : I merely want to emphasize again
that the heart may be seriously damaged and the normal
blood pressure be present, or an abnormal blood pres-
sure may be present with an apparently normal heart.
Also the pulsus altemans; it is not looked for as
often as it should be. It is not a routine procedure
by a good many physicians in making a complete
physical examination.
TRANSIENT AURICULAR
FIBRILLATION
JAMES D. HEARD, M.D., and A. H. COLWELL,
M.D.
nrrsBURGH, pa.
Fibrillation of auricles with its resulting total
disorder of ventricular rhythm, is usually ob-
served at a time when the disturbance of me-
chanism has become permanent. Yet auricular
fibrillation is very often a transient disturbance.
Temporary attacks may be single or multiple;
they may persist for a few seconds only, or may
have a duration of minutes, of hours, or of days.
Isolated attacks usually occur in hearts of ap-
parently normal musculature and may then be
due to some cause outside of the heart itself;
when the cause is removed, normal mechanism
is resumed. Multiple attacks may rarely occur
in normal hearts due to reoccurrence of a given
extrinsic stimulus. On the other hand, a dis-
eased myocardium, especially one which has
been damaged by the toxins of rheumatic fever
or which is a subject of fibrous change, is par-
ticularly prone to fibrillate. In such damaged
hearts attacks are commonly multiple, since
fibrillation may be induced by many and, proba-
bly, by slight causes. In certain instances, it is
probable that fibrillation once induced never dis-
appears. However, it is possible that even in the
fibrillation accompanying mitral stenosis of
rheumatic origin, one or more transient attacks
may have preceded in the final permapent total
disorder of mechanism. The pulse which ac-
companies this arrhythmia has long been known
as "pulsus irregulus perpetuous." Since we now
know that the disorder of rhythm is not neces-
sarily a permanent one, but may be the expres-
sion of a transient disturbance, this term has
been discarded as inaccurate.
The object of this communication is a discus-
sion of the clinical aspects of transient auricular
fibrillation. The discussion will be based upon
the literature, and upon a series of 1 1 cases ob-
served by the authors.
Our material consists of a total of 11 cases
observed at St. Francis Hospital during a period
of 5 years. The diagnosis in each case was con-
firmed by graphic records. Of a total of 835
patients electrocardiographed, auricular fibrilla-
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60
THE PENNSYLVANIA MEDICAL JOURNAL November, 1920
tion was observed in one hundred and nine or
13% of the number. Of these iibrillating cases,
II, or 10%, were of the transient type.
Case Histories:
No. I. (A/. R. a-336). Male,— Age 27. Palpitation,
dyspnoea on exertion, praecordial distress, general
malaise, weakness, apprehension, nausea, vomiting.
Gross disorder of rhythm, no pulse deficit: physical
examination otherwise negative.
(?) Typhoid at 7 and 16 years — Tonsillitis at 22.
Tobacco : 15-20 cigarettes a day. Duration of attacks
4 to 18 hours — beginning and ending of attacks sudden.
Number of attacks as indicated by history, four. No
digitalis. Patient living.
No. 11. (5. L.-A-7S7)- Male,— Age 23. Palpitation,
lassitude. Physical examination negative except for
gross irregularity of heart and acceleration. Pertussis,
age 7. Pneumonia: age 15. Peritonsillar abscess:
age 19. Attacks multiple (by history), induced by
sudden exertion or emotion, duration variable: sud-
den onset and termination. No digitalis. Wassermann
negative. Patient living.
Case No. III. (O. L.-A-303). Male,— Age 55. Pal-
pitation, dyspnoea, faintness. Mitral insufficiency —
chronic myocardial degeneration. Pulse 106, frequent
premature beats. Slight pretibial oedema. History of
repeated "sore throat." Wassermann negative. In-
crease of symptoms during attack. One attack ob-
served. No digitalis. Patient living.
No, IV. (/. S.-A-I02). Male,— Age 65. Dyspnoea,
Haemoptysis, pyrexia. Badly infected mouth. Aortic
insufficiency, cardiac hypertrophy. Marked peripheral
arterio-sclerosis. B. P. 171/69. Broncho-pneumonia.
Two attacks fibrillation observed. Strophanthin in-
travenously. Patient died during period of normal
mechanism.
No. y. (/. C.-A-ig4). Male,— Age 67. Chronic
morphinism. No complaints. Chronic myocardial de-
generation. Moderate cardiac hypertrophy. Occa-
sional premature beat. B. P. 135/60. Two attacks
observed. No symptoms during attacks. Present con-
dition of patient not known.
No. VI. (A. R.-A-48) . Female, — Age 42. Dyspnoea,
palpitation, moderate oedema of legs. Extensive syphi-
litic _ ostitis. Mitral insufficiency. Marked chronic
cardiac hypertrophy. Wassermann four plus. Eight
pregnancies. Chronic illness for many years. One at-
tack of seven days' duration following administration
of tincture digritalis, 5 S. S., daily for 17 days. Pa-
tient still living. Health "as good as usual."
No. yil. (F. S.-A-149). Male,— Age 64. Praecor-
dial discomfort, exhaustion, depression, restlessness,
dyspnoea. Chronic myocardial insufficiency : diabetes
mellitus. History of attacks of irregular heart action
for 15 years, attacks gradually increasing in frequency
and duration. Resumption of normal mechanism twice
during observation, while receiving digitalis. Patient
living, fairly active, reported well.
No. VIII. (M. K.-A-360). Female,— Age 48.
Dyspnoea, palpitation, praecordial pain, moderate
oedema of legs. Moderate enlargement of thyroid,
exopthalmos, nervousness, rapid heart action, slight
cardiac hypertrophy. Mitral insufficiency. Rubeola,
parototis and pertussis in childhood. One attack ob-
served. Patient died one month later of thyrotoxi-
cosis : cardiac mechanism unknown.
No. IX. (M. S.-A-338). Female,— Age 61. Dys-
pnoea, palpitation, cyanosis, extreme distress during at-
tack of transient fibrillation which occurred during
course of lobar pneumonia. Cardiac renal vascular
disease. Only one attack fibrillation observed, dura-
tion six weeks. Strophanthin intravenously and digi-
talis by mouth during attack. Patient living : reported
well.
No. X. (A. M.-A-738). Male,— Age 59. Dyspnoea,
phasic breathing, delirium, pyrexia, diabetic gangrene
of left great toe: acute lymphangitis of left leg.
Chronic cardiac hypertrophy of marked degree:
chronic myocardial degeneration. No marked peri-
pheral arterio-sclerosis. Diabetes mellitus. One at-
tack of transient fibrillation observed, duration nine
hours. Strophanthin intravenously during attack. Pa-
tient died under observation 27 hours later, mechanism
of heart being normal.
No. XI. it. L.-A-738). Female.— Age 50. Dysp-
noea, palpitation, praecordial discomfort, general weak-
ness. Acute purulent bronchitis, marked oral infec-
tion, mitral insufficiency, chronic myocardial degenera-
tion. Very marked peripheral arterio-sclerosis. Two
attacks of fibrillation observed. Duration of attacks
three or four days : symptoms increased during at-
tacks. Patient still living.
FREQUENCY OF THE CONDITION
Since we have been able to report but 1 1 cases
of transient auricular fibrillation as observed in
a large general hospital during a period of 5
years, it might appear that the disorder in ques-
tion is a rare one. But no such conclusion would
be justified. The disorder, as its name implies,
is fugacious. It may occur and pass unnoticed
during sleep, or it may produce no discomfort
when it occurs during the waking state. In
either case, the attention of the attendants is
not directed toward the irregularity. On the
other hand, a physician may be called who has
not accustomed himself to think of cardiac ir-
regularities in terms of mechanism. If this
occur, naturally no attempt at an accurate diag-
nosis is made. It is possible that all cases of
permanent auricular fibrillation are preceded by
one or more transient attacks, and that many
such attacks are undiagnosed. It may be that
with a more widespread ability to differentiate
between the various cardiac irregularities, tran-
sient auricular fibrillation will be found one of
the commonest disurbances of mechanism.
ETIOI/)GY
Sex appears to play an important part in the
transient as well as in the permanent type of
fibrillation. Of our patients seven were males
and four were females. The relationship close-
ly approximates that of 189 subjects of perma-
nent fibrillation studied by Lewis, in whom the
sex distribution was males 1 14, females 75.
The average age of the patients was 51 years.
The patients may be readily sorted into two
groups; namely, a group in whom the hearts
were apparently normal, and a second group in
whom there was definite evidence of damaged
myocardium. Of the first group the average
age was 25; of the second group of nine pa-
tients, the average age was 56.5. In each of the
two patients (Case I-II) of group I, we have a
history of multiple attacks of transient arrhyth-
mia. In one patient, (Case I), the arrhythmia
followed gastro-intestinal disturbance, in the
other (Clase II) emotion or sudden effort. In
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November, 1920
AURICULAR FIBRILLATION— HEARD
61
group II, all patients showed distinct evidence
of myocardial degeneration: all had definite
fibrosis; five (Cases III-IV-VI-VIII-XI), were
the subject of chronic valvular disease; one
(Case VI), was in an advanced stage of tertiary
syphilis.
In addition to the above permanent changes in
myocardium, there has been in every patient but
one (Case III), a recognized toxic influence
which may well have been responsible for the
transient fibrillation. Two of the patients,
(Cases VII-X), suffered with hyperglycemia
with its accompanying and varying stages of
acidosis. In the other patients, fibrillation ap-
peared during thyrotoxicosis (Case VIII),
lobar pneumonia (Case IX), broncho-pneu-
monia (Case IV), acute bronchitis (Case XI),
and chronic morphinism (Case V). In a re-
maining case, (Case III), the provocative agent
was unrecognized. It is interesting to notice
that this patient was in an advanced stage of
myocardial degeneration, clinically associated
with numerous premature contractions. Unfor-
tunately, no graphic record of these premature
contractions was obtained: it is not unlikely
that they were of auricular origin, since auricu-
lar premature beats so commonly precede fibril-
lation.
SYMPTOMS
In one of our patients (CaseV), symptoms at-
tributable to disordered heart action were en-
tirely absent. This patient was the chronic drug
addict mentioned above, and it is not improbable
that the large doses of morphine and chloral
which he was taking prevented him from being
aware of his cardiac disturbance. In three pa-
tients (Cases VI-IX-XI), there was an increase
in previously existant distress ; in three patients
(Cases I-II-VII), who had had no symptoms
previous to attack, there was onset of faintness,
marked general weakness, dyspnoea and palpita-
tion. One of these patients, a clergyman, stated
he felt "like a wilted flower," another, a phy-
sician, said he felt "like H-11." In the remain-
ing five cases, the patients were so acutely ill
that the onset of fibrillation was unnoticed by
them. In the case of a woman (Case IX) who
was suffering from lobar pneumonia, the onset
of fibrillation was associated with an apex rate
of i8o and with extreme distress.
NUMBER AND DUR.\TION OF ATTACKS
In five patients (Cases III-VI-VIII-IX-X),
only one attack is known to have occurred. In
three patients, (Cases IV-V-XI), two attacks
were observed. In three other patients (Cases
I-II-VII), the history indicated that several at-
tacks had occurred; yet graphic records were
obtained for but one attack in one patient and
for two attacks in the others. One patient,
(Case VII), had had many attacks of irregular
heart action, some of which may have been due
to grouped premature contractions: these sei-
zures were associated with cardiac distress,
which had occurred intermittently during a
period of from 15 to 20 years. At first the at-
tacks were of only a few minutes duration;
they gradually came to last for days and even
months. When this patient came under obser-
vation he was in a state of fibrillation. Twice
during his period of treatment there was re-
sumption of normal rhythm with a prompt im-
provement of symptoms, so that he was able to
call our attention to the changed mechanism. It
is of interest to note that the changes from fibril-
lation to normal mechanism in this patient oc-
curred after he had for some months been
taking digitalis at; intervals. The duration of
attacks observed by us, except in the case of the
last patient, was between 9 and 72 hours.
PROGNOSIS
Of our eleven patients, three (Cases IV- VIII-
X), are dead: in two of these (Cases IV-X),
the mechanism of the heart was normal at time
of death ; we have no record as to the mechan-
ism of the third. The apparent causes of death
were thyrotoxicosis, diabetic gangrene and
broncho-pneumonia. It is interesting that of
eight patients who passed from our observation
during a period of normal mechanism, seven are
known to be living and are reported well. We
have been unable to trace the remaining case
( V) . Between four and five years have elapsed
since the discovery of transient fibrillation in
five of the living patients (Cases I-III-VI-VII-
IX). Therefore, it would appear that fibrilla-
tion, if of brief duration, is rarely a serious
menace.
DIAGNOSIS
Auricular fibrillation can usually but not al-
ways be recognized by ordinary clinical means.
Lewis (l) has estimated that 90% of all cases
can be thus diagnosed. Levine (4) believes that
an even, higher percentage can now be recog-
nized without resort to instruments of precision.
In the remaining cases, it will be necessary to
confirm the diagnosis by means of a radial trac-
ing or by an electrocardiogram. The latter is
the record of choice. Fortunately, in large cities
it is no more difficult to obtain such graphic
records than it is to obtain a spinal puncture or
an x-ray. In smaller towns, there should al-
ways be at least one physician who has accus-
tomed himself to the use of the sphygmograph
and to the interpretation of pulse tracings. .The j
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62
THE PENNSYLVANIA MEDICAL JOURNAL Novsmber, 1920
initial expense and the time employed in learn-
ing the method are slight as compared to certain
other diagnostic procedures which are carried
on in the private laboratories of many physi-
cians.
The limits of this paper will not permit a dis-
cussion of the method of interpretation of elec-
trocardiograms or of pulse curves. However,
it is permissible to state briefly the method
whereby a fairly accurate clinical diagnosis may
be made. This diagnosis rests upon the recogni-
tion of a gross disorder of ventricular rhythm
in a patient whose heart rate is usually acceler-
ated, and in whom there is usually a difference
between the rate of apex and of radial pulse.
If due ta fibrillation, the arrhythmia becomes
more apparent if the heart rate be further ac-
celerated by exercise or by drug action (atro-
pine). If occurring in connection with a heart
rate of 120, a marked irregularity is usually an
expression of auricular fibrillation : if the rate
be 140, it is almost certainly fibrillation. With
the onset of fibrillation the presystolic murmur
of mitral stenosis usually disappears. Decom-
pensation is common. A history of rheumatic
fever or evidence of mitral disease, or both, is
usually obtainable in patients who have not
passed the fourth decade : older patients usually
give evidence of the presence of cardio vascular
renal disease. A history of previous attacks of
palpitation can usually be elicited. We repeat
that clinical recognition is impossible in about
10% of all cases. Hence diagnosis should be
confirmed, if possible, by means of the electro-
cardiogram or by a pulse tracing.
TREATMENT
The treatment of our patients has been that
of the underlying cause when such was appar-
ent. Digitalis has been administered when in-
dicated. In three of the patients (Cases IV-IX-
X), strophanthin was used intravenously. In
one of these patients (Case IX), the patient
with lobar pneumonia, there was a steep fall of
apex rate from 180 to approximately normal
with a resulting disappearance of decompensa-
tion which had been profound. In the other
instances, the patients died, although the me--
chanism had returned to normal, J. S., Case IV,
dying of broncho pneumonia and A. M., Case
X, as a result of diabetic acidosis.
DISCUSSION
In our series of 109 cases of auricular fibril-
lation, 10% were of the transient type. This
figure may be profitably compared with the sta-
tistics of Krumbhaar (2), Fahrenkamp (3) and
Levine (4) . Among these authors, Krumbhaar
noted the transient type in 7.5%, Fahrenkamp
in 3.5%, Levine in 14.1%. It is probable that in
each instance the figures should be higher. Fail-
)ure to secure full cooperation with members of
the various services of a given hospital results
in many transient fibrillations passing unnoticed.
Transient fibrillation is seen by the surgeon, the
neurologist, the paediatrist. It is worthy of
comment that few of our cases of transient ar-
rhythmia were referred to heart station from
any service other than the medical. A more
general awareness as to the importance of de-
fining cardiac irregularities in terms of me-
chanism would doubtless result in a reconstruc-
tion of statistics and in an increase of knowl-
edge as to the etiology, clinical recognition,
prognosis, and treatment of fibrillation. A re-
cent study of Levine (5) is illustrative of the
advantage which may accrue to the surgewi
through a graphic study of cardiac irregulari-
ties. Of 9 such cases observed during or fol-
lowing surgical operations, and diagnosed as
"acute dilatation of the heart," four were found
to be cases of transient auricular fibrillation.
Our observation that apparently normal hearts
may be temporarily thrown into fibrillation con-
firms the experience of others. Gossage and
Hicks (6), writing in 1913, reported three such
cases. Robinson (7) appears to have shown
that auricular fibrillation in man may be induced
by an extra cardial factor alone. This author
reported a case in which a presumably normal
heart was thrown into fibrillation during hy-
drogen sulphide poisoning. The disorder of
mechanism passed off with the subsidence of the
acute intoxication. Robinson (8) had previous-
ly reported a case of paroxysmal fibrillation in
which the patient's heart showed no demonstra-.
ble organic lesion. Subsequent observers have
reported similar findings. Of these, the case
reported by Armstrong (9) is of special inter-
est : a man with a gunshot wound in his chest
was found to have total disorder of rhythm ; a
free bullet was demonstrated in the pericardial
sac; normal mechanism was resumed 12 hours
after the bullet had been removed. Krumbhaar
(2) concludes that one or more attacks of fibril-
lation may occur in the course of an acute in-
fection or of an acute intoxication in the absence
of evidence of permanent myocardial damage.
In our two cases with presumably normal hearts,
there was a history of previous attacks of ar-
rythmia, some of which were probably fibrilla-
tion. However, as the nature of these attacks
was not confirmed by electrocardiogram a defi-
nite diagnosis cannot be made.
As pointed out by Krumbhaar (2) and others,
the majority of attacks of fibrillation of tran-
Digitized by VjOOQIC
November, 1920
AURICULAR FIBRILLATION— HEARD
63
sient duration occur in hearts which are the seat
of degenerative change. In such hearts, fibril-
lation may be induced by slight causes. The at-
tacks are apt to be multiple and the condition
tends to become permanent.
While we believe that a diagnosis of auricular
fibrillation can usually be made by clinical means
alone, nevertheless, we wish to repeat that there
are many chances for error. Hence statistics
should be based upon cases in which the diag-
nosis has been confirmed by g^phic methods.
We are aware that digitalis can produce au-
ricular fibrillation both experimentally and clin-
ically. However, in our series of eleven cases,
transient attacks occurred in but one patient
who had been taking the drug. In two of the
remaining cases normal mechanism was re-
sumed during digitalization : while in one case
the return to normal mechanism occurred at a
time when digitalization had been carried to the
point of intolerance as shown by the presence of
coupled beats : 8 patients who had received no
digitalis developed fibrillation. Hence, in only
one of II patients, could digitalis be considered
as a possible factor in the development of the
disorder.
CONCLUSIONS
1. While the statistics would indicate that
transient auricular fibrillation is rare, probably
it is of far more frequent occurrence than is
supposed.
2. Our experience confirms the observation
of others that transient fibrillation may occur in
hearts which are apparently normal as well as in
those diseased.
3. Onset of transient fibrillation may be
without symptoms or may be accompanied by
evidence of severe decompensation.
4. Our series is too small to furnish im-
portant evidence as to prognosis. However, a
study of our cases and of the literature would
indicate that brief periods of fibrillation are
rarely dangerous to life.
5. It is unlikely that digitalis, if properly
administered, will prolong attacks of transient
fibrillation. In our experience, the drug may be
given with advantage where the indications are
urgent, or the attacks prolonged.
(i) Lewis. Thos.; Prom a lecture given at the Peter Bent
Brigham Hospital, October, 1914, quoted b7 Levine (4).
(2) Krumbhaar, E. B.: Archiv. Int. Med. 1916, XVII, a.
(3) Pahrenkamp, K. : Deutsch. Archiv. f. Klin Med. 1914,
CXVII, I, quoted by Levine (4).
(4) Levine, S. A.: Amer. Jour. Med. Sci. 1917, CLIV, t.
(s) Levine, S. A.: "Cardiac Upsets," Jour. Amer. Med. Ass.
19m, LXXV, 12.
(6) Gossage and Hicks: Quart. Jour. Med. 1913, VI, quoted
by G. C. Robinson (7).
(7) Robinson, G. C: Jour. Amer. Med. Ass. IQ16, LXVI, 31.
(8) Robinson, G. C: Arch. Int. Med. 1914, XIII, 2.
(9) Armstrong, G. E.: Bost. Med. & Surg. Jour. I9I3>
CLXX.
DISCUSSION
Dr. Howard G. Schleiter, Pittsburgh, Pa.: Some
years ago I heard Dr. Thomas Lewis read a paper in
Ix>ndon before the Royal Society of Medicine on some
electrocardiographic studies. The paper aroused no
discussion and the next speaker, a very conservative
and very typical British gentleman, said in prefacing
his remarks, "passing now from the realm of pure
speculation to matters of practical interest, I wish to
present some cases of typhoid fever."
Since that time some nine years ago, a great many
things that seemed then matters of speculation have
become almost commonplace and their value in diag-
nosis and treatment requires no proof. So far as the
electrocardiograph is concerned I am sure that no one
would regard it as a means of ultimate diagnosis. It
has, however, taken its place along with the other
diagnostic means at our disposal and a cardiovascular
study made without an electrocardiogram would be as
incomplete as one in which blood count and urinalysis
were omitted.
As has been remarked instances of transient auricu-
lar fibrillation may occur with increasing frequency
and lead to a permanent fibrillation or in hearts other-
wise normal they have appeared as isolated attacks
without recurrence. What then is the significance of
sueh attacks and why is it valuable to recognize them?
After all the aim of our cardiovascular studies is to
determine, so far as our resources will permit, the
functional efficiency of heart muscle. Unfortunately,
we cannot do this except by the study of anatomical
and physiological abnormalities that may be observed.
To my mind then, the value of recognizing these at-
tacks lies in the fact that even in normal individuals
they may point to the heart as a seat of potential
damage. In a heart showing no other abnormalities
the occurrence of a single attack of transient auricular
fibrillation would seem to indicate the presence of an
enemy who has momentarily hoisted his colors.
So far as observed it would certainly seem that these
attacks are not dangerous and also not harmful be-
yond the fact that the heart is doing double or triple
its physiological amount of work in a g^ven time.
Moreover, where fibrillation becomes permanent I be-
lieve it to be to the advantage of the patient — since,
under these circumstances the heart rate is so much
more susceptible to the slowing effect of digitalis.
Where the transient attacks are prolonged, I believe
that digitalis is capable of slowing the rate just as it
is in permanent fibrillation. Whether or not it cuts
short an attack would be difficult to say, but it is cer-
tain that many attacks of transient auricular fibrilla-
tion are self limited and revert to normal rhythm
without any medication whatever.
From the number of cases that have been observed
after surgical operation, I believe that a careful study
of post-operative heart upsets would reveal, as pointed
out by Levine, more instances of transient auricular
fibrillation, flutter and paroxysmal tachycardia and
fewer cases of so-called dilatation. Acute dilatation
is an uncommon condition and the term has been far
too glibly used in speaking of cardiovascular difficulties
following operation.
Dr. Arthur C. Morgan, Philadelphia, Pa.: I have
thought sometimes with regard to Auricular Fibrilla-
tion, a few cases of which I have seen, whether there
is any relation at all between the connection of the
Stokes Adams Syndrome and these cases ; in the lat-
ter we have a geometrical retrogression, and in tii^
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64
THE PENNSYLVANIA MEDICAL JOURNAL November. 1920
transient auricular fibrillation we have a geometrical
progression in cardial rates.
My attention was first directed to this condition
about eight years ago when I was called to see a phy-
sician who was taken with tachycardia as he came
down the steps from a social function, after a hard
day's work, and after having partaken of a heavy
meal, and later dancing. He was apparently quite
well until he was leaving the place, when he was taken
with this paroxysmal condition, in which the pulse rate
was i8o. As he improved in condition the rate came
down to i6o, then to 140, then 120 and eventually, in
about two hours, to 80, his normal rate.
In one case we have a geometrical retrogression as
in Stokes Adams; the other cases are of geometrical
progression. The patient ascribed the attack to eating
«hell fish while fatigued.
Dr. Irwin J. Mover, Pittsburgh: I didn't expect to
discuss this paper, Mr. Chairman, but I might say that
I wish Dr. Heard had discussed more clearly the meth-
ods of diagnosis by clinical bedside methods, without
the electric cardiograph.
I recently had a patient who had a gradually in-
creasing rate of pulse, on which digitalis had no effect.
The patient died, and we found a very much degen-
erated heart muscle. The patient had been in appar-
ently good health until going West into the Rocky
Mountains. He was brought home and died two or
three weeks later.
I would like to hear from Dr. Wedd, a member of
the Ohio Medical Society.
Dr. a. M. Wedd, Pittsburgh : This is a very inter-
esting group of cases which Dr. Heard has reported.
I think we do not see them in the laboratory nearly as
often as they occur elsewhere.
One of the cases in this series which I saw was defi-
nitely associated with an appendicular abscess. I have
also seen one occurring in conjunction with acute ap-
pendicitis; after removal of the appendix the rhythm
became normal ; about six weeks later following an
acute respiratory tract infection the fibrillation re-
turned and persisted for six months when the patient
died.
In considering these cases I prefer to distinguish
two groups, transient and paroxysmal fibrillation. The
cases cited are examples of the former, occurring in
damaged hearts and which will eventually become
permanent fibrillation.
The latter constitutes the group to which Dr. Heard
refered as having apparently normal hearts. Clinically,
these cases are very similar to paroxysmal tachycardia.
I have seen but one such case, that in a gentleman in
whom there was no evidence of cardiac involvement
during the periods of normal mechanism. The at-
tacks came on without assignable cause. They were
the occasion of considerable anxiety to the patient
but always passed off without any complications. The
last time I saw this man he came to the laboratory
with a complete irregularity at a rate of 140. One
hour after leaving his wife telephoned that his heart
had suddenly become normal, and that evening he was
unusually well. There seems to be some fundamental
difference between these cases and those that go to
permanent fibrillation.
Those cases seen in conjimction with appendicitis
suggest that may of the irregularities seen during
acute surgical conditions may be transient fibrillation,
but unfortunately about the only information that the
surgeon gives us is that "the heart was irregular as
the deuce," and a diagnosis can hardly be made from
that Doubtless with the more frequent recognition
of atrial fibrillation will come a higher incidence' of
transient fibrillation.
Dk. Heard, in closing: Mr. Chairman: I was inter-
ested in Dr. Schleiter's discussion. I agree with him
that transient fibrillation is usually an expression of a
diseased heart muscle. In such a case the change in
mechanism is, as Dr. Schleiter says, an incident of the
"enemy hoisting its colors." However, it appears to
be fairly well established that fibrillation may occur
as a temporary phenomenon in a heart the musculature
of which is normal. We have reported two cases in
which clinical evidence of abnormality was absent.
We realize that negative evidence of this kind can not
be regarded as conclusive. However, the cases which
we have quoted as reported by Drs. G. C. Robinson
and G. E. Armstrong, furnish very strong evidence in
favor of the contention that fibrillation may be induced
by an extra cardial factor alone.
We have not feared to give digitalis in fibrillation
of brief duration, and have seen mechanism return to
normal under its use. In no instance have we had rea-
son to believe that our transient fibrillations have been
induced by digitalis. Digitalis appears to act in these
cases in the usual way by slowing the ventricle, and in
the case of at least one patient, the patient with lobar
pneumonia, we believed that intravenous use of stro-
phanthin probably saved the patient's life.
Dr. Moyer has requested a further discussion as to
the clinical recognition of auricular fibrillation. A pa-
tient with gross disorder of rhythm together with an
acceleration of apex rate and a difference in rate at
apex and at radial is usually fibrillating. The pres-
ence of decomposition increases this probability which
becomes almost a certainty if the apex rate is a.bove
140. It is always to be remembered that cases occur
where a diagnosis is impossible without the aid of
graphic records, but with careful clinical observation,
the chance for error is relatively small.
As Dr. Wedd has indicated, these cases may pre-
sent to the casual observer a surgical rather than a
medical aspect. There may be abdominal pain which
may at first call attention away from heart. All car-
diac irregularities should be diagnosed in terms of
mechanism, and when cooperation is secured through-
out all departments of a hospital to the end that car-
diac irregularities of a doubtful nature may be re-
ferred to heart station, few errors in diagnosis will be
made.
TREATMENT OF COMPLICATED
CLEFT PALATE*
JOHN B. ROBERTS, A.M., M.D.
Universltjr of Pennsylvania Graduate School of Medicine
Delay in starting the operative treatment of
congenital clefts of the oro-nasal partition longer
than the first month or two of life usually is an
error of judgment. It is true, however, that
occasionally blood spilling treatment necessitat-
ing general anaesthesia must be postponed for
several weeks or months in malnourished, ill or
prematurely bom infants. Suction in breast
nursing is impossible in most cases of complete
'Read before the Section on Surgery of the Medical Society
of the State of Pennsylvania, Pittsburgh Session, October 6,
1920.
Digitized by
Cnoogle
November, 1920
COMPLICATED CLEFT PALATE— ROBERTS
65
fissure of the palate, alveolus and lip ; and spe-
cial nipples for bottle food, or spoon feeding has
to be used. This generally means modified
cow's milk for nourishment. I have, though
rarely, waited months before attempting to close
even the alveolus and lip. Otherwise, a rapid
FiCUKS I.
operative suture of the lip with worm gut, or
better the alveolus with wire and the lip with
worm gut, will be found more satisfactory.
The osteoplastic restoration of the alveolar
arch may be carried out with little hemorrhage
and little shock, and without a long etherization.
It will frequently be necessary to divide the
bone on one or perhaps both sides of the fissure,
in order to be able to force the two sides of the
cleft together and wire them in proper relation
Figure a.
to each other. This I like to accomplish in the
first month of the baby's life. It may require
considerable force to drive, with the surgeon's
thumb and fingers, the two portions of the max-
illa together after the bone and cartilage have
been cut with saw or heavy knife. The drill
holes for the wire should be high enough above
the edge of the gum to insure their passage
through the already ossified portion of the max-
illa. If this is not done, the elasticity of the
deformed parts will be so great that the wires
will gradually cut through towards the fissure
and the original deformity be allowed to recur
to a considerable degree.
After the ends of the wire have been twisted,
the lip may be pared and sutured, if the child-
has not shown deterioration of vitality during
this short operation. When delay seems wise,
the harelip should be given ' surgical correction
about two weeks after the osteoplastic operation
on the alveolus. It is my practice to leave the
wire in the maxilla undisturbed for 4 to 5
FiGDU 3.
months. The sutures of worm gut are taken out
about ten to fourteen days after the reconstruc-
tion of the lip. No dressing is used on the lip,
which is kept as nearly absolutely dry as is prac-
ticable. The suture line is cleansed with a little
alcohol or very dilute tincture of iodine after
soiling with food. No water is used by me upon
sterile face wounds.
In bilateral* clefts with protrusion of the inter-
maxilla, this bony segment has to be forced back
into its proper site ; it is never removed. It is
too important a part of the oral architecture to
be sacrificed. It is frequently impossible to
shove it into a proper relation with the lateral
parts of the alveolus, unless a V shaped piece
of the vomer and cartilaginous nasal septum is
cut out by the surgeon. The size and direction
of this resected piece is determined by the char-
acter and amount of intermaxillary deformity.
Sometimes this operation may be done submu-
cously. I at times use a saw to cut through the j
Digitized by VnOOQlC
66
THE PENNSYLVANIA MEDICAL JOURNAL November, 1920
base of the projection to enable me to obtain a
nearly normal reconstruction of the incisor
region of the alveolar arch.
When the intermaxilla has been finally re-
placed, the vomerine edges may or may not be
sutured with chronicized gut. The two sides of
PMJtCTIOM or
MT(IIMA1IIU.A ■•>
00W9I.C HANfkf^
4 CLcrT Mun
„„.„ ., *< cur mm
FicurS 4.
the intermaxilla are wired to the abutting ends
of the lateral portions of the alveolus. I do not
raw the ends before they are drawn into contact
or nearly into contact with each other.
The plastic construction of the deformed hare-
lip is not discussed in this paper. It may be un-
dertaken 15 or 20 days later or carried out at
the time of this first operative attack. The floor
of the nostril or nostrils will probably need
operative attention at the same time.
The whole portions cut from the edges of the
labial fissures may be kept attached at their
upper ends, turned into the mouth behind the
lip and below the nose, twisted a little, and
stitched into, or close to, the anterior end of the
opening in the hard palate. This nubbin of
otuoLC ci.trr.ALvaui$
Ftcuu $.
muscle and mucosa will increase as the baby
grows, and thus provide tissue to be utilized for
blocking up the anterior part of the opening in
the bony palate when the uranoplasty is at-
tempted.
Inspection of the child, when six or eight
months old, will show quite satisfactory repair
of lip, the alveolar arch continuous or with mere
slits between the wired ends, and the front of
the palatal cleft much narrower relatively than
when the child was bom. The ala of the nose
may still be somewhat flattened and the edge
and surface of the upper lip rather irregular.
These defects, however, need only moderate
plastic modelling to make them quite presenta-
ble. Such modification is often more practicable
when the little patient is several years old, than
when the features are still so infantile.
In the complicated oral fissures now under
discussion, it is usually wise to delay the urano-
plasty proper until the age of eight or ten
months. I then undertake the closure of the
deft in the bony palate (uranoplasty). The
questionable closure of the soft palate (staphy-
lorrhaphy) at the same operation is settled in
the affirmative or negative by the width of the
fissure through the entire palate structures and
the anticipated difficulties of suture without
undue tension. My chief desire is to secure
closure of the bony fissure, even if I must leave
the cleft in the velum for subsequent operation.
Practically in most operations, I try to close
both hard and soft palate at once ; but usually
failure occurs in one or the other region. The
unclosed portiori is then treated by operation
sometime in the child's second or third year.
If the cleft is of moderate width and limited '
to one side, the modernized Langenbeck "sliding
strip" method is apt to be my choice rather than
the Lane "turned over or everted" flap method.
The Langenbeck flap seems valuable also in
mouths with a very high palatine arch and a not
over-wide fissure. I often use the Lane method
or a modification of it under other oral condi-
tions.
When Langenbeck's plan is adopted, a small
puncture is made, with the point of a bistoury
or a tenotome, through the mucous membrane
and periosteum down to the very bone as near
as possible to the alveolus in the midmolar
region. This short incision must be placed so
as not to injure the posterior palatine vessels
passing through the posterior palatine foramen.
Into the cut thus made a rigid slightly curved
elevator without any cutting edge is thrust. A
surgical aneurism needle answers well for this
part of the operation. With this elbow-like in-
6tfT-V«.
Ficu«» 6.
strument, the periosteum is lifted or torn from
the surface of the bone as far forwards as the
end of the cleft and as far back as the posterior
edge of the horizontal plate of the palate bone.
No cutting edge should be used to hack this
muco-periosteal flap's undersurf ace ; and care
should be taken not to damage the anterior or
posterior palatine arteries and veins. The edge
of the cleft is then made raw by cutting off a
Digitized by VjOOQIC
November, 1920
COMPLICATED CLEFT PALATE— ROBERTS
67
strip of mucosa and fascia along its entire
length. This must provide a wide raw surface
for contact with the opposite edge. These pro-
cedures detach the muco-periosteum from the
hard palate everywhere except along the alveo-
lus at the side and in front and behind. At
these places it receives its arterial supply and its
PLAtrie CLOSURE
Ficcut 7.
venous depletion. Instead of making the small
puncture and raising the periosteum from the
alveolar border toward the cleft, the operator
may pare away the edge of the cleft first and
tear up the periosteum from the cleft edge to-
wards the aveolus. The formation of a second
"strip flap" on the other side of the fissure com-
pletes this stage of the operation.
Detachment of the velum, from the posterior
edge of the palate's horizontal plate is a most
important step. This is accomplished by cutting
with scissors or knife the nasal mucosa and the '
intermucous fibrous layer of the soft palate
transversely, so as to permit the soft palate to
drop down toward the tongue.
I usually use silk worm gut for sutures in both
the hard palate and soft palate flaps, except that
in the uvula I like a more flexible thread like
linen or silk. The sutures for the velum should
be inserted about a third of an inch from the
rawed edge ; usually I insert one suture to sus-
tain the others at about one-half inch from each
margin of the cleft. The strips cut away to
freshen the borders of both hard and soft palate
should remove enough tissue to leave a thick
raw edge for union of the two sides of the open-
ing.
There should be no real tension of the tissues
»
after sutures are tied. If tension exists, sup-
puration and failure of the flaps to unite across
the gap in the roof of the mouth is almost cer-
tain to occur. Moderate tension may be relieved
by short longitudinal incuts near the alveolar
process in the region of the bony palate or in
the lateral region of the soft palate after the
sutures have been tied. If there is much ten-
sion, failure by suppurative infection is almost
inevitable in at least the tightened portions of
the reparative line of contact. Injurious ten-
sion may sometimes be averted by drawing the
anterior pillars of the fauces towards each other,
as a last step in the operation, with a plain cat
gut suture carried across the pharyngeal open-
ing. This will be absorbed and drop out in a
irrACHMcMT «'
VCtUM^
aoNi
FiGuut 8.
few days. Its support during the early part of
convalescence may be valuable to avert infec-
tion following suture tension.
The Langenbeck flaps mentioned in the above
description of the uranoplastic operation may be
raised from each lateral portion of the fissured
palate by working under the periosteum out-
wards from the median border towards the al-
veolus. In this modification there is no iieed of
the preliminary puncture or incision near the
alveolus. Brophy likes this method. It seems
to me to be valuable only in comparatively nar-
row gaps and highly arched palates.
When the fissure is wide, Lane's method of
everting a large flap from the bony or the soft
palate or both, on the side of the cleft which
possesses the broader surface, and tucking it
under the edge of a flap lifted froin the median
border on the other side is usually preferable to
the Langenbeck "slipped ribbon" flap manner of
LAUtt
rvKNCO-oveii
FLAP MrTMJ "
ATTACHta T*
NCSt PIU-
JtCTM
operating. In this operation, the velum in my
experience should be cut loose from the pos-
terior margin of the horizontal plate of the
palate bone as in the Langenbedc operation.
The everted flap may be greatly increased in
size by using for its widening the mucosa and
fibrous tissue covering the adentulous gum.
It is very desirable to suture the edges of the
cleft in the velum in both the methods just de-
Digitized by
Uoogle
68
THE PENNSYLVANIA MEDICAL JOURNAL November, 1920
scribed at the time the hard palate is treated.
I have seldom been successful in getting closure
of hard and soft structures from the incisive
region back to the tip of the uvula by one opera-
tion, except in narrow fissures.
Cleft palate operations by Brophy's "tie
beam" sutures of the maxilla in early infancy
have caused for me undesirable suppuration
within the mouth or severe damage to the al-
veolus. I have, however, a few times intro-
FLAP SUTUI
FiCVKS 10,
duced the wire sutures from the outside of the
cheeks and carried them through the maxilla
across the gap in the roof of the mouth. The
separated bones, still largely cartilaginous, may
be held for weeks near each other, by twisting
the ends of the two sutures together, provided
they first be forced into contact or nearly so by
the surgeon's fingers. The scars in the cheeks
are not necessarily conspicuous and may be
remedied later by plastic sliding of the skin.
When partial closure only has been obtained
in complicated cleft palates, successive attempts
are to be made. I usually wait five or six
months between operations on the roof of the
mouth, but make every reasonable effort to close
the whole gap from nostril, lip and alveolus to
uvula before the child is three or four years old.
These repeated attacks seem to do the average
baby no harm, provided the anaesthetizer is ex-
perienced and the operator himself wide awake
during and after the operations. Cleft palate
surgery of this kind is not to be left to indiffer-
ent nurses or careless surgeons. The personal
responsibility of the operator is grave from start
to finish.
IWC SHORT VELUM OMCLOSIWC
CLtm, V*IMJLJWTI<ANA<*L
^ SUTDKt
FiGUU II.
All sorts of flaps and expedients may be
found useful to get enough thick tissue to bridge
the remaining opening after failures from sup-
puration or sloughing.
Instead of the regular Lane operation, I have
at times employed a modification. In this op-
eration, an oblique flap with a broad pedicle in
the child's molar region near the margin of the
cleft, is cut on the wider portion of the hard
palate. The free end of the flap is rectangular
and may be made even out of the tissue of the
gum, near the incisor part of the alveolus, if no
teeth have been erupted there. This muco-
periosteal flap is everted in the Lane maimer
and its raw surface pushed under the end of a
posterior mucoperiosteal flap lifted from the
bone and soft palate of the narrower part of
the roof of the mouth. This second flap has its
circulation supplied through a pedicle near the
posterior molar and hamular region. The ap-
plication of the raw surfaces of these two flaps
and their retention by mattress sutures build an
oblique bridge across the wide fissure of the
palate without injurious tension. '
Another irregular method is to cut a flap from
the wider part of the hard palate with its pedicle
in the incisor region and slide its free end part
way across the cleft. The median side of this
mucoperiosteal flap is met by the end of a simi-
lar broad flap cut from the velum and hard pal-
ate of the opposite side. This posterior flap
Figure ts.
must be given a turn of about 90° to bring its
square end against the side of the anterior flap.
This method makes a thick oblique bridging of
the palatal fissure without tension.
These nondescript methods close only a part
of the opening between mouth and nose; but
they give a good foundation for subsequent
plastic work.
Wide bilateral V shape clefts of the soft pal-
ate with little or no notching of the posterior
edge of the bony palate, I usually succeed in
closing with one operation. I make an "apron"
flap of mucoperiosteum by means of a convex
incision across the uncleft hard palate and slide
it backward, after detaching the velum from the
posterior edge of the bone. When the loosened
velum hangs freely from the hamular regions,
the fissure margins of the velum are rawed and
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November, 1920
WAR SURGERY OF FACE— IVY
69
sutured without tension. A mattress suture to
draw the middle of the upper margin of the dis-
placed flap and detached velum into contact with
the middle of the posterior edge of the bony
palate is carried through the pharynx and out at
the two anterior nostrils. This suture is fixed to
the columella. The raw bed, from which the
flap was torn, will then cicatrize without drag-
ging the soft palate forward to its old site. The
borders of the cleft in the soft palate are al-
ready rawed sutured without tension. The
nasal suture should not be removed for several
weeks. The nasopharyngeal stitch must not be
drawn very tight. Its ends are tied in front of
the columello or within one nostril; a piece of
rubber drainage tube or the columella itself may
be perforated to steady it.
This same operation, I have used to lengthen
the palate after a previous cleft palate opera-
tion, which had left the posterior part of the
oronasal partition very short and stiff, with the
posterior columns of the fauces dragged for-
ward and attached to the anterior columns and
uvula. I believe it would be available^ for
lengthening short vela left after ordinarily suc-
cessful closure of palatal cleft in childhood;
and thus probably facilitate phonation by enab-
ling the child to shut off the nasal chambers
from the mouth when speaking.
1»RI0C£" ctosuuc
W)T« ANTtniOR AND
pOlTem*" FLAPS
FiGCKS Ij.
After these operations in infants, I wash out
the nose and pharynx with sterile water or salt
solution or boric acid solution, keep them quiet
with paregoric and make little attempt to look
at the throat for several days. Water is allowed
freely. On the evening of the day of operation,
castor oil is given to empty stomach and bowels
of blood swallowed during operation. Modified
milk is used as food and given with a spoon or
medicine dropper.
If there is tension on the sutures, suppuration
is pretty certain to occur in these complicated
clefts; and ail or a part of the suture line sepa-
rates. Occasionally one may Ijmit this misfor-
tune, by reanaesthesia and replacing sutures.
Such success will be very rare. It is far better
to devise a method of operating which gives lit-
tle tension or to put in at the operation one or
two reinforcing sutures with a very wide grasp
of tissue. I prefer to use silk worm gut for the
important stitches, and introduce all at a pretty
distant point from the margins of the cleft in
both soft and hard parts of the palate.
WAR SURGERY OF THE FACE AND
JAWS AS APPLIED TO INJURIES
AND DEFORMITIES OF
CIVIL LIFE*
ROBERT H. IVY, M.D., D.D.S.
PHII,ADEI.PHIA
Owing to the prolonged course of the war
and the tremendous number of casualties sus-
tained, great impetus has been given to the de-
velopment of surgical methods, and many new
procedures have been introduced and still more
which were known previously have been put
upon an established basis. It now remains to be
shown in what way this nfew knowledge gained
during the war is applicable in civil life. I wish
particularly to call attention to certain features
of surgical treatment of maxillo-facial war in-
juries which may be of value in plastic and re-
constructive surgery of the face and jaws to
correct deformities resulting from disease or in-
jury in the practice of peace times.
Perhaps the most important lesson in connec-
tion with maxillo-facial injuries, and which sur-
geons generally have been slow to learn hitherto,
is the necessity for the closest sort of coopera-
tion with the dentist in handling these cases, not
only where the jaw bones themselves are in-
volved, but also in various injuries of the soft
tissues of the face and the nose. Aside from the
construction of fixative and supportive ap-
pliances, no one is better fitted than the dentist
to handle the mouth sepsis arising from bone
sequestra and dental lesions. So that one of the
first points in the treatment of a case of this
kind is to secure the cooperation of a dentist.
I will now call attention to a few of the types
of cases met with in civil practice in which our
war experience has been of great help as a basis
for treatment.
About ten per cent, of gunshot fractures of
the mandible with loss of substance result in
non-union or mal-union and require bone graft-
ing for restoration of function. In fractures
sustained in civil life, loss of substance with
non-union is rare, and cases of this type seldom
require bone grafting. These are, however, two
classes of pathological cases involving loss of
'Read before the Section on Surgery of the Pennsylvania
Sute Medical Society, Pituburgh, Pa., October 6, 1920.,
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THE PENNSYLVANIA MEDICAL JOURNAL NoveMBER, 1920
substance of the lower jaw in which bone graft-
ing should be considered as a reconstructive pro-
cedure. These two classes are: (i) Loss of a
whole segment of the bone following osteomye-
litis and necrosis. (2) Loss of a whole segment
of the bone by an operation for removal of a
tumor. In each case little or no attention us-
ually is paid to maintaining the correct position
of the lower jaw in relation to the upper. Con-
sequently, when the diseased bone is removed,
the ends of the two fragments are allowed to
approach each other, either uniting or forming
a loose fibrous connection with shortening of the
mandibular arch, loss of function and great vis-
ible deformity. Formerly, we were forced, in
the attempt to improve the condition of these
cases to resort to prosthetic appliances (such as
the Martin splint) to replace the lost bone and
hold the remaining portion of the lower jaw in
somewhere near its proper relation to the upper.
These splints left much to be desired, as the pa-
tient never acquired sufficient stability of the
jaw fragments to permit him to masticate solid
food, and the apparatus required constant at-
tention and readjustment. Thanks to the war,
and the large number of cases of fracture with
non-union, the various forms of bone grafting
were given a thorough trial, until at the present
time bone grafting of the mandible has been
established as a definite procedure, with indica-
tions, technique and prc^nosis laid down as
firmly as for almost any other operation in sur-
gery. So that in these peace time cases of loss
of mandibular substance, bone grafting may be
confidently resorted to in restoring continuity.
I will briefly enumerate the methods of bone
grafting that have been most extensively em-
ployed for restoring losses in continuity of the
mandible : ( i ) Pedicled graft from the mandi-
ble itself (Cole). A piece of the lower border
of the anterior fragment is removed, leaving at-
tached to it a pedicle of digastric muscle and
fascia below for nourishment. This is carried
back to fill the gap and fastened to the frag-
ments by means of silver wire. This form of
graft is satisfactory in cases of loss of substance
up to 3 cm. in the body or symphysis of the
mandible. It is not applicable where the ascend-
ing ramus is involved. The pedicled graft is not
so vulnerable to infection as the free bone graft,
and union will as a rule take place more rapidly.
(2) Osteo-periosteal graft (Delageniere). A
thin shaving of bone is reiAoved from the an-
tero-intemal surface of the tibia, the overlying
periosteum remaining attached to the graft.
One piece of this is inserted into pockets beneath
the mandibular fragments, between the bone
and the soft tissues, and another in a similar
manner over the fragments, with the bony sur-
faces of the grafts facing each other. No fixa-
tictti is employed other than suturing the soft tis-
sues over the grafts. The osteo-periosteal graft
is flexible, easily adjustable to the size and shape
of the lost substance, and contains all the ele-
ments necessary for osteogenesis.
(3) Thick graft from tibia, rib, or crest of
ilium. I believe that the crest of the ilium is
more suitable than either the tibia or the rib for
this purpose. The crest of the ilium resembles
the mandible closely in structure and shape, is
spongy and therefore easily penetrated with new
vascular supply. An incision is made in the skin
along the t(^ of the crest of the ilium, banning
at the anterior superior spine, the muscles at-
tached to the inner and outer lips are stripped
away with a blunt dissector, and a piece of the
bone involving the full thickness of the crest re-
moved with a metacarpal saw. The graft is cut
to a size to fit the gap between the mandibular
fragments, preferably to slightly overlap them,
and secured to them by means of silver wire or
kangaroo tendon. The severed hip muscles are
sutured together over the site of bone removal,
and the wound closed. The patient is kept in
bed for ten days to two weeks, and suffers only
very temporary inconvenience. This method
furnishes a graft that can be adapted to a small
or a great loss of substance, and its bulk is ad-
vantageous from a cosmetic standpoint.
The preoperative treatment of all cases re-
quiring bone grafting consists in removal of all
sources of sepsis, reduction of the fragments,
and fixation in such position that the normal oc-
clusion of the teeth is restored.
An example of a case of bone grafting in civil
practice is the following: A young man, now
twenty-seven years of age, when seven years old
had a large portion of the mandible removed for
sarcoma. He came under my care presenting
an absence of two inches of the bone from just
to the left of the symphysis to the left angle,
leaving a portion of the ascending ramus, which
was freely movable. The remainder of the
mandible was drawn considerably over to the
left side, with consequent loss of facial balance
and interference with function. He had worn a
prosthetic appliance for a number of years,
which enabled him to masticate imperfectly, but
this was beginning to lose its fit and scmie of his
teeth to which it was attached were becoming
seriously affected. Splints Were made by Dr.
J. E. Aiguier, fixing the right side of the mandi-
ble in proper relation with the upper jaw. On
March 17, 1920, an incision was made over the
left body of the mandible, the ends of the frag-
ments were exposed and freshened, and a graft
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November, 1920 PAPERS OF ROBERTS AND IVY— DISCUSSION
7\
2^ inches long was removed from the crest of
the ilium and inserted in the manner described.
The wound was closed in two layers. Some
suppuration occurred over the outer surface of
the graft, requiring drainage for several weeks,
but this eventually cleared up, and did not in-
terfere with the vitality of the graft. At the
present time there is firm union at both ends of
the graft, the jaw being in good position.
In another case there was a loss of the entire
right half of the mandible from the symphysis
to the mandibular joint from necrosis follow-
ing a dental infection. The patient had little or
no control of the left half of the mandible,
which was drawn over across the median line
toward the left side, rendering mastication im-
possible, and causing marked disfigurement.
The ordinary bone grafting operation was not
considered feasible owing to the absence of any
fragment posteriorly for attachment of the graft.
•Tt is well known that an end of bone placed in
soft tissues with no contact to other bone, is
likely to undergo rapid absorption. This does
not apply to cartilage to the same extent. In
order to replace the lost bone and condyle, a
piece of the right sixth rib with part of its car-
tilage attached was used. The rib on the right
side was selected as being more in conformity
with the shape of the lost bone. The end of the
mandible near the symphysis was exposed and
the soft tissues were tunnelled up to the glenoid
fossa. The cartilaginous end of the rib was
then inserted to form the joint and the other end
attached to the remaining half of the mandible.
This operation was performed in June, 1920.
The wound healed without any complications,
though it is somewhat early yet to foresee the
ultimate fate of the graft and the functional
usefulness of the new joint.
The principle of transference of pedicled and
sliding skin flaps to cover defects of the soft
tissues was practiced very extensively in the re-
pair of war injuries. A great improvement in
the transference of large flaps from a distance,
such as the chest, to the face was the tubed
pedicle flap method introduced by H. D. Gillies.
The basic principle here is to conserve the cir-
culation by first raising the pedicle, turning its
edges under and sewing them together. After
healing occurs, the flap to be transferred, at-
tached to the lower end of the tubed pedicle, is
raised and carried to the desired position.
Another advance consisted in recognition of
the fact that flaps closing defects of the walls of
facial cavities, such as the nose and mouth,
should be lined with epithelium if shrinkage is
to be avoided. In a 14-year-old patient referred
to me by Dr. Charles H. Frazier, a resection of
the left upper jaw had been performed for sar-
coma four years previously. The operation and
subsequent radium treatment had resulted in a
cure, but there was an opening in the left side of
the nose adjacent to the inner canthus of the
eye i cm. in diameter. The lower and lateraf
margins of the opening were freshened while a
flap was made in the skin above with its base at
the upper edge of the opening. This flap was
turned over like a hinge with its epithelial sur-
face facing into the nose and sutured to the
edges of the opening with mattress sutures. A
raw surface now remained, consisting of the
under surface of the flap which now covered the
opening and the place from which the flap itself
had been taken. The operation was completed
by covering this raw surface with a pear-shapfed
flap turned down from the forehead with its
base at the inner canthus of the opposite eye.
One of the facts brought out during the war is •
that cartilage when transplanted into soft tissues
will generally remain indefinitely, but that bone,
unless brought into contact with living bone,
will undergo absorption. For this reason, we
always prefer to use cartilage in restoring the
bridge of the nose in saddle-nose deformity, be-
cause the contact with bone in this case is un-
certain. Cartilage is also preferable to bone
transplanted to fill large defects in the cheek, etc.
Free fat from the abdominal wall, or prefera-
bly, fascia lata, is very useful in filling defects
in the soft tissues, such as the cheeks, following
excision of depressed scars. We have employed
it many times in war injuries, and expect it to
have a wide application in civil practice. After
excision of the scar, the edges of the wound are
well undermined, preferably with a deep sepa-
rate layer of fascia beneath the skin, forming a
pocket. A strip of fascia lata of suitable size is
then inserted in the pocket beneath the fascia,
and the wound closed over it.
Time will not permit the enumeration of other
methods pertaining to this class of cases, but it
is hoped that sufficient has been said to point
out that the developments of war surgery have
placed within our reach methods of greatly
ameliorating many deformities heretofore con-
sidered practically hopeless from a functional
and esthetic standpoint.
DISCUSSION
ON PAPBRS BY DRS. ROBERTS AND IVV
Dr. Moses Bghrend, Philadelphia : It has also been
my experience in the past year to have had several
cases of this — very marked mal-development or cleft
palate. It has been my custom to operate on these
cases within the first 48 hours if at all possible to do
it. I think the sooner you operate on these cases the
better because the children at birth are usually fat,
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THE PENNSYLVANIA MEDICAL JOURNAL November, 1920
chubby babies while if you allow these children 'go for
a week or month they lose considerable weight on ac;
count of the regurgitation of the food through the
nose. The operation I do is to close the palate first by
means of the Brophy method by the use of lead plates
^nd wires. It is immaterial whether the lip is closed
for the first eight or ten weeks. I do not do anything
to the soft palate for several months. There will be
gradually an inclusion of the two sides. I wish to lay
stress on Dr. Roberts' point that the premaxillary
bone must never be removed. When it is pressed
down on the alveolar bone of the opposite side the lip
naturally falls in line itself and it is a simple matter
in eight or ten weeks to do the regular operation for
harelip. I am tmable to discuss Dr. Ivy's paper, but I
am sure from what you have seen that he is doing
work in a class by itself.
'TUBERCULOSIS AND ITS RELATION
TO INDUSTRIAL MEDICINE*
MERVYN ROSS TAYLOR, M.D.
Medical Officer, The Bell Telephone Compahy of Pennsylvania
and Associated Companies
PHILADELPHIA
Modem industrial development congregating
vast numbers of men and women in industrial
establishments brings prominently before us the
problems of health hcizards, and these represent
a great many varieties of sickness that are pre-
sented as industrial accidents on entering com-
pensation claims. Some of these are tubercu-
losis, syphilis in various disguises, rheumatism,
teeth, tonsils and gonorrheal infection. These
latent diseases and others are readily activated
by trouma. Hence how can we escape our re-
sponsibility in not eradicating from the working
people certain correctable defects which mean
to the worker so much for future health and
happiness. If then a study of these problems is
vital to the employee, it is fundamental to the
employer, as it stands for increased production
and diminished labor turn-over as well as con-
tented ranks of healthy, happy, veteran em-
ployees— all tending to increased production and
profits. Of health hazards probably none is now
more important than the question of tuberculd-
sis, and certainly no one has a better opportunity
of studying physically as well as sociologically
its every phase than the industrial physician.
Pulmonary tuberculosis, in industry, is a
many-sided problem. It cannot be looked upon
as a trade disease any more than a dermatosis is
a distinctive ailment of a chemical plant ; natural
and acquired susceptibility occur to both dis-
eases, although the etiological cause in each is
different. We realize the incidence of pulmon-
ary tuberculosis, accentuated in certain dusty
trades, although dusts in themselves are not in-
*Read before The Philadelphia Association of Industrial
Medicine, February 13, 1920.
fectious, but the injury exerted by certain dusts
as silica, silicosis, marble, calcicosis, coal miners
develop aertfaacosis, from iron workers may de-
velop siderosis ; all produce an injury and irrita-
tion to the Itmg tissue which creates a vulnerable
spot for the growth and propagation of the tu-
bercle bacilli ; but these health hazards have been
much reduced by suction devices for the removal
of dust at its source. The inhalation of foreign
substances, such as iron, stone, textile fibers, ani-
mal hairs and furs, also grain dust, gives rise to
pigmentation of the lungs. The pigmentation in
itself is of no consequence, and everybody has
it to some extent. Dusts are mostly filtered out
in the nose; if the dusts reach the bronchial
tubes they are caught in the bronchial cilia and
coughed up, being expectorated with the bron-
chial secretions. It is thought that dust is never
conveyed as far as the alveali; particles that
reach the peribronchial lymph-nodes and the
mediastrial lymph nodes penetrate through
lymph channels from the bronchi, neither lung
pigmentation and lymph nodi infiltration are
dangerous until tubercle bacilli have been im-
planted. It is impossible to definitely state
where this or that victim has acquired pulmonary
tuberculosis. There is no definite period of in-
cubation of pulmonary tuberculosis and the
time which elapses between the exposure to the
tuberculosis infection and the actual incidence of
the disease is usually so great that the discover-
able source of infection is often passed unob-
served. We know that a walled off tubercular
area may lie dormcuit for many years, but may
at any time break down and cause a dissemina-
tion or an outbreak of the disease from this old
focus of infection. Some clinicians are of the
opinion that primarily tuberculosis never invades
individuals over fifteen years of age, cldming
that after or before this age there is a state of
tissue immunity established and that the infec-
tion occuring in adults is but a reoccurrence of
childhood tuberculosis. We all, of course, rec-
ognize the greater susceptibility to the disease in
the young. A study of pulmonary tuberculosis
incidence on the basis of occupation taken from
the statistics of many sanatoria shows conclu-
sively that no occupation is exempt, so that it
cjuinot be fastened on any single industry or
group of industries. Dust inhalation in one in-
dustry, a textile plant, was thought to be the
causative factor. On close survey 85% of the
cases investigated showed a near relative to be
suffering from pulmonary tuberculosis. The re-
maining 15% had a more remote source of tu-
bercle bacilli infection not revealed in the inves-
tigation. I am firm in the belief that the danger
in contracting pulmonary tuberculosis is not in
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November, 1920
TUBERCULOSI S— TAYJ^R
73
the average industrial plant, but that the infec-
tion lurks in the unsanitary homes and in
houses infected with tubercle bacilli. Landis re-
ports the investigation of an outbreak of pul-
monary tuberculosis in a cigar factory in which
tobacco dust was thought to be the cause. The
factory was found to be neat and clean and
there was practically no dust. He remarked that
it is obvious that no tobacco dust could be pres-
ent, as in order to work the tobacco in the mak-
ing of cigars the leaf and filler must be kept
moist, likewise the stock must be moistened and
never allowed to dry out. The source of infec-
tion was found to be in the atrocious sanitary
conditions found to be present in the houses of
the underpaid workers. The class of employees
that recruit the tuberculosis army is chiefly those
that have relapses of old tuberculosis, those liv-
ing with victims of the disease in homes, those
living in houses already infected with the tu-
bercle bacilli, those that have in other ways been
exposed to the insidious infection. Tuberculosis
is essentially a house disease and indoor life is
largely responsible, and it cannot be classified as
a trade disease, and there are few cases that ever
can be distinctly traced to an occupational cause.
Nontuberculosis employees should be spared the
hazard incident of working near those who are
coughing and spitting in the active stages of the
disease, as association at work or anywhere else
with those suffering with active pulmonary tu-
berculosis is always a menace to health. The
industrial physician should be at all times alert
in detecting signs of pulmonary tuberculosis
among employees, and this means that he must
suspect many cases coming under his care as
probably suffering from the disease until he has
by every means satisfied himself of the contrary.
There are innumerable border line cases present-
ing indefinite physical signs in their lungs, at the
same time having malnutrition, loss of weight
and perhaps a cough, but having a negative spu-
tum in which incipient pulmonary tuberculosis
may or may not be present. It is comparatively
easy to diagnose a moderately advanced case of
pulmonary tuberculosis, but it is the very early
incipient cases that tax our utmost diagnostic
skill in definitely determining whether they have
or have not the disease in an early form; and
these early incipient cases are the class which
if they are given prompt and radical treatment
will net us the greatest reward in the number
of permanent recoveries. I am conservative
when I state that if this class of sufferers from
the disease is given the treatment covered in my
routine, later to be discussed, that fully 90 to
95% will, at the expiration of three months, be
able to return and take up their work cured.
Too much cannot be said in favor of social serv-
ice in industry with coordination of industrial
and community health centers as a means of cor-
recting unsanitary homes or living conditions
which are so necessary in the curbing of tuber-
culosis dissemination, also in closely cooperating
with health boards in all measures for the eradi-
cation of contagious disease.
Classification of Tuberculosis.
Usually pulmonary tuberculosis is classified
into three stages : incipient, moderately advanced
and advanced; the incipient stage covering all
degrees from the smallest recognizable physical
signs in the chest, biological reactions and labo-
ratory findings to the more pronounced evidence
of commencing lung involvement. The mod-
erdtely advanced stage, in which solidification of
the lung is present to a moderate or marked ex-
tent. Advanced, in which all stages of involve-
ment may be found throughout the lung struc-
ture from solidification to cavity formation. I
have, in my industrial work adhered to the classi-
fication as laid down by Dr. John Billings, of
New York, which is incipient, early favorable,
moderately adzKtnced, and advanced, believing
that each stage of pulmonary tuberculosis re-
quires a selective environment in order to ob-
tain the best results. The incipient pulmonary
tuberculosis case, as I classify it, then distinctly
comes under the category of those who present
the very earliest signs of commencing lung in-
volvement with loss in weight and other evi-
dence of beginning general health impairment,
with or without cough and in which the sputum
is negative. The other stages conforming to the
later physical signs of pulmonary involvement.
Physical Diagnosis in Incipient Tuberculosis.
In the early stages of the disease there may be
absolutely no recognizable signs and the diagno-
sis may be established only by the positive result
of a tuberculin injection or by the combination
of debility, indigestion or loss of weight with
slight fever not otherwise to be accounted for.
In some cases the earliest evidence of the dis-
ease is hemophthisis. When a patient consults
a physician on account of hemophthisis, it is
frequently impossible to find any physical signs
of disease in the lungs; not until weeks or
months later do the characteristic changes recog-
nizable by physical examination make their ap-
pearance. The very early hoarseness of the
voice in tuberculosis patients is of great impor-
tance and often attracts our attention to the
lungs when the patient has said nothing about
them. Definite physical signs in the lungs and
tubercle bacilli in the sputum artificially ob-
tained by giving the patient potassium iodide
Gr. X, three times daily, may occasionally be
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74
THE PEN1«YLVANIA MEDICAL JOURNAL November, 1920
demonstrated before any cough has appeared;
on the other hand, the patient may cough for
weeks before anjrthing abnormal is discovered in
the lungs. Occasionally tuberculosis begins with
an ordinary bilateral bronchitis or broncho pneu-
monia. I have found tubercle bacilli in several
such cases. Usually the earliest physical signs
are fine crackling rales heard at the apex of one
lung, heard only with or after cough and at the
end of inspiration, more rarely squeaks may be
heard, a slight diminution in the excursion of the
diaphragm on the affected side as shown by
X-ray or by Littens diaphragm shadow. Slight
diminution in the intensity of the respiratory
murmur, with or without a high pitched or inter-
rupted inspiration cog-wheel breathing. In or-
der to properly examine the apices of the lungs
for early evidences of pulmonary tuberculosis
one should secure perfect quiet in the room, the
clothing of the patient should be removed from
the chest, the skin of the chest should be mois-
tened, also the bowl of the stethescope. After
listening during quiet breathing over the apices
above and below the clavicle in front and above
the space of the scapula behind, the patient
should be instructed to breath out and then at
the end of the expiration to cough. During this
cough and the deep inspiration which is likely to
precede or to follow it, one should listen as
carefully as possible at the apex of the lung
above and below the clavicle concentrating atten-
tion especially upon the cough itself and upon
the last quarter of the inspiration, when rales
are most apt to appear sometimes only one or
two crackles may be heard with each inspiration
and often they are ftot heard at all, unless the
patient is made to cough. When listening over
the apex of the lung never allow the patient to
turn his head from side to side, since such move-
ments stretch the skin and muscles, creating ad-
ventitious sounds, i. e., muscular and skin rubs.
Lowered shoulders and a thoroughly relaxed at-
titude are essential. The diminution in the ex-
cursion of the diaphragm upon the affected side
in cases of incipient tuberculosis has been much
insisted upon by F. H. Williams and others who
have interested themselves in the radioscopy of
the chest. Littens diaphragm shadow gives us a
method of observing the same phenomenon
without the need of a fleuroscope. Even every
slight tuberculosis changes in the lung are suffi-
cient to diminish its elasticity and so to restrict
its excursion and that of the diaphragm. Com-
parisons must always be made with the sound
side in such cases. It must be remembered that
pleuritic adhesions, due to a previous inflamma-
tion of the pleura may diminish or altogether
abolish the excursion of the diaphragm shadow,
independently of any actual disease in the lung
itself. Some radiologists believe that they can
detect the presence of tuberculosis in the lung
by radioscopy at a period at which no other
method of physical examination shows anything
abnormal, but belief has been proved to be un-
founded. My own experience has been that the
X-ray as a means of diagnosis of incipient tuber-
culosis has as often led me wrong as right in
many cases. Interrupted or cog-wheel respira-
tion, occurring with inspiration as jerky puffs
which have a high pitched sound and which sig-
nifies that the entrance of air into the alveoli is
impeded, is usually very indicative of tubercu-
losis, especially when the condition is present
over a localized area of pulmonary tissue. It
has, however, no relation to the activity of the
process as it may be heard in arrested cases. The
only true signs of an active process are signs of
pulmonary moisture, which is displayed by fine
or coarse crackles with cough. In this paper I
have confined my remarks entirely to incipient
tuberculosis because, as I have said before, this
is the type of case which is most difficult to diag-
nose and, on the other hand, the easiest to cure.
The more advanced type being in comparison
very easy of recognition.
Treatment. From an industrial standpoint,
the question what shall we do with the incipient,
the early favorable, the moderately advanced
and the advanced cases of pulmonary tubercu-
losis presents itself in a very serious form to the
industrial physician. They Sre all working in
our industry when discovered with the disease.
They depend on what they earn to support them-
selves in addition, possibly, a wife and family,
or are contributing to the support of other rela-
tives. Take them away from work, which we
must, evolves responsibilities which you and I
cannot escape from. It seems imperative that
every industry should make provision, if there
be no beneficial association to give ample sup-
port to all cases of tuberculosis or their depend-
ents. It must be borne in mind that each class
of case requires different handling and the costs
of treatment vary. The advanced case as a rule,
should not be sent to a sanatorium provided he
or she can safely remain at home and that the
sanitary conditions are such as to allow home
treatment, that there are no children in the home
and that nursing care and medical care can be
provided. It must be understood that as they
are hopeless cases, many soon becoming bedfast,
that the expenses incident to their care are
higher than in any other type, as constant nurs-
ing attention and medical advice is necessary.
The moderately advanced cases may be sent to
a sanatorium, or at least should remain in a
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SELECTIONS
75
sanatorium sufficiently long to learn from the
institution, by the instructions given them, how
to care for themselves, manners of living and
prevention of contagion. After a period of stay
lasting from six weeks to three months, if their
home conditions are satisfactory, they may re-
turn. Early favorable cases should be sent to
a selected sanatorium where only cases of this
type are admitted ; nothing, in my opinion, is a
greater wrong than, to intermingle these early
favorable cases with those suffering from the
disease in an advanced form, many of whom are
djring. The majority of the early favorable
cases will, if given proper treatment, become ar-
rested cases within six months to a year and re-
turn to their work. The incipient cases of tuber-
culosis are kept under a reasonable amount of
discipline respecting rest and general health
routine, receive a maximum amount of good
nutritious solid food, and in addition, milk
served at regular intervals as well as a maximum
amount of sleep. The rest home should be lo-
cated in the country, not so far remote from the
city where their relatives can visit them easily.
It is necessary that the home be made attractive
in every detail, especially in respect to amuse-
ments, reading material, varied diet, cheerful
surroundings, and above all, conducted by a
woman, preferably a trained nurse, who has the
personal and executive qualities necessary to the
success of such an institution. The incipient
case of tuberculosis can safely be housed with
any other tjrpe of case. They rarely have a
cough, their sputum is negative of the tubercle
bacilli and they present none of the symptoms
except loss in weight which characterizes the
more advanced type of the disease. Therefore,
to the rest home I send not only incipient cases,
but also other patients suffering from malnu-
trition, anemias, nervous asthenics and those
having many other conditions in which rest,
change of air and scene with proper diet will
soon restore to health. It is my policy in every
way to prevent these employees from learning
that they have even been suspected of having
tuberculosis, in fact, the word never enters my
discussion we may have with the patient. The
consequence is that they are not made apprehen-
sive of their physical condition and return, after
three months, stay in the rest home, completely
cured, ready to take up their work. The rules
governing their care are extremely simple. I in-
sist on a varied but simple home diet of well-
cooked foods, served in an attractive manner,
and emphasize the best of butter, eggs and milk
be given them. As rest is of paramount impor-
tance, reclining and steamer chairs with rugs are
furnished them. Rest in bed each afternoon fqr
one hour is insisted upon, and the retiring hour
at night is 9 : 30 p. m. They are allowed to take
walks and, as means of diversion, have sleigh
rides in the winter and picnics in the .summer
and other forms of healthful amusement. They
must agree never to absent themselves from the
premises without first obtaining permission from
the one in charge.
The question may arise in your mind, "Is it
possible to absolutely be sure that the diagnosis
"is without a question correct in all cases sent to
the rest home as incipient tuberculosis ?" In an-
swer, I must unhesitatingly confess that pos-
sibly quite a number so diagnosed do not have
the disease, but in every case the physical signs
present, while not absolutely indicative of the
disease, point so strongly in the direction of pul-
monary tuberculosis that the element of doubt
renders them safer in being so classified, which
following my policy requires that they be taken
away from home and given rest home treatment.
For who can tell just when the havoc of the im-
planted tubercle bacilli begins as a disease proc-
ess? No disease affecting industry is more im-
portant and demands more care and considera-
tion in the details of its management than tuber-
culosis, and I know of none that preventive
medicine will yield greater returns. .
Likened unto the plant which has wilted from
want of air, moisture and sunshine, the incipient
tuberculosis patient will revive, take on new
vigor and strength, and finally bloom out with a
radiance of health, if given rest, food, air, sun-
shine and proper environment. In other words,
if given half a chance to fight down a ravaging
foe.
SELECTIONS
MAJOR GENERAL GORGAS*
William Crawford Gorgas was born at Mobile, Ala.,
October 3, 1854. His father, Josiah Gorgas, was born
in Pennsylvania in 1818, graduated at the United
States Military Academy at West Point in 1841 and
was assigned to the Ordnance Corps. He served with
credit in the Mexican War with the rank of captain.
When the Civil War began he cast his lot with the
Confederates and was made head of the Ordnance De-
partment with the rank of Brigadier General. One of
the buildings in which General Josiah Gorgas manu-
factured gun powder, now unoccupied and falling into
decay, stands near Macon, Ga. After the Civil War
General Josiah Gorgas was elected .Vice-Chanccllor
of the University of the South and later became Presi-
dent of the University of Alabama.
William's mother was Amelia Gayle, the daughter
of John Gayle, governor of Alabama from 1831 to
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THE PENNSYLVANIA MEDICAL JOURNAL November, 1920
1835. He was a presidential elector in 1836 and in
1840, and afterwards served in Congress.
William took his collegiate degree at the University
of the South in 1875 and his medical degree at Belle-
vue Hospital Medical College, New York City, in 1879.
As a student at Bellevue he listened to the first course
of lectures given by Dr. William H. Welch, who had
recently returned from his European studies and who
was destined to become the father of scientific medi-
cine in this country. General Gorgas frequently re-
ferred to Dr. Welch as his revered and beloved
teacher, and it is more than probable that the lectures
of Dr. Welch stimulated the spirit of research in
young Gorgas, as later courses of lectures by the same
distinguished man have stimulated hundreds of others
at Johns Hopkins. After serving one term as an in-
tern in Bellevue Hospital, Gorgas entered the Medical
Corps of the Army. In 1881 Gorgas and Crowder
were young oflScers at the post at Brownsville, Texas.
In that year an epidemic of yellow fever prevailed at
this post An order was issued that no officer should
come in xmnecessary contact with a case of yellow
fever. Crowder was officer of the day and on making
the rounds he fotmd Gorgas making an autopsy on a
man who had died from this disease. Crowder told
Gorgas to wait while he secured his sword. Gorgas
continued bis dissection and Crowder, properly
equipped, came back to the hospital, placed Gorgas
under arrest, and carried him to the calaboose. The
spirit shown by Gorgas in making this autopsy con-
tinued with him throughout life and made him the
greatest expert on yellow fever the world has ever
known and will secure for him the honor of having
eradicated this disease from many parts of the world.
From their Brownsville days Crowder and Gorgas re-
mained fast friends and during the World War there
was the closest affiliation between the office of the
Surgeon General and that of the Provost Marshal
General. Both Gorgas and Crowder delighted in tell-
ing the story of the former's arrest by the latter at
Brownsville in 1881.
In 1898 Captain Gorgas went with the Fifth Army
Corps to Santiago and while there was promoted to
the rank of major. In the Santiago campaign Gorgas
had charge of the Yellow Fever Hospital and it was
largely through his skill in the management of this
disease that the death rate in our Army in Cuba from
the disease was so low. In charge of the yellow fever
patients at Siboney he was untiring in his efforts to
limit the spread of the disease and to properly treat
the sick. The sight of his kindly face was a stimu-
lant which did much to tone up the muscles exhausted
by the exercise imposed upon the body by el vomito
negro. His kindly words to his patients served as
better tonics than any named in the pharmacopeia. As
one of his patients at that time the writer testifies to
the kindness and skill of Gorgas from personal ex-
perience. At Siboney Gorgas contracted typhoid fever
and was seriously ill for several weeks. After his re-
covery in the fall of 1898 he became chief sanitary
officer of Havana. In this position he was in closest
touch with Major Reed and his associates in their in-
vestigations concerning the transmission of yellow
fever. After Reed had demonstrated the truth of the
theory of Finlay and had incriminated the stegomyia,
it was believed that the fight against this disease was
to be waged by immunizing susceptibles by the bites
of infected mosquitoes, but this did not prove prac-
tical. To Gorgas belongs the credit of having origin-
ated and executed methods for the extermination of
the stegomyia. He carried this out so successfully in
Havana that the city for the first time in several hun-
dred years was free from the disease.
When the building of the Panama Canal was under-
taken Colonel Gorges was made chief sanitary officer
of the Zone. It is no exaggeration to say that hit
work on the Zone rendered the building of the canal
possible. It is estimated that for every tie on the
Panama railroad the French left a skeleton on the
Zone. Gorgas so improved the sanitary condition of
this death laden region that it became healthier and
showed a lower death rate than any community in the
United States; indeed, on the Canal Zone Gorgas
demonstrated tiiat malaria ancf yellow fever might be
banished from the tropics and the fairest and most
fruitful reg^ions of the world might become fit and
even delightful habitations for man.
After the completion of the Isthmian canal Gorgas
was made Siirgeon General, and in his honor the rank
attached to this office was raised from a brigadier to
a major generalship.
It is exceedingly fortunate that during the World
War General Gorgas occupied the position of Sur-
geon General of the Army. Everybody knew of him,
was acquainted with the work he had done and had
implicit confidence in him both as a skilled sanitarian
and as a man of honor. During the war his chief con-
cern was the welfare of the soldier. He personally
inspected all the camps and a notification that ai^
camp had an undue amount of sickness was sufficient
to bring General Gorgas to it with the greatest speed.
In making his inspections he insisted that he and those
who accompanied him should take at least one midday
meal in the hospital unannounced and with the pur-
pose of ascertaining by personal experience how the
patients were fed. He not only adhered to this rule
himself, but insisted that all inspectors should do the
same. The skill and devotion of General Gorgas to
the welfare of the enlisted men resulted in the mobili-
zation of a great army with a smaller death rate than
had hitherto been known in the annals of military
medicine.
General Gorgas was deeply interested in the Medi-
cal Reserve Corps and it was largely through their
knowledge of his work and their faith in the man that
more than thirty thousand civilian physicians immedi-
ately offered their services to him. At the beginning
of the war the highest rank that a Reserve officer
could secure was that of major. General Gorgas pre-
pared with his own hands a bill providing for in-
creased rank in the Reserve Corps and personally ap-
peared before Congressional conunittees to secure the
passage of this bill. In this he was successful. He
was not content to visit the camps in this country, but
made a tour of those in France.
General Gorgas' splendid work has received univer-
sal recognition. Before the war he was called by the
British Government to South Africa to advise as to
the methods necessary for the eradication of infectious
pneumonia on the Rand. He was given degrees by
many universities in this country and by the Univer-
sity of Oxford. He received many decorations, both
in this country and abroad. His great ambition was to
completely eradicate yellow fever, and after his term
as Surgeon General had expired he went to South
America as a health commissioner for the Interna-
tional Health Board of the Rockefeller Foundation.
At that time and for many years previously Guayaquil
had been a hot bed and breeding place for this disease.
He succeeded in completely stamping out this disease
at that place. A few months ago yellow fever was re-
ported on the west coast of Africa and General Gorgas
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November, 1920
ABSTRACTS FROM STATE JOURNALS
77
was asked by the British Government to visit that re-
gion and determine whether or not the reported dis-
ease was yellow fever, and if so how it could be eradi-
cated. On his way to South Africa he was stricken
with a cerebral hemorrhage in London and there died.
Certainly if service to his fellow man be a measure
of greatness, General Gorgas' name will take a place
with those of Pasteur, Koch, Ross, Reed, and others
of this class. We mourn his death, but we recognize
the fact that he built for himself, for the medical pro-
fession, and for the world at large, a moniunent more
lasting than one of stone or bronze.
To know General Gorgas was a high privilege and
an education in and of itself. He was as gentle as a
woman, but at all times inflexible in his adherence to
what he believed to be right He would listen with
the g^reatest patience and deference to any suggestion,
but he always acted in accordance with the dictates of
his intelligence and his heart. Companionship with
him was heightened by the vein of true wit and humor
which ran through much of his conversation and his
writings. His book on Sanitation in Panama is inter-
spersed with stories which would have done credit to
Mark Twain.
It was his custom to begin or to end his interviews
with some humorous remark. The sparkle in his eye
always foretold some humorous suggestion. After a
conference with the writer he once said: "This is
your judgment and it is mine, but remember that your
judgment and mine have at times been at fault Do
you recollect that you and I recommended the burning
of the village of Siboney in 1898 in order to stamp out
yellow fever? I have often wondered how many in-
fected mosquitoes were destroyed in that conflagra-
tion."
His story of the stampede among a group of dis-
tinguished sanitarians, who while visiting the hospital
in Havana and standing arotmd a jar filled with mos-
i]uitoes some one accidentally displaced the top of the
jar and set free the host of winged insects, is only
equaled by that of the turkey gobbler at the hospital
at Ancon that became blind from swallowing the qui-
nine capsules surreptitiously dropped in the bushes by
the laborers to whom they were issued as a daily
ration. We hope that Mrs. Gorgas will publish his
letters. In doing so she would confer a favor and, in-
deed, we may say, a boon upon the medical profession.
They would display the inner man of one who has
done great things for the good of mankind and one
we all delight to honor.
In 1885 General Gorgas married Marie Cook
Doughety, of Cincinnati, who has accompanied him
on many of his journeys in search of infection and has
intelligently helped him in his work. They have one
daughter, the wife of Colonel W. D. Wrightson, who
was one of General Gorgas' chief aids on the Canal
Zone, chief of the Sanitary Corps during the war, and
since that time an assistant to General Gorgas in his
work in Central and South America*.
The Medical Corps of die Army, the medical profes-
sion of this country and of the world, all who are in-
terested in the eradication of disease and the allevia-
tion of human suffering, recognize the greatness of the
man and his work and deeply mourn his death. May
his life be an incentive to the young men in our pro-
fession. Victor C. Vauchan.
HEALTH INSURANCE PROPAGANDA STILL
ALIVE
The medical profession must not get the idea that
its unanimous condemnation of compulsory state
health insurance embodied in a resolution adopted at
the last annual meeting of the American Medical As-
sociation in New Orleans, puts an end to the subject
and that it no longer requires attention.
Substitutes and modifications even worse than the
original draft of a so-called "model law" proposed by
the American Association for Labor Legislation are
being proposed in a ntunber of states. In several
others, bills equally visionary and some more vicious
have already been introduced. So far, none have been
passed in this country.
It was generally recognized when the compulsory
health insurance bill was introduced in the Ohio legis-
lature last session that it was more favorable to the
medical profession than any introduced up to that time
elsewhere.
Undoubtedly a similar proposal will become a vital
issue in the next session and in view of the expressed
opposition of the Ohio profession it is almost certain
that the new proposal will be no more friendly than
that previously introduced here for propaganda pur-
poses.
One of the latest moves on the part of the Ameri-
can Association for Labor Legislation is an attempt to
interest the ministry in their paternalistic propaganda.
Dr. Eden V. Delphey of New York, writes that he has
been extremely busy in endeavoring to keep the Fed-
erated Council of Churches of Christ in America from
going over, "hook, line and sinker," to the side of
"social insurance," alias compulsory health insurance.
Referring to the new phase of this propaganda the
Illinois Medical Journal in its last issue stated :
"From several sources our attention has been called
to the personnel of the propagandists in this country
of health insurance and allied schemes. One phase of
this subject we consider alarming. It is this: that
several of the staunchest advocates of these dangerous
doctrines are Russians inoculated with the soviet gov-
ernment bug. Likewise a number of them have
deemed it wise or expedient to shorten materially or
even change the spelling of their names. It has also
been reported that one of them was connected with
the notorious 'Rand School' (New York) which was
raided by the Federal Government some time ago as
being in league with the anarchists, bolshevists, etc.
It seems to us that it is about time for real Americans
to wake up, get busy and help guard American insti-
tutions."— The Ohio State Medical Journal, Septem-
ber, 1920.
ABSTRACTS FROM STATE MEDICAL
JOURNALS
FRANK F. D. RECKORD, M.D.
Assistant Editor
THE TREATMENT OF UTERINE TUMORS
1. Abdominal myomectomy should be considered in
the treatment of uterine myoma causing symptoms in
the woman of thirty-five years or under.
2. Radium is indicated in the cases of small uterine '
myoma causing hemorrhage in patients more than
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THE PENNSYLVANIA MEDICAL JOURNAL November, 1920
thirty-five, in the fibrous uterus, and in the menor-
rhagia of menopause.
3. The dose of radium should be sufficient to control
the menorrhagia but not enough permanently to stop
it in the patient under thirty-five.
4. The large tumors are best treated surgically.
5. A negative diagnostic curettage is not to be relied
on in a case in which the history is suspicious of
malignancy.— Leda J. Stacy, M.D., in The Journal of
the Iowa State Medical Society, September, 1920.
THE ROLE OF THE TONSILS IN PULMONARY
TUBERCULOSIS
1. The combined statistics of pathologists show the
evidence of tonsillar tuberculosis to be about 4 per
cent.
2. Primary tonsillar tuberculosis with surface lesions
appear to be exceedingly rare. While the latent type
may be either the result of primary or secondary in-
fection, the manifest form presenting local signs and
symptoms is usually an evidence of secondary invasion
from some other focus in the body.
3. The frequent occurrence of bone, joint and skin
tuberculosis favors the theory of hemotogenous metas-
tasis.
4. The generally accepted theory of lymphogenous
dissemination from tonsil to hilus and thence by vis-
ceral lymphatics to parenchyma of lung does not sat-
isfactorily explain the frequency of apical lesions.
5. The striking association of tonsillar and glandu-
lar tuberculosis with an apical pleuritis in the absence
of a pulmonary lesion suggests a direct lymphatic
drainage from tonsil to pleura. In the light of
Grober's experiments and the clinical evidence at hand
I believe such an assumption to be well founded.
His experiments included studies on the lymphatic
drainage of the tonsils in dogs. Six months following
the injection of one tonsil with Chinese ink he demon-
strated at autopsy that the dye could be traced into the
deep cervical lymphatics, thence directly to the apical
pleura and into the parenchyma of the lung where it
was seen as a diflFuse grayish discoloration of the cel-
lular structure of the apex. In reviewing the work of
Grober one is much impressed with the painstaking
methods employed. The detailed analysis of autopsies
convinces the reader that his claims for the presence
of a direct lymphatic route from tonsil to lung are
well founded. From R. Bishop Canfiei.d, M.D., in
The Journal of the Michigan State Medical Society,
September, 1920.
TUBERCULOSIS OF THE KNEE JOINT IN
CHILDREN
1. Tuberculosis of the knee is always secondary to
a focus elsewhere in the body and may be caused
either by the human or bovine tuberculosis bacillus.
2. Trauma is a prominent etiologic factor.
3. The disease may be either primary in the synovia
or in the bone. It is difficult to determine which is the
more common. It is the impression of the author
from clinical experience that the synovial type is fully
as common in children as the osteal type.
4. The symptoms are usually mild and the deformity
develops surreptitiously with but little complaint from
the child.
5. The treatment is essentially conservative, and if
instituted early, carefully planned, and carried to com-
pletion affords a good prognosis. — M. S. Henderson,
in The Journal of the Minnesota State Medical Asso-
ciation, October, 1920.
A REVIEW OF THE SURGERY OF GONOR-
RHEA IN THE MALE
Based on the work of many authors and on a series
of 167 vesiculotomies and six vesiculectomies per-
formed by ourselves together with several hundred
operations on the gonorrheal epididymis, we have
reached the following conclusions :
1. In those cases of persistent gonorrhea in the male
in which there is proven involvement of the seminal
vesicle without frank pus therein or marked pain
(perineal or rectal), and in which no marked fibrosis
has taken place, or in which there is no accompanying
arthritis, vasotomy following the technic of Belfield
should be employed with the injection, preferably, of a
collargol solution.
2. In case of vesiculitis showing frank pus, or where
the vesicles do not strip easily and in which there is
no marked fibrosis, or in which arthritis is present,
vesicle drainage following the method of Squier is the
advisable operation.
3. In cases showing fibrosis with perineal or rrctal
pain and accompanied or unaccompanied by arthritis,
vesiculectomy is the operation of choice.
4. In cases of acute gonorrheal epididymitis which
do not show a marked subsidence of pain, tempera-
ture and swelling within forty-eight to seventy-two
hours from onset under proper rest in bed, application
of the ice-cap and supportive measures, epididymotomy
should be performed. This operation should never be
performed without an accompanying vasotomy as de-
scribed above.
5. In recurrent cases of epididymitis or in cases of
acute epididymitis showing marked areas of beginning
necrosis or in those recurrent cases in which there has
been sufficient fibrosis to utterly preclude resumption
of function on the part of the epididymis, epididy-
mectomy is the method of choice.
A final word as to vasotomy, with special reference
as to its technic:
It is highly important that the vesicles be thoroughly
emptied by stripping immediately preceding operation
and that no fhiid be injected into the vesicles other
than that to be used for medication. It is equally im-
portant that the vesicles be filled to the point of un-
comfortable distention in order that the purpose of
the operation may be accomplished, i. e., so distending
the vesicles as to reach all of the vesicular ramifica-
tions. In order to accomplish this we have employed
the following addition to the usual technic : After
opening the vasa and determining their patency by
means of a strand of silkworm gut, the index finger
of an assistant is put into the rectum and pressure
made over the urethral portion of the prostate suffi-
cient to secure a closing of the ejaculatory ducts. In-
jection into the vas is now made until the patient com-
plains of a pronounced sense of fullness in the rectum.
The amount of medicating fluid to be used will be
found to vary from 10 to 30 c.c. We consider this
addition to the technic to be of importance.— Ernest
G. Mark, M.C, in the Journal of the Missouri Stale
Medical Association, October, 1920.
A CLINICAL APPARATUS FOR MEASURING
BASAL METABOLISM
To fill urgent clinical needs the portable respiration
apparatus has been modified, reduced in weight, and
provided with support and stand so as to make it a
strictly portable apparatus. Without gas analysis,
without weighings of any kind, the oxygen consiimp-
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November, 1920
ABSTRACTS FROM STATE JOURNALS
79
tion of patients may be studied by this apparatus in
the customary lo to 15 minute periods, with an ac-
curacy fully equal to other standard methods of study-
ing respiratory exchange. A simple method of timing
the readings of the position of the spirometer bell
eliminates the use of stop watches. Three series of
comparison tests on two different subjects with widely
varying basal oxygen requirements show that the most
satisfactory results can be obtained. — From Francis
C. Benedict and Warren E. Coixins, in The Boston
Medical and Surgical Journal, October, 1920.
RELATION OF HOUSING TO PULMONARY
TUBERCULOSIS
What methods shall be used to Improve the home
conditions and occupational environment of our peo-
ple?
I. If the children are to be the sanitarians of the fu-
ture, there must be systematic health instruction in the
public schools. Carrying out this idea the Pennsyl-
vania State Department of Health purposes to furnish
data on this subject to the Pennsylvania State Depart-
ment of Public Instruction for a book which will be
used throughout the extensive school system in this
state, so that every school child will not only be taught
this major branch but will be compelled to pass an
examination upon its completion. Also the State
Health Department is developing a public health school
which is to be conducted by means of the daily and
weekly newspapers and is comprised of twenty-four
lessons on topics such as tuberculosis, school hygiene,
milk, sanitation, the dinner bucket, colds, flies and
others, written in a style to appeal to the public gen-
erally. The state will be org;anized with classes, each
community having its secretary, who will manage the
affairs. It is to be hoped that the children as well as
adults thus instructed will not be satisfied to continue
to live in an atmosphere or environment, which they
can improve by putting into execution some of the
knowledge obtained. It is not only important to teach
people certain truths, but to see that tiiey make prac-
tiaal use of them. Many of the well-recognized prin-
ciples of |)reventive medicines are thoroughly under-
stood by the laity, but their practice is sadly neglected.
2. More publicity is needed, so as to place the needs
of a town or city before the general public, who may
be ignorant of existing conditions. By the demand of
the public many evils, such as overcrowding, improper
sanitation and poor ventilation in public places, are
eradicated and additions for the public good, such as
fresh air schools, are obtained.
3. Greater effort should be made in connection with
the establishment of fresh-air schools, and rounding
up in the communities and rural districts the children,
who are pre-tuberculous or in the active process of the
disease and in providing treatment for them. It is
hoped that in the future all schools will be conducted
on the fresh air plan.
4. It is important and necessary that employers be
kept reminded as to their duty to their employees.
Rest rooms should be provided where a little recrea-
tion and relaxation may be obtained during the lunch
hour. In many places firms are providing hot lunches
at a reasonable rate to their employees, which does
away with the carrying of cold articles of food and
likewise provides relaxation at meals under favorable
conditions.
5. The establishing of health centers in each of our
cities and in representative towns of the rural dis-
tricts, which shall be the centers of all activities per-
taining to the uplift of the community. These centers
in Pennsylvania are utilizing the rooms used by the
State Clinics and the organizations that are engaged
in this work are composed of individuals who are en-
deavoring to do their share in their particular spheres.
Stated meetings are held which are attended by chiefs
of the tuberculosis, genitourinary, child welfare and
prenatal clinics, the cotmty medical director and repre-
sentatives from the health council comprised of the
American Red Cross, Associated Charities, Women's
Clubs and Societies, Men's Clubs, including the Rotary
and Kiwanis Clubs, Chamber of Commerce, Fraternal
Organizations, Churches and Newspapers. At these
meetings all social problems are considered and plans
made to better exi$ting conditions. Nutrition classes
are being started and children from twelve to sixteen
years of age are taught to cook; also mothers' clubs
where lessons in sewing, plamiing meals and care of
the baby are given ; also little mothers' leagues where
girls are taught how to clothe, feed and bathe the baby.
6. It is important to constantly keep before the pub-
lic, sick or well, the value of stmlight. Sunlight is
needed by all, in fact all measures upon which we rely
for the cure of tuberculosis are those which we should
recommend to the well in order to make them stronger,
happier and more vigorous. In the recent research
work of Sweany and MacLane, Chicago, it was shown
they found that a suspension of tubercle bacilli in salt
solution was killed in twenty minutes in direct sun-
light with the rays of the stm at an angle of 50 de-
grees ; five hours in a film of dust in direct sunlight :
five days in a film of dust in a south room and seven
days in a film of dust in a north room. Soparker
has also performed noteworthy experiments, his work
consisted in testing the resistance of tubercle bacilli
under varying conditions such as sunlight, diffuse day-
light and darkness. He found that the tubercle bacilli
will live twenty days in moist sputum ; three hundred
and nine days in the dark; 4ve days in diffuse day-
light in dust and two hours in direct sunlight in dust.
His work shows clearly that sunlight is the worst
enemy of tuberculosis.
7. We recoil in horror from the leper house or the
cholera camp, yet the deadliest known hotbed of hor-
rors, the spawning ground of more deaths than
cholera, smallpox, yellow fever and bubonic plague
combined, is the dirty floor of the dark, unventilated
living room, whether in city tenement or village cot-
tage, where children crawl and elders spit. However
we may improve the most insanitary house or room,
make it habitable for either sick or well, but if we
neglect to improve the occupants of the house, all our
e/rorts will be of no avail. Every sanitary housing
plan which does not take into account the sanitation or
personal hygiene of its occupants must fail. They are
inseparable. Sanitation of the house must go hand in
hand with personal family hygiene.
8. Instead of nature being able to cure tuberculosis
unaided, as a matter of fact she has neither the ability
nor the inclination to do anything of the sort. There
is no class of patients whose recovery depends more
absolutely upon a most careful and intelligent study
and regulation of their diet, of every detail of their
life throughout the twenty- four hours and of the most
careful adjustment of air, food, heat, cold, clothing,
exercise, recreation, by the combined forces of sanita-
tion, nurse and physician. It is only by education and
education of the highest type that we have any rea-
sonable prospect of cure.
9. Finally, it is the duty of every plv^siCian to influ^
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THE PENNSYLVANIA MEDICAL JOURNAL
NoveMBBR, 1920
ence public (pinion, that the evils incident to bad
housing, occupational environment and sanitation may-
be improved, so that the children, the hope of the fu-
ture, may be given a chance. — Frank F. D. Reckord,
M.D., in the American Journal of the Medical Sciences,
August, 1920.
THE MEDICAL COLLEGES OF PENN-
SYLVANIA
JEFFERSON MEDICAL COLLEGE
OCTOBEK 14, 1920.
The Ninety-Sixth Annual Session of The Jefferson
Medical College was inaugurated on the evening of
September 22, 1920, with an address by Hobart A.
Hare, Professor of Therapeutics, upon "Objects and
Aims of the Student."
The Dean of the College reports having received a
greater number of applications for admission to med-
ical study than at any previous time during its history.
Inquiries relating to admission to the First Year Class
were received from 1,130 prospective medical students.
Approximately 450 made formal application by sub-
mitting credentials, and of these, 300 applicants were
approved as fully meeting the requirements for ad-
mission, the minimum requirement imposed being two
years of College work leading to an Arts or Science
degree, with specifiied College courses in three sciences
and two languages. The completed enrollment shows
a total attendance of 534, distributed, by classes, as
follows :
1st year class 180
2d year class 142
3d year class 96
4th year class 116
In awarding places in the First Year Class, favora-
ble consideration was given only to the applications of
those whose credentialvindicated scholastic attainment
of high order. Particular importance was attached to
excellence in science work in Literary Colleges, and
preference given, to those who had completed more
than the required minimum amount of work. A con-
siderable number of those admitted have already re-
ceived from their Literary Colleges degrees in either
Arts or Science, after four years of work; and an
additional group, after three years of College work,
are registered as Seniors in absentia, and will re-
ceive from their Literary Colleges, after the satisfac-
tory completion of one year in the medical course, a
degree appropriate to the work which they have com-
pleted.
The student body shows a very wide geographical
distribution. The students of the Jefferson Medical
College are more widely distributed, geographically,
than those of any other medical institution. Its grad-
uates were examined before more State Boards of the
United States in the year 1919, than was the case with
any other medical school, emphasizing the national
character of its scope and influence.
A large number of students who had completed two
years of the medical course sought admission to Ad-
vanced Standing in the Third Year. Their previous
courses had been completed in a very considerable
number of University Medical Schools, in which either
the Third and Fourth Years are not given, or in which
the clinical advantages are not equal to those offered
in Philadelphia.
In seeking an explanation for the largely increased
number of young men who are applying for admission
to medical study under entrance requirements con-
siderably and steadily advanced over those of a few
years ago, a number of influences would seem to be at
work. In the first place, the increased number of ap-
plications to first grade medical schools is more ap-
parent than real, since there has been a gradual and
steady reduction in the number of medical colleges in
the United States during the past fifteen years imtil,
at the present time, the total number is less than one-
half the total in existence at the beginning of this
period. Obviously, the total medical student body
must now be distributed among a much smaller num-
ber of colleges.
Then, too, as regards the present session, it should
be noted that there has been an accumulation of med-
ical students during the war. A considerable number
who had the intention to enter upon medical study
were temporarily diverted from their purpose by rea-
son of war participation, and are added to those whose
preparation was uninterrupted. Following discharge
from army service, many returned to their medical
preparatory courses in the literary colleges, and are
just now able to enter the medical school. There can
be no doubt that the war itself served to arouse in the
general public an enormous amount of interest in med-
ical matters, and made an appeal to the imagination
of the young men. The various activities of the Red
Cross, in which the women of the country found such
varied opportunity for service, dealt largely with med-
ical supplies, service and problems. Thirty-three
tliousand physicians were withdrawn from civil prac-
tice to enter the commissioned medical forces of the
nation — a circumstance which in its results affected
every community profoundly, and almost every family
individually. The enlisted medical personnel of the
army created another large medical group. The or-
ganization of base hospitals was g^ven much attention
by the press, and aroused much interest in the com-
munities in which they were organized. The part
which the Medical Department played in the war it-
self was highly creditable, and reflected favorably
upon the profession, its work, aims and ideals, and
was the Subject of much general interest and favora-
ble comment, and the foregoing is true of tiie medical
corps of the armies of almost all, if not all.-of the na-
tions who took part in the conflict
Probably another not inconsiderable influential fac-
tor was the epidemic of influenza, the greatest disease
tragedy of the century. The wave of disease and
death which swept across the country found the med-
ical profession woefully inadequate in numbers to deal
with the situation. Whole communities, for the first
time in the lives of their residents subordinated every
other consideration to orgjanize against a foe more
dreadful and deadly than they had ever known. The
circumstances focussed the attention of the whole na-
tion upon the compelled-to-stay-at-home doctors, as
the war had done for those away in service. The
apparent dearth of physicians, the opportunity for un-
selfish service, the general appreciation and com-
mendation of the work of the physicians, and the large
participation of voltmteers and the public in their
work, doubtless aroused the desire in many to become
members of such a profession.
Finally, general economic' conditions have not been
without a considerable influence. General prosperity,
large wages and big profits have made a medical edu-
cation financially possible to many who would other-
wise have been deprived of the much desired oppor-
tunity to enter a college and a medical school.
RSFOKTBB.
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TRUTH ABOUT MEDICINES
81
TRUTH ABOUT MEDICINES
Nature's Creation.— This is one of the fake con-
sumption cures. It was originally put on the market
as an absolute cure for syphilis. When analyzed in
the A. M. A. Laboratory it was found to be essentially
a solution of potassium iodid in a vi«akly alcoholic
medium containing vegetable extractives and flavoring
matter, and small quantities of inorganic salts (Jour.
A. M. A., Sept 11, 1980, p. 758).
More misbranded nostrums and drugs products. —
The following products have been the subject of
prosecution under the federal Food and Drug Act:
Beecham's Pills were held misbranded because the
■curative claims made for them were false and fraudu-
lent, and because the pills were not made in England
as claimed. Pike's Liver, Kidney and Stomach Rem-
edy, because the therapeutic claims were false and
fraudulent. Ergot Apiol Compound (Evans Drug
Co.), because the capsules did not contain the claimed
amounts of drug and because they were an imitation.
Prescription 1000, sold in two forms, a copaiba prepa-
ration for internal use and a dilute potassium perman-
ganate solution for external use, was sold under false
and fraudulent therapeutic claims. Rival Herb Tab-
lets were tablets falsely claimed to be chocolate coated
and sold under false and fraudulent therapeutic claims.
Wilson's Solution Anti-Flu consisted essentially of oil
.of eucalyptus, methyl salicylate and thymol or oil of
thyme, and was falsely claimed to be effective as a
remedy for influenza, colds and grippe. Castor Oil
Capsules (Evans Drug Co.), did not contain the
amount of drug claimed (Jour. A. M. A., Sept. 4, 1920,
p. 690).
Prevention of Goiter. — ^The latest report on the pre-
vention of goiter by administration of sodium iodid
by Marine and Kimball — an investigation carried out
under a grant from the Therapeutic Research Com-
mittee of the Council on Pharmacy and Chemistry —
.indicates a striking difference between those girls not
-taking and those taking iodin. The difference is mani-
fested both in the prevention of enlargement and in a
-decrease in the size of existing enlargements. Of
.2,190 pupils taking 2 gm. of sodium iodid twice yearly,
.five have shown enlargement of the thyroid, while of
2,305 pupils not taking the prophylactic, 495 have
rshown enlargement of the thyroid. Of 1,182 pupils
with thyroid enlargement at the first examination who
took the prophylactic, 773 thyroids decreased in size,
while of 1,048 pupils with thyroid enlargement at the
.first examination who did not take the prophylactic,
145 thyroids decreased in size (Jour. A. M. A., Sept
4, 1920, p. 674).
Lyko. — This is an alcoholic tonic which has been
-widely advertised in the newspapers. It is put out by
the Lyko Medicine Co., Kansas City, Mo. Lyko is
•claimed to stimulate the appetite, tone up the diges-
tive organs and to have laxative qualities. It is said
to contain caffein, kola, phenolphthalein and cascara
.sagrada. The advertising does not discuss the most
powerful ingredient, alcohol, although the label de-
•clares the presence of 83 per cent, of this drug. As a
result of an exhaustive examination, the A. M. A.
Laboratory cotKludes that Lyko is essentially a sweet-
•«ned solution containing about 22.2 per cent, of alcohol
Ttogether with insignificant amounts of caffein, cascara
•extractives and phenolphthalein. There was no evi-
•dence to show that the product is sufficiently medi-
•cated to prevent its being used as a beverage (Jour.
.A. M. A., Sept. 11, 1920, p. 757).
lodex, A Misbranded Iodin Ointment. — (1) Claim:
5 per cent, iodin. Finding : iodin content only about 3
per cent (8) Claim: free iodin. Finding: no free
iodin. (3) Claim: absorbed through the skin, iodin
can be found in urine 30 minutes after inunction.
Finding: the assertion that iodin can be found in the
urine after lodex has been rubbed on the skin has been
experimentally disproved. The preceding is taken
from a poster of the A. M. A. Chemical Laboratory at
the A. M. A. New Orleans meeting (Jour. A. M. A.,
Sept. 18, 1980, p. 830).
Diabetic Foods. — A report from the Connecticut
Agricultural Experiment Station on diabetic foods in-
cludes not only the content of carbohydrate in these
products but also that of protein and fat in view of
the recognized necessity of taking into account all of
the nutrients in any proper formulation of regimen
for the diabetic patient. There is no satisfactory defi-
nition of what a diabetic food is, nor is there any uni-
versal diabetic food. The value of accurate informa-
tion regarding the makeup of such products as may
find special application in the dietotherapy, such as
given in the Connecticut report, lies in the fact that it
enables clinicians and the patient to proceed intelli-
gently in the direction of diet planning with a view to
tolerance of all the nutrients. Of particular interest
in the report are the analyse of bran, which is being
widely used at present to give bulk to the food resi-
dues in the alimentary canal. It appears that common,
unwashed bran frequently contains no more than half
as much starch as some of the advertised brands of
"health" bran (Jour. A. M. A., Sept 18, 1920, p. 818).
Value of Schick Test. — The Shick test, which can
readily be applied to a large number of persons, makes
it possible to differentiate those immune from those
susceptible to diphtheria. It also facilitates the at-
tempt to increase the number of the immune by suita-
ble prophylactic toxin-antitoxin injections.' By the use
of the Schick test and toxin-antitoxin injections, in-
stitutions have been kept free from cases of diphtheria
for years (Jour. A. M. A., Aug. 21, 1980, p. 545).
The Bethlehem Laboratories, Inc., Preferred Stock.
— Physicians in various parts of the country have re-
ceived advice that they have been selected to share in
the profits of the Bethlehem Laboratories, Inc., New
York City. The company claims to control the manu-
facture of hydorite, a product accepted by the Coun-
cil on Pharmacy and Chemistry. These physicians
are given an option to purchase four shares of the
company's stock for four hundred dollars. The di-
rectorate of the Bethlehem Laboratories, Inc, is stated
to be composed of business men of Bethlehem, Pa.,
the president of the General Laboratories, Madison,
Wis., a "prominent physician" of Bethlehem, and J.
Jay Reilly, Philadelphia, a "prominent Philadelphia
surgeon and consulting chemist to several large manu-
facturing drug concerns." Hyclorite, manufactured by
the General Laboratories, Madison, Wis., was accepted
by the Council on Pharmacy and Chemistry for inclu-
sion in New and Nonofficial Remedies because at the
time that it was considered, it was marketed in accord-
ance with the Council's rules. The investment propo-
sition which the Bethlehem Laboratories makes to
physicians is an insult to decent medical men. When
physicians are interested in products they prescribe
or recommend, the public does not get a square deal.
It is against public interest and a degradation of scien-
tific medicine for physicians to be financially inter-
ested in the products they prescribe (Jour. A. M. A.,
Aug. 14, 1920, p. 493).
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THE PENNSYLVANIA MEDICAL JOURNAL November, 1920
THE PENNSYLVANIA
Medical Journal
Published monthly under the supervision of the Publication
Committee of the Trustees of the Medical Society of the State
of Pennsylvania.
Editor
FREDERICK U VAN SICKLE, M.D Harrlsburg
Antitant Editor
FRANK F. D. RBCKORD Harrlsburg
Aitooiata Editors
Joseph McPaklahd, M.D., Philadelphia
Gkokcx E. Pfahler, M.D Philadelphia
I<AWiENCE Litchfield, M.D., Pittsburgh
GsoacE C. Johnston, M.D Pittsburgh
J. Stewast Rodman, M.D Philadelphia
JoBN B. McAi.iSTEa, M.D Harrisburg
BiBNABD J. Myehs, Esq Lancaster
PnbUcatlon Oommlttea
Tea G. Shoeuakee, M.D., Chairman Reading
Theodore B. Appel, M.D Lancaster
Feank C. Hammond, M.D Philadelphia
All communications relative to exchanges, books for review,
manuscripts, news, advertising and subscription are to be ad-
dressed to Frederick L. Van Sickle, M.D., Editor, 2i2 N.
Third St., Harrisburg, Pa.
The Societjr does not hold itself responsible for opinions ex-
pressed in original papers, discussions, communications or ad-
vertisements.
Subscription Price — $3.00 per year, in advance.
NOVEMBER, 1920
EDITORIALS
TETANUS AND ITS ANTITOXIN
Following the introduction of the antitoxin
treatment of diphtheria by Behring, in 1890,
about a decade was required to convince the
medical profession of its prophylactic and ther-
apeutic value, and another decade had to pass
before statistical computations based upon mil-
lions of cases, could be made convincing as to its
value.
When Park, in 1912, published his tabulation
of cases from 18 of the world's largest cities,
there was no other possible explanation of the
diminution of the death rate from 66: 100,000
among 16,526,135 population in 1890, to 19:
100,000, among 22,790,000 in 1905, than that it
resulted from the increasing use of the antitoxin,
and a better acquaintance with the methods of
administering it.
The statistical studies of diphtheria, with re-
gard to the value of antitoxin in its treatment,
were, however, comparatively simple when con-
trasted with similar studies upon tetanus and its
antitoxin.
Tetanus antitoxin, first made by Behring and
Kitasato, in the same year, 1890, as the diph-
theria antitoxin, and more and more hopefully
received and employed as the benefits derived
from the diphtheria antitoxin were made more
and more clear, failed to give the same conclu-
sive evidences of usefulness.
There were many explanations of this. In the
first pl£ice, diphtheria is a common disease, teta-
nus a rare one. Diphtheria is a readily transmis-
sible— highly contagious disease — ^and tetanus
scarcely at all so. The former was therefore
early made the subject of strict registration, the
latter only much later made reportable. For long
it was quite enough to report it when the patient
was dead. Statistics could be easily computed
from the entire number of cases occurring in
diphtheria, while only from the number dying in
tetanus. Only in hospitals, where both the num-
ber of cases and niimber of deaths were known,
could the two be satisfactorily compared, and in
any of them the total number of cases was too
small.
Such was the state of affairs with regard to
tetanus when Moschowitz published his review
of the subject in 1900. He had to cull out of the
literature of medicine, the cases reported to have
been treated with antitoxin, and those reported
as not having been so treated, and then make his
comparisons. This was both difficult, and as re-
gards error, dangerous. Many whose patients
recovered from tetanus without the antitoxin,
hastened to report the fact, while others, whose
patients died in spite of it, suppressed the in-
formation, fearing that the publication, appear-
ing before the failure could be properly ex-
plained, might be productive of harmful results.
However, comparing the two groups of cases
as well as he was able, Moschowitz came to the
conclusion that under the antitoxin treatment,
the death rate from tetanus had been reduced
from 80%, at which it stood in the non-antitoxin
cases, to 40% in the antitoxin treated cases.
Most subsequent writers, though few have found
so high a percentage of benefit as Moschowitz,
find a decided diminution in the death rate in
favor of the antitoxin treated cases.
Their difficulties were much the same as those
of Moschowitz. All of the cases of the disease
had not been reported; those reported had not
been similarly treated; those that had been
treated had received very diflFerent doses and
methods of administration, so as not to be easily
comparable — there was no satisfactory standard
of comparison.
It is therefore with much interest and satis-
faction that we have read the "Analysis of 1,458
cases of tetanus that occurred in Home Military
Hospitals, during the years 1914-1918," pub-
lished by Sir David Bruce in the Journal of Hy-
giene, July, 1920, Vol. xix. No. i.
To give in abstract all of the interesting and
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November, 1920
EDITORIALS
83
valtiable contents of this paper is impossible, but
certain of the conclusions of its author cannot
fail to impress the reader.
Thie number of wounded soldiers sent from
the Western Front between August, 1914, and
November, 1918, was 1,242,000. The number
of tetanus cases among them was 1,458, and the
statistical study of them is the substance of the
paper, the facts being displayed in many charts
and tables.
The first thing to strike the reader is the over-
whelming disproportion of cases that occurred
in the montns of September and October of
1914.
In August of that year there were 3 : 1000 ; in
September, 9 : 1000 ; in October, 7.5 : 1000 ; and
then, though the war goes on as usual, and mul-
titudes of men are wounded, the incidence of the
disease declines to about 3 : 1000, above which
figure it never again rises. This is to be ex-
plained by the fact that at the very beginning of
the war the importance of tetanus was not yet
recognized, and no satisfactory means was at
hand either to prevent its occurrence or to com-
bat it where it already existed.
In answering the question, "Why this con-
tinuous and progressive diminution leading to-
wards the final extinction of tetanus as a com-
plication of wounds took place ?" Bruce answers
as follows: "Unfortunately the causes are
mixed, and two separate measures were intro-
duced for the prevention of the occurrence of
tetanus." Of these he speaks as follows :
"The surgeon's knife, after all is said and
done, is the best means of preventing the occur-
rence of tetanus after the wound has been in-
flicted. Dead putrifying tissues is the best cul-
ture medium for the anaerobe. At the beginning
of the war the treatment of wounds was not
thorough at the primary operation. It was
thought sufficient to wash out the wound and
apply an antiseptic. Controversy was acute in
regard to the merits of chlorine, common salt,
bipp, flavine, etc. It was only when surgical
teams were boldly pushed up to the front, and
thorough excision of the damaged tissues in the
wounds carried out, with primary or secondary
delayed suture, that any real advance was made
in the treatment. Anyone who saw these wounds
in the base hospitals in France a few days after
they had been inflicted, must have been struck
by the extraordinary results. One could almost
foresee the time when the antitetanic serum
would no longer be required."
"Some two months after the beginning of the
war it was ordered that every wounded man
should receive an injection of 500 units of anti-
tetanic serum as soon after he was wounded as
possible:* This had a most important influence
on the incidence of tetanus among the wounded
men * * * the ratio of the number of cases
of tetanus to the number of wounded was sev-
eral times as high in September and October as
in November and December. In September it
was 9: 1000, in December it fell to 14: 1000.
Now this fall was undoubtedly due to the fact
that that few prophylactic inoculations of anti-
tetanic serum were made until the middle of Oc-
tober. It appears that only a small quantity of
the serum was taken out with the Expeditionary
Force in August, 1914, and this only for the pur-
pose of treatment. It was not until the number
of cases of tetanus became alarming that steps
were taken to secure a large supply and ensure
that every wounded man received a prophylactic
dose. It was not until about the middle of Oc-
tober that prophylactic inoculation was intro-
duced on anything like an adequate scale, and
it was at this time that the remarkable fall in the
incidence of the disease took place."
In regard to the prophylactic employment of
the serum, Bruce comes to the following conclu-
sions : "At the beginning of the war one prophy-
lactic inoculation was the rule, but in June, 191 7,
it was ordered that four should be given at in-
tervals of seven days, each injection to consist
of 500 units." Col. Lingard, of Queen Mary's
Military Hospital, Walley, gives some interesting
details bearing upon this question. He states
that since the order was issued t)n 17th of June,
1917, and had time to be introduced and carried
into effect, 15,152 surgical patients of the Brit-
ish Expeditionary Force have been admitted to
this hospital, without a single case of tetanus de-
veloping. He considers this a most encouraging
and satisfactory result, and that it justifies all
the extra expense and labor involved in the mul-
tiple inoculations."
The prophylactic inoculations increase the du-
ration of the incubation period. "With one in-
oculation the average incubation is 38.2 days;
with two, 33.6 days ; with three, 51 days ; and
with four or more, ^3.7 days."
"Wounded men who received one inoculation
had a case mortality of 25.1 per cent. ; those who
received two, 21.3 per cent.; three, 16.^5 per
cent. ; and four or more, 7.1 per cent."
The best dose for prophylactic purposes is
placed at 500 units.
In regard to the therapeutic value of the anti-
tetanic serum, Bruce has much to say.
"The only specific therapeutic treatment is by
the injection of tetanus antitoxin. It has been
proved up to the hilt that the prophylactic in-
oculation of antitoxin is of very great value;
lowering the incidence, lengthening the period of
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THE PENNSYLVANIA MEDICAL JOURNAL November, 1920
incubation and lessening the death rate. But
when an attempt is made to appraise the value
of antitoxin, given after the symptoms of teta-
nus have declared themselves, great difficulty is
met with. Wide differences of opinion are held,
many holding that if given early and in sufficient
quantity it acts powerfully for good; others
doubting its usefulness but hesitating to discard
it altogether. The latter argue that as it is the
only rational specific drug against tetanus in
our possession it would be wrong to withhold it
in such a fatal disease as tetanus. They think
there is an off chance that it may turn the scale
in favor of the wounded man."
"In regard to the statistical proof of the value
of antitoxin as a curative agent it is very doubt-
ful if any truth can be .arrived at by the study
of the figures at our disposal. There is no uni-
formity in the treatment of tetanus in man. The
men who suffer are also, as a rule, suffering from
other grievous maladies — wounds, fractures, sep-
ticaemias, pneumonias, hemorrhages, heart fail-
ures, etc., so that if a man dies it is impossible
in many cases properly to fix the blame. Capt.
Golla, a member of the tetanus committee, has
compared the results obtained from the use of
therapeutic serum in this war with those of pre-
serum days. He is of the opinion that the rate
of mortality in cases of tetanus in this war which
did not receive a prophylactic injection of anti-
toxin, but did receive therapeutic treatment, ap-
proaches very closely to the rate of mortality in
pre-serum days. In other words, it would ap-
pear from his figures that the therapeutic use of
serum is of little or no practical value in treat-
ment. It is taught at the present time that teta-
nus toxin that has been taken up and fixed by
the nerves or nerve cells is inaccessible to anti-
toxin. If a lethal dose has been taken up by the
nerves and is traveling towards the nervous cen-
ters, before the serum treatment is begun, then
no amount of antitoxin will save the patient.
But in spite of these statistical considerations,
and in view of the experimental results, it is
clear that medical officers will continue, for the
present, to give a case of tetanus the benefit of
the doubt and use antitetanus serum therapeuti-
cally. As Ransom states, it may neutralize some
of the free toxin in the blood and lymph, and
prevent it ultimately entering the nervous sys-
tem and causing death, when the toxin already
admitted through the motor nerves is not suffi-
cient to do so."
In regard to the best method of administra-
tion, Bruce falls back upon the experiments of
Prof. Sherrington, in stating that the intra-
thecal mode of injection is the best. Sherrington
experimented upon' 130 animals. Of these there
were no recoveries when the injection was made
intra-durally into the cerebral tissues. Two re-
covered when the injection was made subcutane-
ously; 14 out of 25 recovered when the injec-
tion was made into the lumbar r^on of the
spinal cord.
"One therefore would conclude that a dose of
20 c.c. of high potency serum, containing 16,000
units, given intra-thecally in the first and second
days, supplemented and continued by intra-
muscular and subcutaneous injections would be
sufficient to keep the fluids of the body amply
supplied with antitoxin."
"In England alone, during this war, it is prob-
able that some two millions of prophylactic doses
of antitetanic serum have been given. Out of
this huge number only 11 cases of anaphylactic
shock have been reported. All 11 cases recov-
ered. No doubt these cases appear very alarm-
ing when they occur, but they are so rare that
they may be looked upon as negligible."
"Two per cent, of the cases of shock followed
the intrathecal injections, 6 per cent, the intra-
venous, 1.2 per cent, the intramuscular, and ojz
per cent, the subcutaneous route of injection. It
is evident from these figures that the most dan-
gerous route for the therapeutic injection of
antitetanic serum is the intravenous."
"Anj^hylactic shock is by no means a rare
phenomenon after therapeutic injections of anti-
tetanic serum, and markedly reduces the ques-
tionable usefulness of therapeutic serum."
J. Mc. F.
THE BUCKEY DIAPHRAGM IN X-RAY WORK
Some fifty years ago, it is reported that a clerk
hi the U.- S. Patent Oflice resigned his position,
havii^ become convinced that everything hu-
manly possible had already been invented and
that invention must, therefore, cease and with it
his job. He, therefore, resigned a few days in
advance of the coming event.
We who have observed the development of
the x-ray, sometimes approach the attitude of
the gentleman referred to, but just as we have
decided that nothii^ new will arise, behold a
whole crop of discoveries. At the meeting of
the American Roentgen Ray Society in Min-
neapolis,, September 14th to 17th, there were
presented two decided novel ideas.
Dr. Potter, of Chicago, showed results in ra-
diography of the spine, pelvis, hips and kidnqr
such as have long been the dream of all roent-
genologists. The result is obtained by the use
of an adaptation of the Buckey Diaphragm, a
device which had been abandoned by the pro-
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November, 1920
EDITORIALS
85
fession because of the fact that its glaring image
disfigured every plate made with it. Potter, by
ingeniously giving the device a constant motion
during the exposure, prevents its image from
appearing at all upon the plate or film. It is a
cold statement of fact that this device will open
up new possibilities in kidney, gall-bladder and
orthopedic diagnosis. A moving grid of lead
strips radially placed as a segment of a cylinder
and interposed between the body of the patient
and the surface of the plate or film, intercepts
practically all the scattered radiation from the
body of the patient, permitting only those direct
rays, causing correct images of the part to reach
the plate. When it is realized that frequently
80% of the total blackening of an x-ray plate is
due to these scattered rays which have no pic-
torial value, but merely fog the image, and that
these are almost completely eliminated by Pot-
ter's device, its wonderful utility becomes ap-
parent.
Morrison, an engineer connected with a con-
cern manufacturing x-ray apparatus, presented
a scheme for balancing a high voltage felectrical
circuit, so that the approach of any conductor
to such a circuit results in the immediate open-
ing of a circuit breaker, rendering the line harm-
less. Thus, if a patient under examination, or
treatment should lift a hand into the yicinity of
the tube terminals, or if the operator should ap-
proach within dangerous proximity to any elec-
trified portion of the apparatus, a delicate relay
at once operates a circuit breaker. A considera-
ble attention is being given to the development
of safety devices of various characters since a
modem x-ray apparatus, particularly one oper-
ated on an alternating current line with an auto-
transformer, is a potentially dangerous installa-
tion. Even the small transformers of relatively
low voltage used in the operation of dental
x-ray machines are sufficiently powerful under
favorable conditions to become very dangerous.
G. E. J.
WHO POINTS THE WAY?
Those who have followed the profession of
medicine during the centuries of the past have
had leaders, who by precept and example have
taught and led the student and practitioner of
the healing art. There have been times of ebb
and flow in this current, when great leaders-
lived, and others when lesser lights made the at-
tempt to educate and direct. History affords
many examples of the advance of a certain
period in medicine, followed by a decline or
even retrogression in scientific medicine. Dif-
ferent observers have placed one century above
another in importance in this respect. Great
leaders of one century have been discredited
during another. And so the world has run.
We in medicine of the present century are living
much different lives from those of our fellows
in past history, or at least so it seems to us. At
the present time we observe a great restlessness
on the part of men in medicine and greater agi-
tation of subjects as they affect the profession,
and professional thought and action.
We have wondered, in casting about for an
answer to the question, as to the cause for tliis
commotion. Is it a reflection of other business
or professional disturbance, or is it the result of
lack of serious and energetic leadership that
allows of confusion and too much dissatisfac-
tion?
We may then raise the question : "Who points
the way?" Have we in America men and
women of high standing who are leaders^ with
influence in medical affairs, and to whom we
may look for guidance in times like this ? True,
we have many organizations, both state and na-
tional, from which we receive much in the way
of information and profitable advice. But do
we have concentrated, effective centralization of
medical affairs at a point where all may look for
aid, and from which source may come organized
and constructive plans for the upbuilding of
everything affectifig our daily work in the field
of medicine?
We would expect to find such authority in
national and state organizations, and perhaps we
may not appreciate the work done by our gov-
ernment. We are impressed, however, with
something lacking in this field of leadership.
Would we be any better off for having a Secre-
tary of Health in the cabinet of the President?
Some have said — yes, and that from such a
source and through such an office should come
the leadership which apparently is lacking, to
correlate the forces necessary to reduce to or-
derly sequence the plans whereby many of the
visionary schemes are suppressed and rational
medicine furnished the people of the states.
Sane and logical practice should give to all the
people all the time that which many are criticis-
ing our profession for not fumishing.-.-We
need to have the way pointed out for future ac-
tion.
CURBSTONE DISCUSSIONS
Did you ever observe how many animated dis-
cussions occur at the close of a meeting of your
county or state medical societies ? This has so
many times impressed us with the feeling that
many of our members have thoughts and ideas.
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86
THE PENNSYLVANIA MEDICAL JOURNAL November, 1920
often criticism, which they wish to make, but
instead of presenting them during the meeting,
wait until its closed and then gather a circle of
boon companions on the stair landing or side-
walk and hold an adjourned meeting with often
heated discussions, either on the papers pre-
sented or of more personal observations. Why
is this ?
Would it not be better to express in open
meeting those discussions, comments or even
criticisms and thereby not only take part, but
frequently pave the way for a better fraternal
and professional relationship.
HOW DO WE OBTAIN NEWS ITEMS?
Those of you who take sufficient interest in
the Journal to read its pages, no doubt scan the
news item column to learn what has occurred
in your county among medical men or women,
and are often disappointed in not finding a men-
tion of the names you expected to find. This
omission you of course charged up to the lax-
ness of the Editor in not having noted the events
associated with affairs in your county. But
have you thought how the said Editor obtains
such news items? If you do not know, let us
remind you that not being possessed of super-
natural powers he must clip from papers or
other journals, or have them sent us by county
society reporters, secretaries or friends inter-
ested in this Journal, or we do not get such
news items. It is up to you, then, to be an aid
as a news gatherer if you expect to receive a no-
tice of yourself or your fellow practitioners in
your county of such data as you wish us to
print.
MEDICOLEGAL
AN INNOVATION
As a rule the average practitioner of medicine
has but little knowledge of the application of
general and special laws to his own interests.
Absorbed in his profession, confining his read-
ing-more or less to subjects of medical interest,
he pays but little attention to legal affairs until
he is confronted unexpectedly with some tech-
nicality, which often occasions both discomfort
and chagrin. To obviate this as well as to make
thek Journal more interesting and of greater
practical value, a new department is about to be
developed. At the Pittsburgh meeting of the
Board of Trustees, the Hon. Bernard J. Myers,
Deputy Attorney General of Pennsylvania, was
selected as legal counsel of the Society. He has
agreed to act as an Associate Editor of th^
Journal and will, from time to time, contribute
editorials explanatory of medicolegal subjects.
In addition he will give notice through these
columns of judicial decisions interpreting laws
with reference to the medical profession and
comments on the application of existing r^ula-
tions. Mr. Myers is especially fitted to handle
this department from his experience in the At-
torney General's office, where he has had prac-
tically entire charge of all the legal business of
the State Department of Health.
•SOCRATES REDUX"
SHOULD OUR JOURNAL EXIST?
Long ago, in the golden days of Athens, when
each of the many different schools of philosophy
were fully convinced that it was right and that
"the truth would die with it," an old, unattrac-
tive man used to spend much of his time in
going from one to another of the temple porches
and asking questions. His name was Socrates
and he was without fame, without reputation,
and was commonly regarded as a nuisance.
To be sure all that he did was to ask questions,
but questions are embarrassing at times, and the
more of them Socrates asked, the more he em-
barrassed his distinguished contemporaries, and
the more unpopular he became, until a false
charge was trumped up against him and he suf-
fered death for his pains.
He was no sooner out of the way, however,
than some began to see wisdom in his kind of
foolishness, and the most learned of them, one
Plato, began to eulogize and glorify him. It
was perfectly safe to do this for the old fellow
was dead and gone and no further embarrass-
ment was to be feared from any further ques-
tions that he might ask.
Of course those who knew that they were
right in what they had said and thought during
his life continued to think and believe that they
were still right and that it had been a good
thing to have the old man out of the way, but as
time went on there was an ever increasing num-
ber of thoughtful men who came to the conclu-
sion that it was not so bad to have someone
about to ask questions, for it made them think
to answer them, and not infrequently made
them open their eyes to facts that were perfectly
evident if they had not been blinded by prej-
udice.
However, the embarrassing questioner has
never attained popularity. We sometimes won-
der whether, if a Socrates were to arise to-day
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November, 1920
EDITORIALS
87
and set about quizzing the medical profession,
he would not suffer much the same fate as his
antecedent, barring, of course, the hemlock that
is no longer in use.
For example, suppose that he should begin by
asking "Of what use is this Journal? What
excuse has it to offer for its existence?" We
should certainly feel that we were being un-
fairly treated — insulted even. If we felt that
we were under obligations to pay any attention
at all, we might say that we are not in any way
responsible for the existence of the Journal,
that others had started it, that we are only the
Editor and that our responsibility ends there.
"Very well," says our questioner, "Do you so
faithfully perform your duty that every article
that appears in your columns is so original, so
useful, and so accurate that the profession of
the state awaits each issue impatiently, reads it
through with interest and feels that it cannot get
along without it ? If not, why not?"
Here we find ourselves embarrassed for we
do not believe that there are many men in the
state who feel that way, but we again hasten to
explain that our function is to publish what is
furnished us by the secretary of the society, who
in turn has to accept the manuscripts of the
papers that have been read at the meetings of
the Society of which this Journal is the official
organ.
"And who determines who shall read and
publish these papers ?"
"There is a program committee that arranges
all that," we answer.
"Oh, what a fine system," cries our old nui-
sance, with a bit of malice in his smile. "A
committee invites men who have no particular
interest in a subject, to write papers upon it,
read the papers at a public meeting, and then
publish them in your Journal !"
"But," we cry, "this is the system. We are in
no way responsible for it, we may even see its
defects, and may want to correct them, but it is
no less the system under which we work, under
which our predecessors have worked, and which
our membership seems to approve."
"You think then that your members are so
thoughtless as to approve a system by which
they are furnished with well-known facts hastily
brought together by those) who have no other
interest in them, than that of courteously re-
sponding to the li^quest of a committee?"
"We think that that is a very blunt manner
of saying it."
"What do you suppose those not members of
your Society think of your Joxhinal ?"
"That is a question that does not concern us."
"ni tell you how to find that out: look at
your subscription lists and see how many ac-
tually pay for the Journal, instead of getting
gratis because they are members of the Society."
"We do not feel called upon to furnish such
information to a stranger."
"Of course not, but look it up for yourself
and when you have found out that nobody cares
for your Journal except those who get it for
nothing, and when you add to that that of those
who do get it for nothing, very few read it when
they do get it, and to that, that they do not very
highly regard it when they do get it, and that
it is a very rare thing for anything in your
Journal to be quoted in any other journal, I
think that you will find it hard to escape the con-
viction that there is something radically wrong
with the Journal or with the system and that
the whole thing ought to be changed or cor-
rected."
The old man moved off, and we were glad
that he had gone, but we were annoyed. Some-
how faith in ourselvesj went with him and we
found ourselves wondering whether his remarks
were justified and the system ought to be
changed, or whether the whole argument was a
sophistry.
INTERESTING REVELATION
Never before were the pernicious eflfects of the so-
called "patent medicines" so apparent as they have
been since national prohibition became effective judg-
ing from the annual report of the superintendent of
police for Washington, D. C, which shows that drunk-
enness and serious crimes have increased in the na-
tion' capital during the past fiscal year, in spite of a
decided decrease in the number of arrests and minor
crimes.
Judging by this report and other apparently au-
thentic information, many firms and individuals are
manufacturing beverage concoctions under the guise
of "medicine," for the sole purpose of avoiding the
Federal laws.
These police statistics not only indicate that drunk-
enness has increased during the fiscal year but that the
majority of these cases were the result of the sale of
patent medicines containing alcohol. A recommenda-
tion restricting the sale of such articles probably will
be included in the superintendent's formal report, so he
states. — The Ohio State Medical Journal, August, 1920.
The Journal of the American Medical Association,
in commenting on the hospital intern problem, says
that it is certain that the increased demand for interns
does not justify either the lowering of educational
standards or the miilti^fication of medical schools. A
good suggestion is made that hospitals should employ
physicians on salaries and delegate to orderlies a cer-
tain part of the routine unskilled work which now is
done by interns. There is also a crying need for
stenographers in most hospitals to take down records
and do away with the endless waste of the intern's
time caused by the necessity of filling in records and
reports. — The Journal of the Indiana State Medical
Association, September, 1920.
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The Medical Society of the State of Pennsylvania
OFFICERS' department
WALTER F. DONALDSON, M.D.
Secretary
8014 Jenkins Arcade Bldg., Pittsburgh, Pa.
1920 CHANGES IN CONSTITUTION AND
BY-LAWS
The 1920 House of Delegates made changes in
the Constitution and By-Laws as follows :
Chapter V. Section 5, page 20, now reads:
The Executive Secretary shall organize the medi-
cal profession for efficient action on proposed or
pending l^slation of interest to the general pub-
lic and the medical profession. // shall further
be his duty to organize the machinery for the in-
vestigation of illegal practitioners of the healing
art in the Commonwealth of Pennsylvania. He
shall be appointed by the Board of Trustees.
He shall act with the Committee on Public
Health Legislation and shall be ex-officio a mem-
ber of this committee. Adequate salary and
other expenses of his office shall be provided for
by the Board of Trustees.
Article IV, Section 2, page 8, now reads:
Members whose assessments are received by the
secretary of this society on or before March 31
shall be entitled to all the privileges of this so-
ciety, for the current year. One whose assess-
ment is received after March 31 shall be entitled
to all the privileges of this society, except that
he shall not be entitled to any benefit from the
Medical Defense Fund from January 1 up to
the date of the receipt by the secretary of this
society of his name and assessment. The per
capita assessment for new members elected and
reported after July i, shall be one-half the
yearly per capita assessment. .(To take effect in
1921.)
The above changes and additions are of great
importance. It is to be hoped that all members
possessing a copy of the Constitution and By-
Laws as adopted September 23, 1919, will
promptly insert therein the changes noted.
THE MEDICAL LEGISLATIVE' CONFERENCE
OF PENNSYLVANIA
The Medical Legislative Confeirence of Penn-
sylvania is composed of the public health legis-
lation committees of the Medical Society of the
State of Pennsylvania and the Homeopathic
and Eclectic State Medical Societies. It is its
function to present properly to the law makers
of this state the advice and opinion of the eight
thousand organized physicians of Pennsylvania
on questions concerning public health. To carry
on the conference, conduct its meetings and
maintain an adviser during the L^slative ses-
sion requires a moderate expenditure of money,
which should be provided in advance. Early in
the current year the conference addressed a let-
ter to ten thousand physicians in Pennsylvania
appealing for contributions. The response was
puny, and might have discouraged less experi-
enced and courageous men than those compris-
ing the conference — which is now in its third
year. Facing a possible deficit between the esti-
mated income from the 1921 per capita tax and
the estimated outlay of expense for the coming
year, the Board of Trustees of our Society very
wisely decided to appeal to the component so-
cieties to respond to the request of the Legisla-
tive Conference.
The members of the Board of Trustees of the
State Society will therefore carry the appeal for
contributions to this indispensable work into the
various county medical societies of their respec-
tive councilor districts. It is to be hoped that
all component societies will make liberal appro-
priations which should not of necessity be in-
terpreted as interfering with contributions from
individual members. The trustees request that
such contributions be forwarded to Dr. George
A. Knowles, 4812 Baltimore Avenue, Philadel-
phia, chairman of the Committee on Public
Health Legislation of the Medical Society of
the State of Pennsylvania.
It is undoubtedly the duty of the medical pro-
fession to maintain its fight against ignorance
and greed in their eternal and powerful eflforts
for existence at the expense of the health of this
commonwealth.
Fortunately the material interests of the
eleven thousand physicians of Pennsylvania will
be best sustained by such health laws and med-
ical practice acts as best serve the eight million
inhabitants of our state. We may therefore be
sanguine in the face of any accusation of selfish-
ness in our legislative interests.
REGISTRATION
The total registration of 1,122 members of
the Medical Society of the State of Pennsyl-
vania at the 1920 session compares very favora-
bly with that of recent years, that of 1919 in
Harrisburg being 682 ; 1918, Philadelphia, 819;
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November, 1920
OFFICERS' DEPARTMENT
89
and 191 7, Pittsburgh, 875. It is estimated that
the registered members and visitors would easily
bring the total attendance at all sessions to 1,500
physicians. This is as it should be, except that
all in attendance upon the scientific sessions and
exhibits — ^members and nonmembers — should
be expected to register. The attendance upon
most sections was sufficient frequently to exceed
greatly the seating capacity, a condition not al-
ways desirable, but often contributory to en-
thusiastic discussion. The registrants choice of
sections was as follows: medicine, 555; sur-
gery, 337; eye, ear, nose and throat, 130; pedi-
atrics, 69; section not designated, 37; guests,
33 ; delegates from other societies, 2.
The total registration by counties was as fol-
lows: Allegheny, 600; Philadelphia, 78 ; Wash-
higton, 50; Westmoreland, 49; Beaver, 23;
Armstrong, 21; Lawrence, 19; Fayette, 18;
Cambria, 17; Lycoming, 15; Mercer, 15;
Venango, 14; Luzerne, 13; Clearfield, 11;
Dauphin, 11; Butler, 11; Erie, 10; Lancaster,
10; Lackawanna, 10; Blair, 9; Greene, 8; In-
diana, 8; Crawford, 7; Somerset, 7; Warren,
7; Bradford, 6; Huntingdon, 6; Jefferson 6;
York, 6; Clarion, 5; Center, 5; Clinton, 5;
Delaware, 5; Lehigh, 5; Montgomery, 5;
Northampton, 5 ; Bedford, 4 ; Carbon, 4 ; Mon-
tour, 4; Schuylkill, 4; Franklin, 3; Berks, 3;
Chester, 3 ; Northumberland, 3 ; Bucks, 2 ; Elk,
2 ; Lebanon, 2 ; McKean, 2 ; Mifflin, 2 ; Colum-
bia, I ; Cumberland, i ; Juniata, i ; Perry, i ;
Ti<^, i; Union, i; Wyoming, i. This repre-
sents fifty-six of the sixty-three county medical
societies.
The splendid showing by Allegheny and ad-
joining counties, while not extraordinary, never-
theless formed the foundation for the undenia-
ble success of the 1920 session. Here's to the
1921 session and a registered attendance of
1,800!
CHANGES IN MEMBERSHIP OF COUNTY
SOCIETIES
The following changes have been reported to Octo-
ber 23:
Adams: Removal — Harry S. Crouse from Littles-
town to York.
Aixegheny: New M«w6er*— (Reinstated) Edwin
H. Parkin, New Kensington; Michael J. Depta, 128
Greenfield Ave.; Alvin W. Sherrill, S5o6 Ellsworth
Ave.; James H. Hammett, Hiland Bldg.; Norbert J.
Resmer, 315 Brownsville Road, Pittsburgh; E. S.
Warner, Wilkinsburg Bank Bldg., Wilkinsburg.
Transfer — David Reiter, 4025 Girard Ave., Philadel-
phia, to Philadelphia County; Wayne S. Ramsey,
Pearson House, New Castle, to Lawrence County. Re-
moval—Sidney G. White from Pittsburgh to Warsaw,
Indiana.
Bbavbr : New Members — ^Joseph J. Scroggs, Beaver ;
Harry L. Grazier, Woodland; Roy R. Norton, New
Brighton.
Berks: New Members — Leland F. Way, Reading
Hospital, Reading; John G. Ziegler, Lt. C, M. C.,
U. S. N., U. S. Naval Hospital, Guam.
Blais: i?emowo^Andrew S. Stayer from National
Military Home, Wisconsin, to National Military
Home, Kansas.
Cambkia : Transfer— Kim D. Curtis of Revloc from
Indiana County. Removal — Walter C. Raymond from
Lilly to 5212 Chestnut St, Philadelphia.
Dauphin: New Me«^^r-^Charles E. L. Keene,
1849 Berryhill St., Harrisburg.
Favettb: New Jl/«»nt»>r— Edward H. Rebok, Wal-
tersburg.
Huntingdon: Death — Harry B. Fetterhoof (Hahne-
mann Homeo. Med. Coll., '99) in Huntingdon, Sept.
21, aged 49.
Indiana: New Members— W\\\\xm H. Heiser, Al-
verda ; Edward A. Haegeli, Ernest ; Malcolm L. Ray-
mond, Waterman. Death — ^John M. St. Clair (Univ.
of Penn., '75) of Indiana, recently, aged 7i-
Lackawanna: W*w JI/*i»ifr*r*—( Newly elected) P.
John O'Dea, S. Main St. ; Elmer B. Shaul, 345 Wy-
oming Ave., Scranton; (Reinstated) Daniel A. Webb,
310 Wyoming Ave. ; J. Nelson Douglas, 1501 N. Main
Ave. ; ' Eugene Curtin, Connell Bldg. ; M. M. Rosen-
berg, State Hospital; Nellie G. O'Dea, S. Main Ave.,
Scranton.
Philadelphia: Deaths — Benjamin F. Baer (Univ.
of Penna., '76) in Philadelphia, Sept. 11, aged 74;
Joseph Marshall Sterling (Medico-Chirurg. Coll.,
Phila., '12) in Philadelphia recently, aged 31 ; Henry
C. Paist (Penna. Med. College, '54) in Philadelphia,
Sept. 21, aged 87.
Somerset: New Members— lAoyA A. Heikes, Bos-
well. /?fmovo/— William T. McMillan from Meyers-
dale to 3969 Budlong Ave., Los Angeles, Calif.
Washington: New Members— Walttr R. Living-
ston, Ellsworth; Clyde E. Tibbens, Washington Trust
Bldg. ; Roy S. Clark, 141 W. Chestnut St., Washing-
ton.
Westmoreland: New Member— CharXes H. Poole,
RufFsdale.
PAYMENT OF PER CAPITA ASSESSMENT
The following payment of per capita assessment has
been received since September 23. Figures in first
column indicate county society numbers; second col-
umn, state society numbers :
Sept 24 Somerset 46 7072 $5.00
Washington 125-127 7073-7075 15.00
27 Indiana 61-62 7076-7077 lo.oo
29 Dauphin 146 7078 5.00
Oct 9 Beaver 56 7079 5.00
13 Fayette 121 7080 5.00
15 Berks 126-127 7081-7082 10.00
Allegheny 1131,1123,1127,
1128,1129 7083-7087 25.00
20 Indiana 63 7088 5.00
Westmqrel^nd ISO 7089 5-00
23 Beaver 57-58 7090-7091 10.00
Lackawanna 180-186 7092-7098 35-00
A FRUIT OF THE INITIATIVE
Oregon is a shrine where the vestal lamp of
reform or change bums forever. Still one feds,
sometimes or oftener, that she's too good for
human nature's daily food. On election day her
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90
THE PENNSYLVANIA MEDICAL JOURNAL November, 1920
voters will have the happiness of voting on an
initiative proposal called an anti-compulsory vac-
cination amendment. This would j)rohibit vacci-
nation, inoculation or other form of medication
as a condition of entrance or attendance at any
school, college, educational institution, or of "the
employment of any person in any capacity or
for the exercise of any right, the performance
of any duty or the enjoyment of any privilege ;"
and would repeal all provisions, constitutional,
statutory, municipal, of charter or ordinance, in
conflict with itself. That is, it would make in-
fection and contagion constitutional, upset all
health regulations, protect disease and the com-
munication of diseases, encourage and dissemi-
nate disease^ discourage and prevent health.
There are some rare reformers in Oregon, but
a queerer specimen of their pernicious activity
has seldom been offered to that long-suffering
and much voting state.— The ^iiw York Times,
October 13, 1920.
C. B. LONGENECKER, M.D.
Assistant Secretary
Philadelphia
THE HOUSE OF DELEGATES AND THE
PRESIDENCY
The Medical Society of the State of Pennsyl-
vania exhibits a certain amount of provincialism
in adhering to the clause in its constitution which
specifies that no member of the House of Dele-
gates shall be 'eligible for the office of the presi-
dent.
Just what fault exists in the several members
of the house that causes this ban to be placed on
them is past finding out ; the writer has been as-
.sociated with delegates more or less intimately
and pleasantly for several years, and so far he
has failed to find the reason for this disqualify-
ing condition. Some years ago hehad an amend-
ment prepared to remove this disqualification,
which seemed rather one-sided, in that it was
discriminatory, but in an endeavor to ascertain
the individual opinion of a number of delegates
from this section of the state he was so shocked
when informed by many of them that the dele-
gate was a mere politician and unfit to have con-
ferred on him the exalted office of president that
the amendment was never presented. He does
not believe that this measure of a delegate pre-
vails at the present time, and questions whether
the opinion then obtained was not a local opinion
and more or less biased. For who can attend
a session of the House at the present time with-
out realizing that it is the live member of his
society, the member who has the uplift of his
society at heart, who is sent- to represent it? It
is admitted that politics occasionally crops out,
but are those who are not delegates always free
from this accusation?
Is there much, or any, difference between a
delegate and one who is slightly removed there-
from ? Is there likelihood that men like Stevens,
Jump, Hartman and others who could be men-
tioned, who have had ripe experience with and
in the House have been contaminated by such
association ? The mere fact that these men were
not members of the House when nominated has
but little weight, for they were as close to and
as conversant with its business as though ac-
tually a member thereof.
The writer knows of instances of those who
had the presidential bee in their bonnet who
actually refused to have their name go in as a
delegate; the lightning did not always strike
where hoped it would, but the circumstance
points a moral.
Finally and to the point: if there is as good
presidential material in the House as there is
outside it (and who can deny this) why not re-
move this discrimination and give a full and un-
biased choice of any member of the society for
the presidency ? Let us hope that Article VIII,
Section 3 of the Constitution will soon be a thing
of the past.
FREDERICK L. VAN SICKLE. M.D.
Executive Secretary
Harrisburg, Pa.
AFTERMATH OF THE PITTSBURGH SESSION
It is usually interesting as well as helpful for
the officers of our Society to learn of the opin-
ions expressed by those who attended the ses-
sions of the State Society, in annual meeting.
We, of course, enjoy compliments rather than
criticism. The session in Pittsburgh brought
both, but many more of the former than of the
latter.
We have endeavored to learn what the mem-
bers thought of the scientific sessions and find
many favorably impressed with the papers and
discussions presented, all of which were instruc-
tive and helpful. We especially noted the inter-
est manifested in the Medical and Pediatric sec-
tions, which were more than well attended. It
was regretted that the meeting rooms were not
sufficiently large to properly seat those in at-
tendance. ^
The lantern views this year were good in all
sections and rather more papers were illustrated
than they usually are. The motion pictures in
the Pediatric Section brought a large attendance.
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November, 1920
OFFICERS' DEPARTMENT
91
Take the sessions all in all, they were satisfac-
tory to the greater number present.
The commercial exhibitors have written, many
letters expressing satisfaction with the exhibit
and service during the sessions. They say the
effort to have the members of our Society visit
their exhibits was successful, and report "good
business."
Should there be those who have suggestions
to offer as to how the Pittsburgh meeting can be
improved upon for future sessions, now is the
proper time to submit them.
THE LEGISLATIVE SESSION OF 1921
November 2d has passed and with it the elec-
tion of men to fill positions of honor, of trust, of
dignity and efficiency, to fill the offices of repre-
sentatives and senators, as well as higher offices
in the state and nation ; and now that these men
have been elected the members of the medical
profession in this state have a real and vital duty
to perform. Early in the year we appealed to
you, at least to those of you who were in a
position to act, either as members of the Com-
mittee on Public Policy and Legislation of your
society, or as a friend of some representative or
senator, to interview prospective candidates.
This you did, and for this we thank you.
At the coming session of the legislature of the
State of Pennsylvania certain bills are sure to be
presented, and the menacing features of these
call for the united opposition of all members of
the profession in the state. First, is the bill that
will be presented by the osteopaths of the state
to grant them the privilege of practicing medi-
cine. Probably this will be nearly the same bill
as that presented in 1919, merely revamped to fit
the present conditions. This cult is preparing to
wage an aggressive campaign in Pennsylvania to
procure the passage of their bill.
Your first duty is to see the representatives
and senators of your district and tactfully re-
quest (some would say demand) that they do not
sanction or vote for bills such as the osteopaths
request, which, if they became laws, would per-
mit the osteopaths to practice medicine without
passing the same examination as all others are
now required to pass in order to practice, and
would most surely open the door to all types of
cults and quacks. Thus the high standards of
medical education would be lowered for all time.
The next measure to be opposed is one we are
assured will be presented by a group of fanatical
people, obsessed with visionary ideas, who will
present a bill to prevent experimenting for scien-
tific purposes on all animals adapted to that use.
This is loiown as the Anti- Vivisection bill. They,
too, have amassed sufficient funds to conduct a
campaign for the passage of their pet measure.
Along with these people will be the anti-
vaccinationists, who probably will not be as fierce
this year as in 1919, because acts passed in 1919
will be hard to upset through amendments.
Labor, and possibly capital, will probably seek
amendments to the Workmen's Compensation
Act, now on the statute books, but we do not
advocate any change of Section 306, paragraph
E. It may be necessary to make the wording
clearer as to the standing of the surgeons, as well
as of hospitals, regarding payment for services.
This should be so dear as to be incapable of mis-
interpretation.
Social insurance, as advocated in Compulsory
Health Insurance, is still a possibility which nrnst
not be forgotten by the medical profession of
this state, and it may be possible that our society,
as well as all other societies, will be called upon
to oppose such a measure in the legislative ses-
sion of 192 1. We have no assurance that such a
bill will not be submitted, and if it is, the legis-
lators from your district must be told in no un-
certain terms that the medical profession does
not advocate any measure which will lower the
standard of medical practice, which will change
the relationship between doctor and patient, or
which will in any way produce inferior service,
with no apparent benefit to the people of this
commonwealth.
This, then, is your duty. Not only is it the
duty of every committee on public policy and
legislation, but the duty of every doctor in Penn-
sylvania, who has at heart the best interests of
the profession and of the people in general, and
who has at stake his own security, to see and in-
terview the legislators who will represent the
people of this state in the 192 1 session at Harris-
burg.
MEDICAL LEGISLATIVE CONFERENCE
A meeting of the Medical Legislative Confer-
ence was held in the Hotel Rittenhouse, Hiila-
delphia, Pa., Friday afternoon at 3 o'clock, Oc-
tober 22, 1920.
Drs. Steedle, Holmes, Swartz, Hazen, Van
Sickle, Fox, Hartman, Krusen, Knowles, and
Hillegas were the members present, and the visi-
tors were Drs. Henry D. Jump, Clarence Bart-
lett, A. Hewson, Jr., F. C. Hammond and Mr.
Robert Haight.
Dr. Hewson presented a request of the Ana-
tomical Board that a reamendment should be
made to the Anatomical Act to provide sufficient
material for the study of anatomy in the medical
colleges of the state. During the past year in-
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THE PENNSYLVANIA MEDICAL JOURNAL November. 1920'
sufficient material has been supplied, only 424
bodies having been received, to supply the needs
of five collies and anatomical societies.
He stated that Philadelphia and Allegheny
Counties did not supply any bodies to the Ana-
tomical Board, as the coroners refused to release
any unclaimed bodies. Dr. Hewson's request
will receive the consideration of the conference
and the wishes of the Anatomical Board will be
complied with.
Mr. Robert Haight presented a working
schedule for the conference with an outline of
what is being accomplished by organizations
which will seek the passage of laws during the
coming session of the legislature, the need of
funds to carry on the work of the conference
and the type of opposition which we must ex-
pect during the next session.
There have been several committees appointed
for the purpose of systemizing the work of the
conference, and these committees were charged
with certain matters of constructive legislation,
with a view to the preparation necessary for en-
tering into the work outlined for the Medical
Legislative Conference during the session of the
legislature for 192 1.
IN MEMORIAM G. FRANKLIN BELL, M.D.
Trustee, 1919-1920
Dr. G. Franklin Bell, of Williamsport, Pa., died at
the W'illiamsport Hospital, August 9, 1920.
He became ill while preparing to perform a surgical
operation at the hospital, August 2, 1920. He appar-
ently was improving, but on August 9th suddenly be-
came worse and died a few minutes later.
Dr. Bell was elected a trustee to represent the Tenth
Cotincilor District, at the Harrisburg session in Sep-
tember, 1919, and during that brief period of time
served the society faithfully and well. He also served
the State Society as a vice-president for one year. He
was much interested in medical society affairs and was
a regular attendant at his Cotmty and State Medical
Societies and also the West Branch Medical Associa-
tion.
He was active in the practice of medicine and sur-
gery since 1885, and at the time of his death was
Surgeon-in-Chief of the Williamsport Hospital. Be-
sides being a successful practitioner, he was active in
civic aifairs of Williamsport.
He had a very pleasing personality, made friends
readily, and enjoyed their fellowship. It seems fitting
that the Trustees should give some expression to his
death.
Therefore, be it
Resolved, That we sincerely regret his untimely
-death, believing him to have been a valuable and wise
Councilor, and that we feel the State Society has sus-
tained a great loss in being thus deprived of a mem-
ber who was always willing to help maintain the high
.standards of our profession.
Committee of the Board of Trustees
appointed to draft resolutions :
Donald Guthrie,
Theodore B. Appel,
Howard C. Frontz, Chairman.
RESOLUTIONS ENDORSED BY THE HOUSE
OF DELEGATES IN SESSION AT
PITTSBURGH, OCTOBER, 19».
"Whekeas, The Harrison Law for the control of
narcotic drugs was devised for the furtherance of the
public health and
"Whereas, The original tax of one dollar annually
levied upon the members of the medical profession
was generally understood as merely a nominal tax.
Congress being unable to exercise jurisdiction save
through the subterfuge of a revenue measure, and
"Whereas, The recent enactment for the control of
narcotic drugs has increased the tax imposed upon the
members of the medical profession to three dollars^
be it
"Resolved, That the Medical Society of the State of
Pennsylvania hereby protest against the unjust dis-
crimination against the members of the medical pro-
fession in imposing upon them the financial support of
a measure distinctly in the interest of the public at
large, which the general public in true equity should
financially sustain:
"Resolved, That the Medical Society of the State of
Pennsylvania tirge the expeditious removal of this un-
just, inequitable tax by an amendment of the present
law, which shall expunge therefrom the registration
fee levied upon the members of the medical profession.
"Resolved, That these resolutions be printed in the
Pennsylvania Medical Journal and that copies of these
resolutions be forwarded to the members of the Na-
tional House of Representatives from Pennsylvania,
and to the American Medical Association.
Whereas, There exists a lack of provision for the
care and treatment of advanced cases of tuberculosis
in Pennsylvania, and
Whereas, These sufferers are a distinct menace to
the other members of their own families and the pub-
ii<, therefore be it
Resolved, That this association endorse the plan of
erecting a hospital for each county or group of coun-
ties for the care of indigent persons suffering from
advanced tuberculosis.
Resolved. That a copy of these resolutions be pub-
lished in the Pennsylvania Medical Journal, and
that a copy be sent to every general hospital within
the State, to the State Commissioner of Health, as well
as to Dr. Frederick L. Van Sickle, the Executive
Secretary, with the request that he urge the adoption
of their provisions by the Legislature.
TRUTH ABOUT MEDICINES
Silver Salvarsan. — According to a report of the
Medical Research Committee of Great Britain, silver
salvarsan is apparently a molecular combination of
arsphenamine and silver in some form. The substance
is on trial, and its promiscuous use at this time would
be ill advised. In the United States no license for the
sale of silver salvarsan has been granted by the Treas-
ury Department and hence it may not be sold in in-
terstate commerce (Jour. A. M. A., Aug. 28, 1920, p.
626).
Calcidin Tablets-Abbott. — Calcidin is claiifaed to be
a mixture of iodin, lime and starch. In contact with
water, the iodin and lime react to form colcium iodid
and calcium iodate. By the acid of the gastric juice,
the calcium iodid and calcium iodate are decomposed
with liberation of free iodin. The administration of
calcidin tablets amounts to giving free (elementary)
iodin. The effects produced by the administration of
free iodin appear not to differ from those produced
by the administration of iodids, and, therefore, cal-
cidin has no advantage over the iodids, such as soditmi
iodid (Jour. A. M. A., Sept. 25, 1920, p. 892).
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County Medical Societies
REPORTERS OF COUNTY SOCIETIES:
Adams — Henry Stewart, M.D., Gettysburg,
Allxchimy — Paul Titus, M.D., Pittsburgh,
AsMSTBOMO— Jay B. F. Wyant, M.D., Kittanning.
Buvsi— Fred B. Wilson, M.D., Beaver.
BCDFoiD— K. A. Timmins, M.D;, Bedford.
BUKS— Clara Shetter-Keiser, II.D., Reading.
BUUB — James S. Taylor, M.D., Altoona.
BaADVoan — C. L. Stevens, M.D., Athens.
BvcKS — Anthony F. Myers, U.D., Blooming Glen.
Butler — L. Leo Doane, M.D., Butler.
Cambria — Frank G. Scharmann, M.D.. Johnstown.
Carbon — Jacob A, Trcxler, M.D., Lehighton.
Center — James L. Seibert, M.D., Bellefonte.
Chester — Henry Pleasants, Jr., M.D., West Chester.
Clarion — Sylvester J. Lackey, M.D., Clarion.
Clearfield — J. Hayes Woolridge, M.D., Clearfield.
Clinton — R. B. Watson, M.D.. Lock Haven.
Columbia — Lutbcr B. Kline. M.D.. Catawissa.
Crawford — Cornelius C. Laffer, M.D., Meadville. _
Cumberland — Calvin R. Rickenbaugh, M.D., Carlisle.
Dauphin — Marion W. Emrich, M.D., Harrisburg.
Delaware — George B. Sickcl, M.D., Chester.
Elk — Samuel G. Logan, M.D., Ridgway.
Erie — J. Burkett Howe, M.D., Erie.
Fayette — George H. Hess, M.D.. Uniontown.
Franklin — John J. Coffman, M.D.. Scotland.
Greene — Thomas B. Hill, M.D.. Waynesburg.
Huntingdon — John M. Beck, M.D., Alexandria.
Indiana — Alexander H. Stewart, M.D., Indiana.
Jefferson — John H. Murray, M.D., Piinxsutawney.
Juniata — Isaac 0. Headings, M.D., McAlisterville.
Lackawanna — Harry W. Albertson, M.D,, Scranton.
Lancaster — Walter D. Blankenship, M.D., Lancaster.
Lawrence — William A. Womcr. M.D., New Castle.
Lebanon — Samuel P. Heilman, M.D., Lebanon.
Lehigh — Martin S. Kleckner, M.D., Allentown.
Luzerne — Peter P. Mayock, M.D., Wilkes-Barre.
Lycoming — Wesley F. Kunkle, M.D., Williamsport.
McKean — James Johnston, M.D., Bradford.
Mercer — M. Edith MacBride, M.D., Sharon.
Mifflin— Frederick A. Rupp, M.D., Lewistown.
Monroe — Charles S. Logan, M.D., Stroudsburg.
Montgomery — Benjamin F. Hubley. M.D., Norristown,
Montour — Cameron Shultz, M.D., Danville.
NORTHAXIPTON — W. Gilbert Tillman, M.D., Ea.ston.
Northumberland — Charles H. Swcnk, M.D., Sunbury.
Perry — Maurice I. Stein, M.D., New Bloomfield.
Philadelphia — Samuel McClary, 3d, M.D., Philadelphia.
Potter — Robert B. Knight, M.D., Coudersport.
Schuylkill — George O. O. Santee, M.D., Cressona.
Snyder — Percy E. Whiffen, M.D., McClure.
Somerset — H. Clay McKinley, M.D., Meyersdale.
Sullivan — Carl M. Bradford, M.D., Forksville.
Susquehanna — H. D. Washburn, M.D., Susquehanna.
TioOA— Lloyd G. Cole. M.D., Blossburg.
Union — William E- Metzgar, M.D., AUenwood, R. D. 2.
Venanco — John F. Davis. M.D., Oil City.
Warren— M. V. Ball, M.D., Warren.
Washington — Homer P. Prowitt, M.D., Washington.
Wayne — Sarah Allen Bang, M.D., South Canaan.
Westmoreland — Wilder J. Walker, M.D^ Grcensburg.
Wyoming — Herbert L. McKown, M.D., Tunkbannock.
York — Nathan C. Wallace, M.D., Dover.
November, 1920
COUNTY SOCIETY REPORTS
ALLEGHENY— OCTOBER
The regular Scientific Meeting of the Allegheny
County Medical Society was held at the Assembly
Rooms, 43 Fernando Street, October 19, 1920. Vice
President Dr. Thomas A. Miller in the chair. The
meeting was called to order by the vice president at
8 : 40 p. m.
CASS SEPORTS
Dr. J. I. Johnston reported a case of spontaneous
Pneumothorax of Idiopathic Origin. Discussion by
Dr. I. H. Alexander, who questioned whether this pa-
tient had suffered from influenza, stating that he had
seen similar cases with no other known etiology. Dr.
John W. Boyce stated that Pneumothorax was by no
means so fatal as was generally supposed, and that he
believed the pain and discomfort of those suffering of
Intrathoracic positive pressure in the valvular type
could be readily relieved by the use of puncture to
equalize pressure. Dr. Johnston closed the discussion.
Dr. C. C. Wholey presented a case of Amyotrophic
Lateral Sclerosis with rather unusual rapidity in the
development of sjrmptoms occurring in a man younger
than the usual age for the incidence of these types.
PAPGRS
Dr. John W. Boyce read a paper entitled "Theoreti-
cal Basis for Fluoroscopic Diagnosis of Early Tu-
bercle."
Discussion by Dr. Lester Hollander.
Dr. Albert J. Guerinot read a paper entitled "Newer
Interpretations of Blood Chemistry." Discussion by
Dr. J. I. Johnston.
Dr. E. Bosworth McCready read a paper entitled
"The Nervous, Delicate and Backward Oiild as a
Medical Problem." Discussion by Dr. C. C. Wholey.
Adjournment at 10 : 30 p. m.
BRADFORD— SEPTEMBER
The Bradford County Society met in the grand jury
room of the court house, Towanda, September 14,
with eighteen members and thirteen visitors present,
and was called to order at 2 : 05 by the secretary. Dr.
P. N. Barker, Troy, was elected president pro tem.
The minutes of the meeting of August 17 were read
and approved.
Dr. Arthur C. Morgan, associate professor of medi-
cine of the University of Pennsylvania Graduate
School of Medicine, addressed the society on "The
Post-Influenzal Chest," using a young jnan as a model
for his instructive demonstration. Following the epi-
demic of 1918 of influenza, pneumonia and other com-
plications, many patients were slow in accomplishing
convalescence. This was particularly noticed in the
study of a large number of soldiers. Because of the
persistence of evidence of pulmonary pathology and
the possibility of tuberculosis being present, the sur-
geon general directed) that all soldiers convalescent
from the epidemic should be examined with a view of
transfer to a general hospital where the patient could
receive prolonged treatment under suitable and fav-
orable environment. Most of the cases were ambulant
patients whose general condition had improved up to
a certain point, and who yet lacked restoration to full
health, therefore requiring constant medical observa-
tion. Since returning to civil life much the same class
of patients have been observed by the speaker.
The persistence of jrfiysical signs that indicated se-
vere pathology caused considerable difficulty in the
study of these cases as to the discrimination between
a real post-pneumonia pathology and the implantation
or activation of a pulmonary tuberculosis. It has been
found in a large number of post-pneumonic patients
that the physical signs in the upper chest seldom ex-
tended beyond the upper border of the scapula, where-
as in tuberculosis apical signs are the rule. The points
of contrast therefrom should emphasize (i) the pri-
mary implantation of tuberculosis at an apex, with its
tendency to progress downward and outward by con-
tinuity of structure with no normal tissue intervening ;
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THE PENNSYLVANIA MEDICAL JOURNAL
November, 1920
<2) that pneumonia ordinarily shows its maximal
pathology during the height of or soon after the dis-
ease has run its course, without tendency to become
t>rogressive ; (3) post-influenzal pneumonia has a ten-
dency to manifest generalized areas of pathology, fre-
quently bilateral, and usually with intervening portions
of apparently normal lung.
The discussion on Dr. Morgan's paper and demon-
strations was opened by Dr. Walter E. Lundblad,
Sayre.
Dr. George E. Gorham, Albany, N. Y., who was a
Bradford County boy, favored the society with a very
entertaining paper on "Anxious Thought: Its Role
in Functional Disease," showing how the mind affects
the body and how much the physician may do for the
patient by inspiring confidence in the prescribed treat-
ment. When a patient has recovered from his original
disease without realizing the fact, it requires skill, care
and assurance to bring about a complete restoration of
health and activity.
Dr. Donald Guthrie, Sayre, opened the discussion on
the paper by Dr. Gorham, emphasizing the fact that
most patients are both mentally and physically ill and
the necessity for care in seeing that all the surround-
ings of the patient tend as far as possible to quiet the
patient's apprehension and give him or her confidence
in those in charge.
Dr. Charles W. Shelton, Tioga, supervising medical
director for Tioga, Lycoming, Potter, Bradford and
Sullivan Counties, in speaking of the work of the State
Department of Health, said that the patients at the
Venereal Clinics may be divided into three classes:
pay patients, part-pay (for medicine) and charity.
The department has no desire to rtm in opposition to
doctors. An individual cannot be arrested because he
has a venereal disease but he can be quarantined, and
then if he break the quarantine he can be arrested for
breaking quarantine and placed unaer detention.
President Parks, who had come during the meeting,
assumed the chair, and on motion of Dr. Woodburn,
seconded by Dr. Barker, the society unanimously
adopted the following: Resolved, That the Bradford
County Medical Society heartily endorses the ideas
embodied in the plan for a state-controlled genito-
urinary clinic to be installed at the Robert Packer
Hospital, Sayre, tmder the direction of Dr. Carlyle N.
Haines.
Rev. H. I. Andrews, Towanda, speaking for himself
and he thought for the clergy present, offered to co-
operate with the physicians of the_ county_ in their
efforts for the prevention and alleviation of disease.
Society adjonrned at 4 : 30 p. m.
C. L. StevENS, Reporter.
CHESTER— SEPTEMBER
The regular monthly meeting of the Chester County
Medical Society was held at the Chester County Hos-
pital on Tuesday, September 21, 1920, with President
W. Wellington Woodward in the chair.
Dr. Thomas G. Aiken, of Berwyn, addressed the
Society on the subject of "Bronchial Asthma," giving
a resumi of the etiology, pathology, symptomatology,
and treatment of this condition, which is published in
this issue.
Dr. Aiken's paper was discussed by Drs. Sharpless,
Margolies, Patrick, Davis, Klevan and Pleasants. Dr.
Sharpless cited an interesting instance of a patient who
reacted to so many of the allergen tests that the series
showed as one large wheal. He advised, therefore,
that in making the skin tests sufficient space be al-
lowed between the scarifications.
Dr. Davis gave his experiences with a new proprie-
tary remedy which is evidently intended for use in
such cases of asthma as are known to have no idio-
syncrasy towards the iodides as it is used intraven-
ously. The cases cited were interesting, and certainly
suggest the possibilities of success along these lines.
Several of the members present gave their experi-
ence with the hypodermatic use of Adrenalin Chlo-
ridel-iooo solution in the treatment of the acute cases.
There seems to be no strong contra-indication to the
use of this drug in doses of from five to fifteen minims.
In some instances a marked fall of blood pressure fol-
lowed the injection. This seems to be contrary to the
teachings of physiologists in regard to the vaso-
constrictive action of adrenalin, but is easily explained
by the fact that in some cases the high blood pressure
is due to the tremendous strain of the patient to get
his breath, and the relief of this strain is immediately
followed by a drop in pressure.
Henry Pleasants, Jr., Reporter.
EIGHTEENTH CENSORIAL DISTRICT-
SEPTEMBER
The seventeenth annual meeting of the Eighteenth
Censorial District of the Medical Society of the State
of Pennsylvania (formerly the Seventeenth District),
composed of Columbia, Montour, Northumberland and
Snyder Counties, was held in Danville, September 10,
1920.
The first session was held in the George T. Geisinger
Memorial Hospital, at 10:30 a.m. In the temporary
absence of the president. Dr. R. S. Patten, the meet-
ing was called to order by the secretary, Dr. L. B.
Kline, and Dr. R. A. Keilty was elected president pro
tempore.
On assuming the chair Dr. Keilty offered words of
greeting and welcome to the visiting physicians.
Registration was made, showing attendance as fol-
lows: from Columbia, twenty-two; Montour, thir-
teen; Northumberland, sixteen; Snyder, nine, with
three additional — 9. total of sixty-three, which ex-
ceeded the attendance of all previous meetings.
The first scientific paper was presented by Dr. H.
V. Pike on "Etiological Factors and Differential Diag-
nosis of Mental Diseases." The discussion of the
paper was opened by Dr. J. Allen Jackson, Superin-
tendent of the State Hospital, followed by others.
The session was then adjourned and followed by a
surgical clinic conducted by Dr. H. L. Foss, Surgeon-
in-Chief of the Hospital, in which a number of cases
were presented and discussed by Dr. Foss, after which
a variety of major and minor operations were success-
fully performed by Dr. Foss. AH present were edified
and greatly pleased with the clinic. The clinic was a
new feature in a censorial meeting of this district.
Following the clinic the members proceeded to the
Montour House, where an elegant and up-to-date
chicken dinner, with all the appurtenances, was served,
at $1-75 a plate.
The afternoon session was held at the State Hos-
pital, opening at 2 : 00 p. m.. Dr. R. S. Patten presiding.
The session opened with an address on health insur-
ance by Dr. Frederick L. Van Sickle, of Harrisburg.
The doctor discussed the various aspects of the pro-
posed enactment, presenting many objections to same.
A number of questions were asked him by members
and the subject generally was discussed by Doctors H.
H. Simmonds, Kline, Gass, Becker, Stengel and others,
with the discussion closed by Dr. Van Sickle. The
consensus of opinion was emphatically against any
compulsory insurance law.
The next subject was a "Symposium on the Acute
Abdomen," as follows: Pathologico-Physiological
Aspect, Dr. R. A. Keilty, followed by Dr. Alfred
Stengel, Professor of Medicine, University of Penn-
sylvania, on the medical aspect. Doctors Shearer.
Keilty and Stengel, each presented the aspect as as-
signed to him in an able, practical, and clear manner,
which was enjoyed and appreciated by all present
General discussion was opened by Dr. J. W. Brunner.
followed bv Doctors H. W. Gass, J. T. MacDonaldl
and F. R. Clark, each adding valuable suggestions.
The general feeling was that the meeting was one
of great interest, enjoyment and profit.
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COUNTY MEDICAL SOCIETIES
95
On motion, thanks and appreciation were tendered
to the Montour County Medical Society, to the super-
intendents and authorities of the Gersinger and State
Hospitals for the hearty and generous welcome ac-
corded the association; also to Professor Stengel and
Dr. Van Sickle for their addresses, and to all assigned
a part on the program.
Officers were elected for the year, as follows : Presi-
dent, Dr. Wm. T. Graham, Sunbury; vice president.
Dr. C. W. Rice, Sunbury; secretary, t)r. L. B. Kline,
Catawissa. .
The meeting for 1921 will be held at Sunbury, the
date to be determined by the district censors.
LuTHGR B. KiiNB, Reporter.
FRANKLIN— SEPTEMBER AND OCTOBER
The September meeting of the Society was held in
Upper Strasburg where we had prepared for us a
good dinner which was served at 6 p. m. Every one of
us enjoyed it immensely.
Immediately following the dinner, the meeting was
called. The program was a very interesting one and
proved to be very insttuctive. We had a very good
attendance.
Our October meeting was held in St. Thomas along
the Lincoln Highway and there, too, we had a chicken
dinner at 6 p. m., which I know every one enjoyed.
After dinner the meeting was called to order. Dr.
Guy P. Asper read a paper on "Diabetes Mellitus"
with special reference to treatment. The paper itself
was an excellent one, enjoyed by all and was thor-
oughly discussed.
For several years past our monthly meetings during
the summer months have been held in various parts of
the county, and we have found it to be a pleasant and
effective way of getting the men together. Our at-
tendance has increased greatly. The feature of hav-
ing dinner there seems very attractive.
S. D. Shuix, Reporter.
LANCASTER MEDICAL CLUB— OCTOBER
One of the most pleasing events ever held in eastern
Pennsylvania was the reception given to several of-
ficials of medical organizations on the evening of Oc-
tober 22, by the Lancaster Medical Club. The honor
guests included I>r. Frank G. Hartman, president-
elect of the Pennsylvania State Medical Society; Dr.
Henry D. Jump, president of the Pennsylvania State
Medical Society ; Dr. George W. Hartman, of Harris-
burg, president of the Pennsylvania State Homeopathic
Medical Society, and Dr. R. Hamill D. Swing, presi-
dent of the Pennsylvania State Dental Society.
The membership of the Club includes physicians of
the old school, homeopathics, eclectics, dentists and
pharmacists. A large turnout of all the members and
their friends, professional and lay, gave a very repre-
sentative audience. After a very pleasant hour of
social intercourse, during which a delicious buffet
lunch was served and harmony dispensed by a selected
quartette. Dr. Theodore B. Appel, trustee of the State
Society and president of the Medical Club, in his
usual eloquent style, gave the ptvpose of the meeting
and introduced the first speaker, Dr. Hamill D, Swing,
president of the State Dental Society.
Dr. Swing congratulated the president-elect of the
State Medical Society upon his election to that high
office and expressed himself as elated that the phy-
sicians and dentists of a community found it possible
to mingle freely one with the other. He showed con-
clusively that the two professions are more united to-
day than ever before and predicted that in the near
future that union would become even more firm.
Dr. Henry D. Jump expressed himself as delighted
with the selection the state society had made in select-
ing Dr. Frank G. Hartman as president-elect and said
that his year of office would be a burdensome one but
that the proper man had been selected. He told of
the pitfalls confronting the profession and their clien-
tele in the matter of vicious legislation and asked in
behalf of the state organization the loyal support, of
all the members of the profession.
Dr. George W. Hartman, president of the Homeo-
pathic Society, told of the necessity of physicians en-
tering politics in order to get proper recognition in
public health matters.
Hon. Bernard J. Myers, attorney of the Pennsyl-
vania Medical Society and Deputy Attorney General
of the Commonwealth, stated that he had thoroughly
enjoyed his experience as attorney for the State De-
partment of Health and that because of that experi-
ence he had become more or less familiar with public
health problems. It is impossible under the present
system of government to keep health problems out of
politics and the needs of the day demand that the phy-
sician enter the political arena if he would best serve
the interests of the community.
Dr. Wilmer Krusen, formerly Director of Public
Health in Philadelphia, was never heard to better ad-
vantage and his address will long be remembered by
all who heard it. He emphasized the point that in
fighting vicious legislation the fight is not a selfish
one, but that the public is what we are concerned
about. He congratulated his classmate. Dr. Hartman,
upon his election and pledged the loyal support of all
physicians toJhis administration.
Dr. Frank G. Hartman, president-elect, was the last
speaker and pledged himself to give his very best to
the presidency of the state organization.
Among the members and guests present upon this
memorable occasion were: Drs. John R. Simpson, of
Pittsburgh; F. L. Van Sickle, executive secretary of
the State Medical Society; Drs. T. B. Appel, F. G.
Hartman, E. J. Stein, W. D. Blankenship, T. C
Shookers, H. C. Kinzer, D. E. Cary, P. P. Breneman,
J. L. Atlee, E. B. lUyus, E. I. Noble, E. K. Smith, S. S.
Rine, J. M. Shartle, H. B. Davis, W. B. Hamaker, Frank
Alleman, Richard Reeser, H. B. Roop, J. Paul Roebuck,
L. K. Leslie, J. D. Hershey, W. N. Keylor, C. E. Helm,
L. M. Bryson, J. J. Newpher) J. L. Lehman, Walter
Leaman, W. G. Hess, A. F. Snyder, C. P. Stahr, J. P.
Ziegler, G. E. Day, W. M. Tome, W. J. Stewart, Vere
Treichler, Henry Walter, A. V. Walter, C. H. Witmer,
H. M. Sultzbach, Harry Pomerantz, John Herr, H. G.
Reemsnyder, D. J. Reemsnyder, G. A. Harter, B. F.
Herr. N. E. Bitzer, H. G. Barsumian, H. J. Blough, S.
W. Miller, and W. H. Moorehouse of the regular pro-
fession ; G. A. Sayres, E. S. Snyder, E. T. Prizer, G.
C. Schwartz, Grant Weaver and Moyer, of the homeo-
pathic society; C. V. Snyder, Paul Byerly, George
Wagner, W. H. Trout, W. H. Lowell, O. G. Lonecker,
M. A. Becker, J. B. Bolton, Richard Helig, E. J. Diehl,
L. O. Loeckel, Frank D. Witmer and W. D. Twitmire,
of the dental profession; Messrs. Frank Deen and
Clyde Cooper, pharmacists; C. W. Cummings, S. W.
Diller, Enos Mowerer, J. Harry Rathfon, Chauncey
Longenecker, Rev. John Reeves, Rev. Clifford G.
Twombly, Rev. J. H. Musselman and Hon. B. J.
Myers. W. D. Blankenship, Reporter.
MERCER— OCTOBER
Met at the Sharon Country Club, Sharon, Pa., Tues-
day evening, Oct. 19, 1920. Dinner was served at 6
o'clock, after which an excellent program followed.
Forty-five members and some gue.«ts were present.
Dr. Henry D. Jump, of Philadelphia, president of
the Pennsylvania State Medical Society; Dr. H. W.
Mitchell, of Warren, Pa., superintendent of the State
Hospital at Warren, and district councilor, and Dr.
Everhart, of Harrisburg, of the State Department of
Health, were the speakers.
The following members from the Lawrence County
Medical Society were present: Dr. W. A. Wormer
and Dr. Lenore H. Gageby, of New Castle ; Dr. Eliza-
beth McLaughry and Dr. Katherine Cook, of the Over-
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THE PENNSYLVANIA MEDICAL JOURNAL
November, 1920
look Sanitorium of New Wilmington. We were also
glad to Have with us Dr. Montgomery and Dr. Alex-
ander, dentists of Sharpsvitle.
A short business meeting followed the program.
The excellent addresses were enjoyed by all.
Edith MacBhidb, M.D., Reporter.
WARREN COUNTY
The October meeting of the society was held in the
Elk's parlors, Monday, October i8, and was attended
by an exceptionally large number of members, twenty-
five being present. The special attraction was an ad-
dress by a representative of the State Department of
Health, on the "Venereal Program."
Dr. Cans was to have been present but was unable
to come, and sent Dr. Eberhart, who in a thorough
manner outlined the work the department is carrying
on in the fight against venereal disease. The discus-
sion centered about the advisability of opening a ve-
nereal clinic in a town like Warren. Warren has no
red light district, is free from a factory or foreign
population, and has very few inhabitants unable to pay
for treatment. The hospital, which is open to all phy-
sicians, receives charity patients whether afflicted with
venereal disease or not. The only reason for a clinic
would be the better opportunity of following up cases
which might become a public menace, and also to train
physicians in becoming more expert in the diagnosis
and treatment of syphilis. A committee of five were
appointed to make a further report as to the necessity
of such a clinic.
An account of the state meeting was given by your
reporter.
Since the last meeting we have lost by death Dr.
Siggins, of Tidioute. Dr. Siggins was taken sick about
six months ago with pneumonia, from which he never
fully recovered. He was but 39 yeafs of age and had
practiced in Tidioute for the past six years. He leaves
a widow and one child. Dr Siggins was very much
liked by everyone who knew him, and the community
in which he lived will greatly miss him.
Dr. Parmenter, of Buffalo, is expected to speak be-
fore the society in November.
M. V. Ball, Reporter.
WASHINGTON— SEPTEMBER
The September meeting was a great success. The
writer is sorry there weren't more present to enjoy an
unusual day so close to nature mingled with splendid
fellowship. The attendance was good but should have
been great. The Washington County Medical Society
never did a more worthy thing. We can all well be
proud of the record our men made. The address of
Dr. Henry W. Temple was full of well-deserved praise
for our men. He complimented. the profession for its
work at all times and especially for its part in the
great struggle through which we recently passed. Dr.
W. H. Riddle, West Alexander, responded in a very
appropriate address in receiving the tablet. His was
full of actual experiences in the war. His closing in
memory to the deceased whose name concludes the list
on the tablet was indeed touching and conveyed real
sympathy and admiration. Every physician responded
to the request of the program committee. The talks
were all good and showed that physicians can do litera-
ture stunts.
The address by Mr. W. F. Penn, of the Western
Pennsylvania 'Training School, whose guests we were
for the day was well received. It gave the workings
and result of the institution with a great deal of in-
formation for the present. Mr. Penn proved that the
institution is doing a great work for those who are
unfortunate at the period of greatest susceptibilities.
It was indeed very acceptable information that we had
of our own institution.
The presence of county commissioners and others
interested in the community welfare was appreciated
by the medical profession.
At the business session a motion was unanimously
passed extending our hearty thanks to Mr. Penn for
his hospitality and for the splendid music furnished by
the boys of the home. All went home highly pleased
with the reception and entertainment throughout.
F.CS.
NEWS ITEM
FROM THE MINUTES OF THE HOUSE OF
DELEGATES, PITTSBURGH SESSION.
OCTOBER 7. 1920
"Governor Sprout has appointed a commission to re-
vise and codify the laws relating to the insane and
feeble-minded. The personnel of the commission is
as follows: Honorable Isaac Johnson, Media; Dr.
Owen Copp, Philadelphia ; Dr. Theodore Diller, Pitts-
burgh; Dr. D. C. Herr, Harrisburg; and Dr. Charles
Frazier, Philadelphia.
"The commission is actively at work at its task.
Between now and January it expects to hold some
public hearings.
"In the meantime, any member of the State Society
who has any suggestions to offer regarding^ our law
relating to die insane or feeble-minded, is invited to
write to the secretary. Dr. Charles Frazier, 1724
Spruce Street, Philadelphia, with the assurance that
his communication will receive careful attention."
STATE NEWS ITEMS
DEATHS
Dr. Henry C. Paist, of Philadelphia, died Septem-
ber 2ISt.
Dr. J. Marshall Sterling, died September 24th, in
Philadelphia, after a long illness.
We are sorrv to report the death of Dr. John M.
St. Clair, of Indiana, Pa., father of Dr. J. R. St. Qair,
of Alexandria.
Dr. Warren F. Klein, 60 years old, for a quarter
century a leading physician and surgeon in Lebanon,
was found dead in his office September 27th, having
died from heart disease. Because of failing health, he
had recently given up his general practice.
Dr. Samuel W. Horning, who practiced for nearly
half a century in Collegeville and vicinity, died at his
home in Norristown, to which place he came a year
ago after trying to recuperate his health in Florida.
His death was due to chronic heart disease.
While on his way to a school to examine pupils.
Dr. James A. McGinty, of Olyphant, Lackawanna Co.,
was struck and killed by a passenger train on the
Delaware and Hudson Railroad in Olyphant October
22d. The physician stepped from behind a freight
train, directly in the path of the passenger train.
Dr. William W. Moody, 86, for forty-nine years a
practicing physician in Sunbury, died there on October
i8th, of a complication of diseases. It was his boast
that he had voted for fourteen Republican Presidents
and intended to vote for the fifteenth next month. Dr.
Moody graduated from the Unversity of Pennsylvania
in 1861.
Dr. John C. Cope (University of Pennsylvania.
1900) died in Greensburg, Pa., September 39th, aged
42. Dr. Cope received a cut on one of his fingers
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STATE NEWS ITEMS
97
while performing an operation on a patient in the
Westmoreland Hospital, September 20th. Septicaemia
developed. He had been suffering from diabetes for
several years and this trouble aggravated the cut on
his hand and caused death. Dr. Cope was an ex-
president of the Moses Taylor Hospital, Scranton, and
of the Episcopal Hospital, Philadelphia.
WnxiAM M. Hownx,.73 years old, was almost in-
stantly killed when his automobile was struck by a
freight train at the Hepbumville grade crossing near
his home, October Sth. Doctor Howell was returning
from a call upon one of his patients, his machine being
struck by the second section of a freight train which
he did not know was following the, one for whose
passing he had waited at the crossing. The doctor
was a native of Orangeville, Columbia County, and a
graduate of Bellevue Hospital Medical College, New
York, in the class of 1869.
Dr. GeoKGB Barclay Porch, of Johnstown, passed
away August isth. Dr. Porch was bom near Ligonier,
Westmoreland County, February 18, 1845. He was
the son of George and Susan Barclay Porch. He
served two enlistments in the Civil War, the first with
the _i68th Regiment and the second with the 103d
Regiment. He entered Jefferson Medical College in
1867^ and graduated in 1871. He began his practice in
Davidsville, Somerset County, and came to Johnstown
in the early 8o's. He was a member of the Cambria
Lodge, No. 278, Free and Accepted Masons, a member
of the Pennsylvania State Medical Society and the
American Medical Association.
Dr. Charles B. Gardner, Philadelphia, died October
19th, at his home on N. loth St Dr. Gardner was
82 years old. He practiced medicine in Philadelphia
until about two years ago. He was graduated from
Bellevue, New York, in the class of 1868. In the
Civil War Dr. Gardner was an assistant surgeon with
the First Pennsylvania Cavalry, in which capacity he
served from 1861 until the surrender of General Lee.
Dr. Gardner came to Philadelphia in the early seven-
ties. Previously he practiced medicine in Pithole,
Venango County. Dr. Gardner was a member of Post
94, G. A. R., Loyal Legion and United Veterans'
League. He is survived by a son.
Dr. Samuel C. Mover, of Lansdale, was fatally in-
jured, August 3, when the horse and buggy which he
was_ driving, was struck by the Scranton Flyer at
Orvilla, a small station two tniles north of Lansdale.
The train struck the horse with terrific force on the
side and hurled the carriage and the doctor forty feet
away, the doctor was thrown aside and sustained a
fractured skull and spinal column, death ensuing a
half hour later. The crossing is only a mile distant
from the doctor's country home. The flyer was late;
two trains were passing each other in opposite direc-
tions at this point at the time which evidently con-
fused the doctor. 'Dr. Moyer still used a horse and
carriage for his individual driving in the country, al-
though he possessed a splendid car for his younger
sons to take him when so desiring. He was a lover
of a fine driving horse.
Dr. Samuel Clymer Moyer was bom in Mil ford
Township, Bucks County, on November 17, 1846. He
attended public school and spent two years at a private
seminary in Ohio; he taught school for several years.
He graduated from the Hahneman Medical College,
Philadelphia, 1872. He located at Lansdale soon after-
wards, the year in which the village was incorporated
into a borough.
Dr. Moyer was an exceptional man; he possessed
and made bequests of high idealism. He was a father
of twelve living children, to all of them who had
passed the :^e of secondary education, he gave a col-
leg^iate training in diversified careers — a splendid fam-
ily and exceptionally well endowed in educational
attainments and noble heritage.
The doctor was a keen observer and a close stu-
dent; he was a very successful general practitioner
and possessed the confidence ajid esteem of an exten-
sive clientage, which was considerably enhanced by his
own lofty conception of ethics and professional court-
esy. In his private life, he tried to live and act so
that the world might be the better for his living in it.
He was liberal and frugal and obtained a fine com-
petence with which he so liberally endowed his chil-
dren. His son, Herbert T. Moyer, M.D., his assistant
for ten years, will succeed to his practice. Another
son is attending a medical college.
Dr. Moyer was a member of the Pennsylvania State
Homeopathic Society, a director of the Grand View
Hospital Association, Sellersville, and a member of
the North Penn Clinical Society. He was a member
of the Mennonite (New School) denomination. His
remains were interred at Line Lexington Mennonite
cemetery, his sons acting aspall bearers. Thus a good
man passed away. — From The Bucks County Medical
Monthly, September, 1920.
ITEMS
Dr. L. S. Walton spent some time "vacationing"
and touring along the Jersey coast.
The typhoid fever epidemic at Downingtown
reached the number of forty cases.
Dr. H. G. Fortner, Centralia, and Miss Margaret
Bright, Ashland, were married in Christiana, Pa.
Dr. Wiluam Webb, of Unionville, is visiting rela-
tives in West Chester, after three years' residence in
France and Germany.
During the last month Dr. and Mrs. Wilkinson
took their annual motor trip through the beautiful
scenes of New England.
Dr. and Mrs. Thomas Cook Stellwaoon, Jr., of
1912 Pine Street, Philadelphia, are being congratulated
upon the birth of a daughter.
Dr. Josiar F. Rsed, of Harrisburg, has been ap-
pointed director of prenatal clinics of the state de-
partment of health by Commissioner Edward Martin.
The campaign for a $200,000 maintenance, endow-
ment and building fund for the Clearfield Hospital,
resulted in subscriptions of $70,000 the first two days.
Dr. and Mrs. George W. Harpel, formerly of
Mount Carmel, but now of Rochester, N. Y., ai-e visit-
ing Mrs. Harpel's sister, Mrs. C. S. Henderson, Kulp-
mont.
Dr. William W. Keen, Professor Emeritus of Sur-
gery at the Jefferson Medical College, presided at the
International Surpcal Society Conference m Paris in
July.
NoRRiSTOWN. — When automobiles of John Brownlie
and Dr. George F. Hartman collided in Upper Merion,
the Hartman car upset and the doctor had several ribs
broken.
Dr. and Mrs. Mitchell Walter, of South Bethle-
hem, have announced the engagement of their daugh-
ter, Elsie Walter, to Dr. Paul F. Sterner, of
Bethlehem.
When the automobile in which they were riding
overturned near Dauphin, Dr. Martin C. Hershey and
Levi Hess, both of Hershey, sustained severe lacera-
tions and bruises.
The botlding committee of St Luke's Hospital,
Bethlehem, has awarded a contract for extensive im-
iwovement and alterations to several buildings at a
cost of more than $50,000.
Dr. John B. Carrsu, recently tried his luck at
"ship-bottom" fishing along the Atlantic. It's great
sport, but by close questioning, he revealed,
that he caught only one silly "spot." ji
11 V Kic«L
.W6§1e
98
THE PENNSYLVANIA MEDICAL JOURNAL November, 1920
Dr. Jambs R. Montgomery, Jr., of Bloomsburg, and
Miss Myrtle Constance Hartman, assistant superin-
tendent of Bloomsburg Hospital, were married on
Monday, September 27, 1920.
Dr. B. p. Steelb and family, of McVeytown, with
Miss Jean Wakefield and Miss Jessie McKee, have ar-
rived home after an automobile trip of three months
across the continent and along the Pacific Coast.
CoL. W. J. Crookston, of Pittsburgh, in charge of
the tuberculosis division of the State Department of
Health, has assumed duties of chief of the division of
school hygiene. No appointment to succeed Col. Theo-
dore Hazlett as director of the Mont Alto Sanitorium
has been made.
Dr. and Mrs. Calvin Miles Thompson, of Win-
chester, Ky., announce the engagement of their daugh-
ter. Miss Clara Belle Thompson, and Dr. William
Chambers Powell, Jr., of Bryn Mawr. The wedding
will take place on December 29 at Winchester.
"Thomas W. Powell will be best man.
The name "medicine store" has the same meaning
under the law as "drug store," and it is unlawful for
any other than a duly registered pharmacist to con-
duct such a place, L. L. Walton, secretary of the State
Board of Pharmacy, is informed in an opinion ren-
dered by B. J. Myers, Deputy Attorney General.
Dr. William Morton Kennedy, Philadelphia, has
been appointed Visiting Physician to St. Mary's Hos-
pital, of the same city. Dr. ICennedy has served for
five years as Chief of the Out-Patient Medical Depart-
ment, and is still retaining his position as lecturer on
Materia Medical and Therapeutics to the Training
School of St. Mary's.
A CARD HAS BEEN RECEIVED from Dr. Roberta Fleagle,
of Hanover, saying that she arrived safely at her
destination, Kalgan, China, on June 26, and was ready
to begin the study of the language. She said she en-
joyed every minute of her wonderful voyage and is
pleased widi the outlook of her work. She is to have
charge of a hospital for women and expects to be gone
five years.
The eleventh annual meeting of the Nurses'
Alumni Association of the Montefiore Hospital was
held in the William Penn Hotel October 13. The com-
mittee in charge of the affair included the Misses Rae
Handmaker, Margaret Gordon, Sadie Sandler and Ida
Beerman. Members of the reception committee were
Miss Tresita Allen, Miss Crumble Stein Kraram, Mrs.
Fischer White and Mrs. Pearl Cooper.
Dr. John L. AtlEE, the surgeon, originator of the
idea of a Lancaster County Dog Protective Associa-
tion, was elected president of the organization formed
recently. Its purpose will be to promote breeding,
raising and betterment of dogs and to prevent by
theft and destruction by poison. Other officers elected
were: Vice-president, E. W. Cramer; secretary. Dr.
H. W. Barnard ; treasurer. Major W. C. Rehm.
On Sunday morning, October 17th, a special service
for physicians and surgeons was held at St. James'
church, Philadelphia. Dr. W. W. Keen made the ad-
dress. October 17th was selected because of its prox-
imity to the Day of St. Luke, the beloved physician.
For many years the physicians and surgeons of the
British Empire have held a service on the Sunday
nearest St. Luke's Day in commemoration of that
.great Saint and Doctor.
The Village Improvement Association, of Doyles-
town, an organization with 150 members, will launch
the annual drive for funds in that borough for the
Emergency Hospital now in operation there, under the
supervision of the Red Cross and the Village Improve-
ment Association. Last year, $1,788.30 was donated by
residents of the borough, and this year, in a three-day
campaign, an effort will be made to pass the $2,000
mark. The visiting nurses made 3,205 calls last year.
The Chiropractors' Association of Pennsylvania
held its tenth annual assembly in October at the Adel-
phia Hotel, Philadelphia. The association is trying to
obtain legislation in this state that will give chiroprac-
tors recognition and prevent fraudulent practice.' The
following officers were elected : President, Dr. Charles
Stuart; vice-president. Dr. Blanche R. Young; secre-
tary. Dr. J. D. Armstrong; treasurer. Dr. W. E.
Keitzer; directors. Doctors Wyland,. Gregorson, Wid-
man, Hurley and McClosky.
On October 23d the Beetem Cottage, Mount Gretna,
was the scene of a wedding of unusual interest to so-
ciety in Lebanon, Harrisburg and Mt. Gretna. It was
that of Miss Dorothy Beetem, daughter of J. R.
Beetem, of Harrisburg, and John Allen Walter, son of
Dr. John Walter, of Lebanon. The ceremony was per-
formed by the Rev. M. R. Heilig, pastor of the Lu-
theran church of Downing^own. Miss Alice Heilig
was maid of honor and Daniel E. Walter, brother of
the bridegroom, was best man. After a wedding trip
the young couple will reside at Akron, Ohio.
Dr. Albert P. Francine, 264 S. 21st St., Philadel-
phia, has accepted the appointment of chief of the
Division of Tuberculosis Dispensaries and will assume
his duties Monday. Announcement to this effect was
made to-day by Colonel Edward Martin, State Com-
missioner of Health. Dr. Francine succeeds Colonel
W. J. Crookston, transferred to the Division of School
Hygiene. Dr. Francine has been in charge of the
Philadelphia clinic of the Department of Health. Dur-
ing the war he was in charge of tuberculosis work for
the American forces in Europe. He is also connected
with Phipps Institute.
On October 8th the Alumni Association of Jeffer-
son Medical College dedicated a bronze tablet as a
memorial to the graduates of the college who died in
service during the World War. The exercises were
held in the Hospital Amphitheatre with the Hon. Wra.
Potter, President of the Board of Trustees, presiding.
The Invocation was delivered by the Rev. John Chap-
man, D.D., chaplain of Jefferson Base Hospital No. ^
Introductory remarks were made by Dr. S. Solis-
Cohen, president of the Alumni Association. The
tablet was presented by Dr. J. Chalmers DaCosta and
Samuel D. Gross, professor of surgery, and accepted
by Owen J. Roberts, Esq., member of the Board of
Trustees.
The United States Civil Service Commission an-
nounces an open competitive examination for assistant
field agent, protective social measures, on November
17, 1920, at Altoona, Chambersburg and Galeton, Pa.
Vacancies in the United States Interdepartmental
Social Hygiene Board, for duty in Washington, D. C,
and in the field, and in positions requiring similar
qualifications, at salaries ranging from $1,200 to $2,000
a year, will be filled from this examination, unless it is
founti in the interest of the service to fill any vacancy
by reinstatement, transfer, or promotion. The en-
trance salary within the range stated will depend upon
the qualifications of the appointee asi shown in the
examination and the duty to which assigned.
Medical inspectors op schools have been appointed
as follows by Col. Edward Martin, State Commis-
sioner of Health: Drs. C. C. Dickey, Finleyville and
New Eagle boroughs and Union township, Washing-
ton county; Louis DeHaven, Donegal borough and
Donegal and Cook townships, Westmoreland county;
W. S. Adams, Sykesville borough and Henderson
township, Jefferson county; James Crowe, Hatboro
and Rockledge, Upper and Lower Moreland townships,
Montgomery county; Duer Reynolds. East Marlbor-
ough township, Chester county; H. B. Davis, Newliq
township, Chester county; Robert Jackson, Philips-
burg borough; A. L. Russell, JBridgeville and Upper
November, 1920
GENERAL NEWS ITEMS
99
St. Claire township, Allegheny county; D. L. Pratt,
Monroe, Standing Stone, North Towanda, Asylum,
Shesequin, Wysox and Towanda townships and Mace-
donia district, Bradford county; J. S. Miller, Col-
legeville and Trappe boroughs and Upper Providence
township,' Montgomery county. Dr. W. G. Francis has
been appointed assistant in the Coatesville clinic.
The Pennsylvania Osteopathic Association held
a special convention in October in the Hotel Adelphia,
for the purpose of considering means and measures
whereby to compel the State Health Department, the
Compensation Commission and like organizations to
accept health certificates signed by osteopaths the same
as those signed by physicians of other schools. The
present State Health Commissioner, Dr. Martin, has
declined to accept certificates of health signed by
osteopaths, whereas, however, his predecessor. Dr.
Samuel G. Dixon, accorded osteopaths the same legal
recognition that was accorded to the allopaths, homeo-
paths and eclecftics. It was decided by the convention
that these organizations be mandamused and a com-
mittee was appointed to carry out this provision. The
committee consists of Dr. E. M. Downing, York; Dr.
O. J. Snyder, Philadelphia, and Dr. H. M. Vastine,
Harrisburg. At yesterday's session a resolution was
presented petitionmg the Governor to reappoint Dr. O.
J. Snyder to the Board of Osteopathic Examiners, and
, this was unanimously carried. Action was also taken
looking forward toward full and complete recognition
of the Osteopathic School of Practice by the Federal
Government.
Pennsylvania physicians will be gratified to know
of the termination of the suit for malpractice brought
against Dr. F. L. Schum, of Huntingdon, by Caroline
White in a verdict for the defendant by instruction of
the court. The case is an interesting one, in that suit
was brought against the family physician for alleged
breach of contract in the operation performed on the
person of the plaintiff's mother by another surgeon,
resulting in the death of the patient the next day.
The evidence showed that the . patient had suffered
from a toxic goiter for a number of years and had
several times refused operation. Finally she consented
to operation, and it was the plaintifPs contention that
a simple ligation of the thyroid arteries was the only
operation authorized. The surgeon who had done the
operation testified for the defense that his intention
had been to simply ligate the arteries, but owing to
the friable nature of the thyroid gland, it was necessary
to do a partial thyroidectomy in order to stop the ex-
cessive hemorrhage. It was shown that no more exten-
sive operation was done than the exigencies of the case
demanded. As there was no evidence tending to show
lack of reasonable skill in the execution of the opera-
tion, the court instructed the jury to find for the de-
fendant September Term, Huntingdon County Court,
Judge T. F. Bailey.
A BRONZE tablet jp memory of nurses of the Epis-
copal Hospital who served in the World War was
unveiled at 3 p. m. October 6th in the nurses' home,
Front Street and Lehigh Avenue, Philadelphia. Ad-
dresses were made by the Rev. Dr. Louis C. Wash-
burn and Dr. John S. Carson, who was a major during
the war.
The nurses with base hospital 34 entered the service
in November, 1917, and were sent to France, where
they were scattered for a short time in hospitals at
Paris, St. Nazaire and Camp Costquidan. While at
base hospital loi, St. Nazaire, Miss Alice Ireland con-
tracted pneumonia and died February 2, 1918. She
was buried in the American cemetery there with mili-
tary honors.
The various groups were reunited when base hos-
pital 34 was opened at Nantes, where, after the battle
of Chateau Thierry, between 1,600 and 1,700 patients
were cared for.
Among those who served at the front are Miss Lucy
Griffen and Miss Marian Cook, who were there three
months; Miss Anna Behman and Miss Katherine Hel-
ler, who served six months on the front with a surgical
team. While on duty with the Forty-second Division
this team was cited by General Pershing for working
under shellfire the night of July 14.
The Pikst annual session of the Pennsylvania
Clinical Section of the American College of Surgeons
was held at Pittsburgh on October 7, 8 and 9. It con-
sisted of clinics in surgery and its various specialties,
with related demonstrations in group medicine, path-
ology, roentgenology and obstetrics.
Dr. Franklin Martin, of Chicago, secretary-general
of the American College of Surgeons, delivered an
address in which he' told of the aims of the American
college of Surgeons, the requirements for membership,
and the growth and efficiency of that body since its
organization.
Conservation of life and function, from a surgical
standpoint was discussed by Dr. W. L. Estes, of South
Bethlehem, and Dr. Donald . Guthrie, of Sayre. Dr.
Estes gave examples of cases in which needless opera-
tions had been performed because of incorrect diag-
nosis and also told of cases in which operations were
absolutely necessary. He stressed the point that an
efficient surgeon be called upon to diagnosis a case
about which there was any doubt.
Dr. Guthrie pointed out that thousands of lives
could be saved yearly if the laity were properly in-
formed about cancer and also showed that during the
war more deaths were caused in the United States by
tuberculosis than by bullets and shells on the battle-
fields of France. He concluded by expressing the
hope that in the Cabinet of the next President of the
United States the name of an eminent surgeon would
appear as secretary of public health.
Dr. Carl Davidson, professor in surgery at the Uni-
versity of Illinois ; Dr. Emil Beck, an eminent Chicago
surgeon, and Dr. Frank L. Hupp, of Wheeling, West
Va., spoke on the prevention of cancer mortality. The
aid of laymen in the standardization of hospitals was
asked by John G. Bowman, of Chicago, director of the
American College of Surgeons.
Clinics were held in all the principal hospitals of
Pittsburgh and the general conduct of the session was
similar to the annual session of the Clinical Congress
of the American College of Surgeons, of which this
body is a branch.
GENERAL NEWS ITEMS
Prop. Wilhelm Wundt died in Leipsic on August
31, aged 88 years. Professor Wundt held the chair of
philosophy at Leipsic, where he had founded an insti-
tute for experimental psychology.
State Society Meeting. — The Medical Society of
Virginia held its annual meeting, October 26-29, at
Petersburg. It is confidently expected that the attend-
ance will outnumber the record of previous years.
Twenty buildings of the former United States Base
Hospital No. i, now abandoned, in the Bronx, New
York City, were destroyed by fire on the night of Sep-
tember 2. The damage is estimated at $20,000.
As a memorial to General Gorgas, who cleaned up
the disease conditions in the Panama Canal Zone, it is
planned to erect in Panama an institute for the study
of tropical diseases.
The Harvard Medical School is the recipient of a
gift of $350,000 for the development of psychiatry and
$300,000 for the teaching of obstetrics, from the
Rockefeller Foundation.
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THE PENNSYLVANIA MEDICAL JOURNAL November, 1920
At the UQuest of the late Doctor J. H. Carstens,
Doctor E. K. Cullen was appointed several months ago
acting head of the Department of Gynecology in the
Detroit College of Medicine and Surgery for igao-
1921.
Ohio Valley Association Meeting. — The twenty-
third annual meeting of the Ohio Valley Medical As-
sociation will be held in Evansville, November 9 and
10, under the presidency of Dr. Virgil Moon, In-
dianapolis.
Trained nuksBs in South Bend, Indiana, have raised
their rates to $6 a day for general and obstetrical cases
and $7 a day for contagious cases. One dollar a day
extra will be charged for each additional patient in a
household.
New York Health Department Budget. — The
budget estimates for the Department of Health for
1921 total $8,821,027.23, as compared with $4,758,951
for 1920. Of this amount, $7,551,798 is to defray the
expenses of the department and the remainder for
new buildings.
Osteopaths Seek Unrestricted Permit.— It has
been reported that the New Jersey Osteopathic Society
recently drafted a bill for introduction in the legisla-
ture by which osteopathic practitioners will be per-
mitted to practice surgery or to prescribe narcotics
and drugs without restriction.
Physician Sentenced. — Dr. Joseph H. B. Adams,
Indianapolis, Indiana, reported to have been arrested
twice within fourteen months on the charge of having
performed criminal operations, is said to have been
fcimd guilty, fined $1,000 and sentenced to the peni-
tentiary for from three to fourteen years.
Ask Physical Test for Auto Drivers. — Health
Commissioner Copeland, of New York City, has made
public_ a letter recently written to Secretary of State
Francis M. Hugo, in which he suggests that amend-
ments be made to the sanitary code making it impos-
sible for those with defective vision or hearing, or
those addicted to narcotic drug«,'to become chauffeurs.
Leprosy in Boston.— The Boston City Health De-
partment has dicovered another case of leprosy in
Joaquim de Costa, a 22-year-old mill worker, who is
being held at South Hampton Street Detention Hos-
pital for transfer to Penikese Island. This is the first
case_ coming to the attention of the Boston health au-
thorities within the last six months and .will make
seventeen lepers tmder treatment at Penikese Island.
Railway Surgeons Meet.— The annual session of
the New York and New England Association of Rail-
way Surgeons was held in New York City, October 19,
with headquarters at Hotel McAlpin. Clinics in con-
nection with the meeting were held at the Hospital for
Crippled and Ruptured Children and the Post-
Graduate Hospital and a cancer conference at the Me-
morial HospitaL
Medical College Centenary.— The University of
Cincinnati College of Medicine is planning to celebrate
the one hundredth anniversary of the founding of the
Ohio-Miami Medical College, the name under which
the medical school was first established. It is said
that Sir Auckland Geddes, ambassador from Great
Britain to the United States, has accepted an invita-
tion to speak at the celebration.
College op Surgeons Elects Ofeicers.— At the an-
nual meeting of the American College of Surgeons,
held at Montreal, October 11-15, under the presidency
of Dr. George E. Armstrong, Montreal, the following
were elected to office :_ President, Dr. John B. Deaver,
Philadelphia, and vice-presidents, Drs. Henry G.
Mudd, St Louis, and Charles Sawyer, Marion, Ohio.
The secretary and treasurer were reelected.
Plans are under consideration by state officials for
the erection by New York state of a hospital for
insane soldiers, the hospital to be operated and main-
tained under the supervision of the War Risk Insur-
ance Bureau. In the state of New York there are
about 900 former service men who have become in-
sane. The need of the proposed hospital is evidenced
by the overcrowded condition of the state hospitals for
the insane.
Educational Campaign Against Malaria. — The
Cotton Belt, M. K. and T., and other railroads tra-
versing Texas are cooperating with the state board of
health in conducting an educational campaign against
malaria. The Cotton Belt's health car, "Anopheles,"
which includes model screening demonstrations, a sup-
ply of state board of health literature on malaria, and
illustrations of the life cycle of the mosquito, is being
used for an extensive educational tour.
The Physicians and Surgeonsi Adjusting Asso-
ciation announces that in compliance with the request
of physicians, they are now issuing an engraved mem-
bership certificate, suitable for framing, which entitles
the members to all the benefits and privileges of the
Association, and is a protection against delinquents.
This is furnished free of charge to all doctors sending
in a list of accounts, which automatically entitles the
doctor to membership in the Association.
Effects op Prohibition. — According to statistics
compiled by the Baltimore City Health Department,
in-ohibition is helping to lower the city's death rate,
besides cutting down the number of prisoners in the
Baltimore City Jail and House of Correction and les-
sening the population at Bay View Asylum. There
have been no fatalities from alcoholism this year, as
compared to fourteen in 1919, twenty-eight in 1918,
thirty-seven in 1917, and ninety-four in 1916.
P(h,iomyelitis Reappears. — Following closely on a
warning sent out by Dr. Copeland to every physician
in the city of New York to guard against poliomyelitis
since it had made its appearing in Boston, three cases
were reported, September 25. There have been forty-
eight cases and eight deatHs from the disease in tlus
city since January i, and a few cases have also been
reported upstate. It is urged that all suspicious cases
be at once reported to the health department.
Professor McPhedran Honored.— Dr. Alexander
McPhedran, formerly professor of medicine in the
medical department of the University of Toronto,
was tendered a complimentary banquet and presented
with an oil portrait of himself and a club bag, Septem-
ber 24. Dr. Lewellys F. Barker, Baltimore, unveiled
the portrait and made a complimentary address. Phy-
sicians were present from New York, Cleveland, Con-
necticut, Ottawa, Hamilton, Guelph and other points.
Hospital Association Holds Meeting. — At the an-
nual meeting of the American Hospital Association,
held in Montreal, October 4-8, the following officers
were elected: President, Dr. Louis B. Baldwin, Min-
neapolis; president-elect, Dr. George O'Hanlon, New
York; vice-presidents. Dr. Malcolm T. MacElachem,
Vancouver, B. C. ; Mr. S. G. Davidson, Memphis, and
Miss Alice M. Gaggs, Louisville, Ky. ; secretary. Dr.
A. R. Warner, Chicago, and treasurer, Mr. Asa Bacon,
Chicago.
Child Health Campaign.— The U. S. Public Health
Service has inaugurated a campaign of education for
the promotion of child health. Supplementing the re-
cent propaganda of education on "The Care of the
Baby," a large number of articles have been prepared
and distributed to more than 100 newspapers for pub-
lication in serial form. The series is entitled 'The
Growing Child," and deals with a wide variety of sub-
jects for the maintenance and promotion of the health
Digitized by VjOOQIC
November, 1920
GENERAL NEWS ITEMS
101
The Mississippi Vaixey Mbdicai Assooation held
its session in Chicago, October 26, 27, 28, 1920.
The address on surgery was by Dr. Charles H.
Mayo, of Rochester, Minnesota. That on medicine by
Dr. Henry A. Christian.
There were two leading symposia : one on the pri-
mary anxmias, discussed by Charles P. Emerson from
the internist's standpoint, surgical aspects by Willis D.
Catch, and pathology by Virgil H. Moon. A sympo-
sium on "Disorders of Internal Secretions," was pre-
sented by Cannon, Tierney, Bandler, Hoxie and
Draper.
Bubonic plagus is present in five seaports of the
United States, according to a report made before the
forty-ninth annual meeting of the American Public
Health Association, held in San Francisco. In an ad-
dress to the Association, Dr. W. H. Kellogg, of San
Francisco, says that the plague is present in New
Orleans, Galveston, Beaumont, Pensacola and Port
Arthur, as well as in Hawaii and Vera- Cruz. Dr.
Kellogg goes on to say that the plague is carried by
rats on ships and enters a new territory by way of the
seaports, and the only way to check and eradicate jthe
plagtie is by launching an extensive warfare agamst
rats in all seaports whether or not infected with the
plague.
State Hospitai, fob Ex-Service Men. — Governor
Smith, on September 29, signed the bill appropriating
$3,000,000 for a hospital for the treatment of ex-
soldiers suffering from nervous and mental diseases,
to be erected on the site in Queens County intended
for the Long Island State Hospital. The bill pro-
vides that an agreement may be entered into with the
United States government for a term of not more than
ten years whereby the United States is to equip and
maintain the hospital exclusively for the treatment of
discharged soldiers, sailors and .marines from this
state who became mentally defective from their serv-
ice in the war. Dr. Thomas W. Salmon is the medical
representative of the commission charged with con-
striction of the hospital.
The Fourth Annual Meeting of the Association
of Surgeons of the Chesapeake and Ohio Railway was
held at White Sulphur Springs on September 15. The
meeting was well attended.
Surgeons from Huntington present were Drs. W.
E. Vest, R. J. Wilkinson, F. C. Hodges and C. R.
Enslow, president of the Association.
The program was fully carried out and Dr. E. H.
Griswold, of Peru, Indiana, elected president for the
ensuing year.
The committee of arrangements for the next meet-
ing, the place of which will be determined later by the
executive committee, is composed of Dr. Jas. R Bloss,
of Huntington, W. Va. ; Dr. Garr, of Lexington, Ky.,
and Dr. Hodnutt, of Richmond, Va.
The Numerical Strength of the Medical Profes-
sion.— Doctors of medicine represent the largest single
group of professional men in the country. There are
about 150,000 graduate physicians in the United States,
of whom 140,000 are believed to be in active practice.
The following indicate the number located in the more
thickly populated states :
California, 5,929; Illinois, 11,095; Michigan, 4,598;
Missouri, 6,093 ; New Jersey, 3,153 ; New York,
15,877; Massachusetts, 5,926; Ohio, 8,089; Pennsyl-
vania 11^495; Texas, 6,246.
- As moulders of public opinion, the medical profes-
sion can exert an influence that is not approached by
any other profession or trade because they are closer
to the hearts of the people than any other body o^nen
or women. 1 ^^HH
United States Civil Service Examinations.— Ap-
plications for examination for the position of District
Medical Officer and Assistant Medical Officer, under
the Federal Board for Vocational Education, Rehabili-
tation Division, will be received at any time. Appli-
cations should be filed with the Civil Service Com-
mission, Washington, D. C Application should be
made for Form 21 18, stating the examination desired.
The positions in question will pay from $1,800 to $3,000
per year. It is said that there are numerous vacancies
to be filled, and the examinations are not difficult
The examinations for Bacteriologist, will be held De-
cember I. For this examination apphcation should be
for Form 1312, stating the title of examination and so
on, to the Civil Service Commission, Washington, D.
C This position will pay as high as $130 per month,
with additional allowances.
Increased Entrance Requirements at Johns Hop-
kins.— A report from- the medical department of Johns
Hopkins University states that beginning in Septem-
ber, 1921, at least two years of college work in chem-
istry will be required, of which one and one-third
years must be devoted to inorganic and two-thirds to
organic chemistry. Each year's work should consist
of three didactic periods per week and five or six
hours of laboratory work. This is the minimum re-
quirement and three full years in chemistry are ad-
vised, including lectures and demonstrations in ele-
mentary physical chemistry. After 1923, the three
years' course will be required, consisting of 240 hours
of class work and 500 hours of laboratory work. The
former must include 60 hours in organic chemistry and
a short course in physical chemistry. The latter must
include one year's work in quantitative analysis and
120 hours in organic chemistry.
Pie Okayed.— Ye godsl What will the dyspeptics
do for an alibi now that pie, the great American de-
sert, has been pronounced thoroughly digestible and
less objectionable as an article of diet than many other
things that never have been placed under the ban.
"The lovers of pie will be pleased to know that the
gastro-enterologists at the Jefferson College, of Phila-
delphia, have come to the defense of pie. This may
come as a shock to those wiseacres who have been
forever sounding a note of warning concerning the
indigestibility of pie, and probably is quite as much a
shock as the exploded theory that it is very harmful
to drink fluids with the meals. In fact it is now con-
sidered quite the proper thing to take water with the
meals, which some so-called dietary experts have been
prone to tell us was harmful to digestion. In reality
there is altogether too much advice advanced without
having it based on facts or sviitable foundation.— /our.
Ind. State Med. Assn.
Aeroplane Ambulance for Texas Hospital.— So
far as known, Templ^, has the only hospital in the
world that utilizes air craft for transportation pur-
poses. A new machine has been fitted out as an aerial
hospital for the purpose of responding to emergecy
calls within a radius of two hundred miles of this city.
The plane was given its baptism when an emergency
call was answered from Ireland, a Coryell County
village, 65 miles distant. The trip was made by a sur-
geon and a nurse and the journey was safely negoti-
ated, a successful operation performed and the home-
ward flight accomplished within five hours. By rail
the trip would have consumed two days' time and by
motor car not less than ten hours.
It is planned to use the plane not only for the pur-
pose first named, but also to transport patients living
in remote districts to the hospital where imperative
that hospital aid be given. By this method the uncom-
fortable jolting and disturbance caused by rail and
motor travel will be eliminated and precious time
saved. — DalUu News.
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102
THE PENNSYLVANIA MEDICAL JOURNAL
November, 1920
MoNBY Wasted on Fake Cures for Tuberculosis. —
From $15,000,000 to $25,000,000 each year is wasted by
victims of consumiition in tht; Unit<Kl States on worth-
less fake "Cures" for tabcrculosis, according to an
estimate by the National Tuberculosis Association.
The number of so-called "cures" that have been tried
out and exploited for gain or otherwise during the last
ten years in the United States is well over a thousand,
records show. In Texas, the Texas, Public Health As-
sociation is cooperating with the Vigilance Committee
of the Associated Advertising Clubs of the World,
the American Medical Association, and the National
Tuberculosis Association in waging a war upon these
frauds.
"People who have tuberculosis usually need all their
money for reali cures," said D. E. Breed, executive
secretary of the Texas Public Health Association, "and
cannot afford to pay for these fakes. These 'cures'
may be remedies or devices such as liquids, pills,
powders, plasters, inhalers, patented stoves and nu-
merous other devices which are sold or rented at
prices usually hundreds of times in excess of their
actual value. They are not only worthless, but in- '
variably deprive their victims of an opportunity to get
well because of delay in taking the proper measures.
Some people who have a great belief in their own
'discoveries' recommend such things as dog's blood,
onions, lemons, etc.
".Chemists of the American Medical Association
made tests of material in an 'inhaler,' a device which
many people of Texas paid thousands of dollars for.
It was found to be common Texas clay." — Texas State
Journal of Medicine.
BOOKS RECEIVED
Books received are acknowledged in this column,
and such acknowledgment must be regarded as a suffi-
cient return for the courtesy of the sender. Selections
will be made for review in .the interests of our readers
and as space permits.
Operative Gynecouxjv, Second Edition, by Harry
Sturgeon Crossen, M.D., F.A.C.S., Fellow of the
American Gynecological Society and of the American
Association of Obstetricians and Gjmecologists. As-
sociate in Gynecology, Washington University Med-
ical School, Associate Gynecologist to the Barnes Hos-
pital, etc. 699 pages, 834 original illustrations. St.
Louis : C. V. Mosby Company, 1920. Price, $10.00.
Apter-Death Communications, by L. M. Bazett,
with an introduction by J. A. Arthur Hill. 11 1 pages.
New York : Henry Holt and Co.
Massage and Exercises Combined. A Permanent
Physical Culture Course for Men, Women and Chil-
dren. 93 pages, with 86 illustrations. By Albrecht
Jensen, formerly in Charge of Medical Massage Clin-
ics at Polyclinic Hospital and other Hospitals, New
York. Published by the Author, 220 West 42d St.,
New York, N. Y. Price, $4.00.
BOOK REVIEW
THE MEDICAL CLINICS OF NORTH AMERICA.
September, 1920. Boston Number, Volume 4, No. 2.
Philadelphia and London: W. B. Saunders Com-
pany.
This volume of the Clinics contains articles from
the Massachusetts General Hospital, by Ida M. Can-
non, describing a medico-social clinic, by Drs. Paul D.
White and William D. Reid discussing the diagnosis
of mitral stenosis, by Dr. Stanley Cobb on spastic para-
lysis in children ; from the Boston Dispensary dealing
with vomiting as a symptom in children; from the
Boston City Hospital, by Dr. Edward H. Nichols dis-
cussing the early diagnosis of acute appendicitis, by
Dr. William H. Robey, Jr., on aneurysm of the de-
scending aorta, by Dr. Eidwin A. Locke on empyema
complicating pneumonia, by Dr. Franklin W. White
on modern examination of the stomach, by Dr. W.
Richard Ohler on clinical application of the tests for
renal function, b^ Dr. M. J. English on a case of
atypical pneumonia, by Dr. Albert A. Hornor on en-
cephalitis, by Dr. Archibald Nissen on cirrhosis of the
liver, with jaundice and ascites, by Dr. Frank B. Berry
on lobal pneumonia; from the Children's Hospital,
by Dr. John Lovett Morse on constipation and eczema
from excess of fat in modified milk, by Dr. Lewis
Webb Hill on congenital atelectasis and bronchial
tetany, by Dr. Edwin T. Wyman on acquired heart dis-
ease in childhood, by Karlton G. Percy on chronic in-
testinal indigestion from stardi, with indican reaction,
by Dr. Joseph I. Grover on enuresis and by Dr. Philip
H. Sylvester presenting a case for diagnosis. E.
THE SURGICAL CLINICS OF CHICAGO. Octavo,
Volume IV, Numbers 3 and 4, pages 204 with 52 il-
lustrations and pages 214 with 80 illustrations.
(June and August, 1920.) W. B. Saunders Com-
pany, Philadelphia and London.
These two volumes of the series are characterized
by the usual practical instruction of the lectures and
the exceedingly satisfactory style of illustration. Some
new contributors appear, with a consequent variation
in the subjects submitted to the reader. Dr. G. E.
Schambaugh's lectures discuss interesting cases of sur-
gery of the throat, nose and ear. Dr. E. L. Cornell
deals with some obstetrical conditions, as does Dr. F.
H. Falls. Orthopaedic clinics appear under the name
of Eh-. C. A. Parker.
The specimens of neolithic bone diseases and in-
juries, pictured in Dr. Roy L. Moodie's contributions,
are as interesting as the similar paleontologic ma-
terials referred to in recent notices of the "Clinics."
The articles on empyema, peritonitis, prostatic dis-
ease, fractures, joint operations and abdominal condi-
tions will appeal strongly to surgical readers.
J. B. R.
HIGH FREQUENCY APPARATUS. Design, con-
struction and practical application. By Thomas
Stanley Curtis. Norman W. Henley Publishing Co.,
New York, i'-2o. 275 pages. $3.00.
This book is of value to any physician who is inter-
ested in electro-therapeutics. The subjects are treated
simply, concisely and clearly. It is well illustrated with
diagrams and deals more particularly with the con-
struction of apparatus, and its manipulation, rather
than with the therapeutic indications and methods of
application. The first two chapters tell what the high
frequency current is, how it is produced, and for what
it is used. The next four chapters describe in detail
the principles of the transformer, condenser, spark
gap, and oscillating transformer, and covers the main
points in the design and construction of these devices.
The fourth section is devoted to electro-therapeutics
and x-ray apparatus for the cultivation of plants and
vegetables. G. E. P.
AFTER-DEATH COMMUNICATIONS. By L. M.
Bazett, with an introduction by J. A. Arthur HilL
119 pages. New York: Henry Holt and Company.
This book is a careful record of communications re-
ceived by means of automatic writing during several
years of the author's life. It will doubtless be of
value to those who are interested in this much dis-
cussed subject. M. S. B.
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OFFICIAL TRANSACTIONS
Organized 1848
Incorporated, December 20, 1890
Minutes of the Proceedings of the Medical Society of the State of Pennsylvania
The Seventieth Annual Session, held at Pittsburgh, October 4, 5, 6 and 7, 1920
MINUTES OF THE HOUSE OF DELEGATES
Monday Afternoon, October 4, 1920
The House of Delegates met in room 6 (D) of the
William Penn hotel at 3:15 p. m., and was called to
order by the president, Dr. Cyrus Lee Stevens, Athens.
The Committee on Credentials made a preliminary
report and reported a quorum present.
The president declared the House of Delegates duly
constituted and ready for the transaction of business.
There being no objection, roll call was dispensed
with.
The next order was the presentation, correction and
adoption of the minutes of the Sixty-ninth Annual
Session.
Dr. Henry D. Jump, Philadelphia, moved that the
reading of the minutes of the Sixty-ninth Annual
Session be dispensed with, and that they be adopted
as printed in the Pennsyivania Medicai, Journai,,
November, 1919. Seconded and carried.
President Stevens addressed the House of Dele-
gates as follows:
Fellow Physicians of the House of Delegates:
There is much dependent on our action this week
and it is important that we thoroughly consider all
matters brought before us, and carefully word all
resolutions adopted. The point I wish to emphasize
is illustrated by the following incident: During the
year a large religious body met in Philadelphia and
took almost unanimous action upon a matter that had
been up for consideration for more than twenty years.
Now it develops that the wording of the resolutions
adopted is capable of two entirely different meanings.
It is urged that the reference committees give care'ful
attention to the reports and resolutions referred to
them. The reports of the officers and committees are
so numerous that the one reference committee may not
find time to do justice to the various subjects men-
tioned. If the Reference Committee on Reports of
Officers and Committees feel that they have more mat-
ters than they can properly consider, some of the
reports may be referred to one of the other reference
committees, or to a special committee or committees,
as the House may decide.
Practically every legislature in the sevaral states is
filled with bills asking for social legislation. There
are reformers, good, bad and indifferent. This condi-
tion is not simply the result of the universal unrest
following the World War, but is largely the out-
growth of social questions that from year to year have
received more and more attention.^ We cannot close
our eyes to the far-reaching possibilities of this social
agitation; "the future character of civilization and the
destiny of the human race are involved in it. _ The
whole question as to whether it shall be a blessing to
the world or a curse, is one of leadership." How is
the medical profession going to stand? Will it con-
tinue to take a broad view of those social questions
and remain a leading force in shaping matters of
social betterment, or, fearing that we may be pushed
to the wall, will we consider these practical questions
from a purely selfish point of view and thus place our-
selves outside of the forces that are controlling the
course of events ?
On more than one occasion when the House of
Delegates has hurried through with its business and
adjourned on Wednesday, it has been foimd that there
was business waiting for a meeting on Thursday.
May it not be well to hold a short meeting on Thurs-
day with the understanding that no new business be
introduced except such as may have been referred by
the General Meeting or one of the sections of the
Society ?
It is important that the stenographer, Mr. Whitford,
of Chicago, have the name and address of each mem*
ber speaking. Each one on rising to make a motion
or to speak will give his name when addressing the
Chair.
The president announced the following Reference
Committees as appointed by the President-Elect :
Committee on Credentials : Dr. Walter S. Brenholtz,
Chairman, Williamsport ; Dr. William W. Lazarus,
Tunkhannock ; 'Eh-. J. Paul Roebuck, Lancaster.
Reference Committee on Reports of Officers and
Standing Committees : Dr. John M. Thorne, Chair-
man, Pittsburgh; Dr. John W. West, Philadelphia;
Dr. Jesse L. Lenker, Harrisburg.
Reference Committee on Scientific Business: Dr.
William Krusen, Chairman, Philadelphia; Dr. Alex-
ander Armstrong, White Haven; Dr. Jefferson Wil-
son, Beaver.
Reference Committee on New Business: Dr. Her-
bert B. Gibby, Chairman, Wilkes-Barre ; Dr. Perly N.
Barker, Troy ; Dr. Frank P. Lytle, Birdsboro.
The secretary presented his report as printed in the
September, 1920, issue of The Pennsylvania Medical
Journal.
Dr. Frank C. Hammond, Philadelphia, moved that
the report be received and referred to the Reference
Committee on Reports of Officers and Standing Com-
mittees. Seconded and carried.
The next thing in order was the report of the
Treasurer.
Dr. Hammond moved that the report be received and
referred to the Board of Trustees for audit. Seconded
and carried. (See Pennsylvania Medical Journal,
September, 1520.)
The next report being that of the editor. Dr. Wilmer
Krusen, Philadelphia, moved that it be received and
referred to the Reference Committee on Reports of
Officers and Standing Committees. Seconded and car-
ried.
Regarding the report of the executive secretary. Dr.
Baldy moved that it be received and referred to the
Reference Committee on Reports of Officers and
Standing Committees. Seconded and carried.
With reference to the reports of individual coun-
cilors. Dr. Baldy moved that they be received as
printed in The Pennsylvania Medical Journal for
September, 1920, and referred to the Reference Com-
mittee on Reports of Officers and Standing Commit-
tees. Seconded and carried.
The president called for the report of the Commit-
tee on Public Health Legislation, which included the
Committee on Defense of Medical Research, the Com-
mittee on Promotion of Efficient Laws on_ Insanity,
and the Commission on Conservation of Vision, all of
which are printed in The Pennsylvania Medical
Journal of September, 1920.
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104
THE PENNSYLVANIA MEDICAL JOURNAL November. 1920
Dr. Baldy moved that these reports be received and
referred to the Reference Committee on Reports of
Officers and Standing Committees. Seconded and car-
ried.
The report of the Committee on Society Comity and
Policy was called for.
Dr. Krusen moved that it be received and referred
to the Reference Committee on Reports of Officers
and Standing Committees. Seconded and carried.
The president called for the report of the Committee
on Health 'and Public Instruction, including the Com-
mission on Cancer.
It was moved that the report be received and re-
ferred to the Reference Committee on Reports of
Officers and Standing Committees. Seconded and car-
ried.
It was moved and seconded that the report of the
Board of Trustees and Councilors as printed in The
Pennsylvania Medical Journal for September, 1920,
be accepted, and that the other matter contained in the
report come up under new business, and that the re-
port be referred to the Reference Committee on Re-
ports of. Officers and Standing Committees. Carried.
Dr. Krusen moved that the report of the Committee
on Benevolence be referred to the Board of Trustees.
Seconded and carried.
The secretary presented the following report for the
Committee on Archives :
Report o? the Committee on Archives
To the President and Members of the House of Dele-
gales of the Medical Society of the State of
Pennsylvania:
The chairn^an of this committee has upon inquiry
ascertained that our Society has the following volumes
of its transactions :
In the library of the University of Pennsylvania,
bound volumes of the annual transactions for the
years 1851 to 1896 inclusive.
In the possesion of former Secretary C. L. Stevens,
Athens, Pennsylvania, bound copies of The Pennsyl-
vania Medical Journal from volume one (volume 28
of transactions) to volume 13 (volume 39 of transac-
tions) and 2 to 20 unbound copies for each month of
volumes i to 7 of the Journal.
It is essential that the transactions of our Society
should be preserved in appropriate form and place. It
is desirable that an appropriate number of unbound
copies of each issue of The Pennsylvania Medical
Journal to date should be in the possession of our
Society. We therefore recommend that appropriate
instructions, with power to obtain by purchase where
necessary, be issued to fulfill the above suggestions.
The reports of the Committee on Archives for the
years 1905, 1909 and 1912 will be of great assistance in
promulgating this plan. It is also urgently recom-
mended that each county medical society secure, as far
as possible, a complete set of the Journals for their
own future reference.
Elmer E. Wible,
George G. Harman,
Walter F. Donaldson, Chairman.
It was moved that the report be accepted and re-
ferred to the Reference Committee on Reports of
Officers and Standing Committees. Seconded and car-
ried.
The Secretary presented a report from the delegates
to the 1920 United States Pharmacopceial Convention,
as follows:
Report of Henry Beates, Jr., M.D., Chairman United
States Pharmacopceial Association :
Mr. President and Fellow Members:
Your committee representing the Medical Society of
the State of Pennsylvania at the 1920 session of the
United States Pharmacopceial Association held at
Washington, D. C, begs leave to report that it was
present during the meetings. The committee elected
Dr. Henry Beates chairman. The convention enacted
measures that maintained the standard of the phar-
macopoeia, which serves as a model for almost all the
pharmacopoeias of the world. Representation on the
Revision Committee by manufacturing concerns of
questionable reputation was prevented and the official
character of the pharmacopoeia maintained.
Your chairman was appointed by the convention
chairman of the Nominating Committee of the Phar-
macopceial Convention, and it is gratifying to report
that the business was transacted with a unani'mity of
purpose and spirit of good fellowship Jhat finds the
pharmaceutical and medical members on the best of
terms and eager to achieve the ends in view with
celerity and thoroughness.
Respectfully submitted,
Adolph Koenic,
Wm. Duffield Robinson,
Henry Beates, Jr., Chairman.
Dr. Edward B. Heckel, Pittsburgh, moved that the
report be received and referred to the Reference Com-
mittee on Reports of Officers and Standing Commit-
tees. Seconded and carried.
Dr. Henry D. Jump, Philadelphia, stated that as a
delegate to the Annual Meeting of the Medical Society
of the State of New York, he had the privilege of
talking to several of the officers and chairmen of com-
mittees in regard to the fight they were making on
compulsory health insurance. They told him the plan
they had followed. He communicated with others to
the advantage of tiiose who were making this fight.
It was moved that this verbal report be referred to
the Reference Committee on Reports of Officers and
Standing Committees. Seconded and carried.
Under the head of correspondence, the secretary
read a communication from Dr. Frederick R. Green,
Secretary of the Council on "Health and Public In-
struction of the American Medical Association, which
was referred to the Reference Committee on New
Business. The report is as follows:
Chicago, May 21, 192a
Dr. W. F. Donaldson,
Pittsburgh, Pennsylvania.
Dear Doctor Donaldson:
At the New Orleans meeting of the American Med-
ical Association, the House of Delegates adopted a
recommendation of the Reference Committee that the
work of the Subcommittee on Health Problems in
Education.be endorsed, and that the secretary of the
Council on Heahh and Public Instruction be instructed
to ask the secretary of each state association to have
a committee appointed to attend the next meeting of
the State Teachers' Association and to ask for the
appointment of a committee from the State Teachers'
Assodation to cooperate with the medical profession
in promoting better health conditions in our public
schools.
In accordance with this action, I would suggest that
your state association at its coming meeting be asked
to authorize the appointment of a committee of five
members for this purpose. If this suggestion meets
with the approval of your state association, I shall be
glad to write the chairman of the committee giving
him further details on this subject if you will kindly
notify me of his appointment.
Very truly yours,
(Signed) Frederick R. Green,
Secretary Council on Health and Public Instruction.
Regarding the report of the Joint Reconstruction
Committee, Dr. Krusen moved that it be referred to
the Reference Committee on Reports of Officers and
Standing Committees. Seconded and carried.
The secretary presented a communication from the
National Anaesthesia Research Society, together with
a resolution, as follows :
"All those interested in advancing the science and
practice of Anaesthesia are making a concerted effort
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November, 1920
OFFICIAL TRANSACTIONS
105
to secure a Section on Ansesthesia in the American
Medical Association.
"In this connection will you extend us your coopera-
tion in presenting the following Resolution to the
House of Delegates of the Medical Society of Penn-
sylvania at the forthcoming meeting for its favorable
actioA :
"The specialty of anaesthesia has for years been
recognized by sections in the International Congresses
of Medicine and Dentistry. Also there is a Section on
Anaesthetics in the Royal Society of Medicine.
"Anaesthesia is the only specialty in Medicine' and
Surgery at the present time which is not represented
by a section in the A. M. A., although the American
Association of Anaesthetists has held its annual meet-
ings in conjunction with those of the A. M. A. for the
past eight years.
"The Interstate Association of Anaesthetists has
held joint meetings and sessions with the following
Societies during the past six years : Ohio State Med-
ical Association, National Dental Association, Missis-
sippi Valley Medical Association, Indiana State Medical
Society, American Association of Obstetricians and
Gynecologists and the Medical Society of the State of
Pennsylvania.
"The meeting with the National Dental Association
was so impressive that the N. D. A. at once organized
its own section on Oral Surgery and Anaesthesia,
which has_ been one of the leading features of its an-
nual meetings for the past five years.
"The resolution submitted has the endorsement of
the following Societies: National Anaesthesia Re-
search Society, American Association of Anesthetists,
Inter-State Association of Anaesthetists, New York,
Boston, Providence, Toledo, Louisville, Indianapolis,
Kansas City, Seattle, and Northern and Southern Cali-
fornia Societies of Anaesthetists.
_ "The National Anaesthesia Research Society, with a
limited financial foundation, is trying to standardize
and improve the teaching of anaesthesia in the Med-
ical and Dental Schools and teaching hospitals of the
United States. It is also trying to provide especially
qualified anaesthetists for_ every hospital in the coun-
try. Also it is underwriting research work that is
pertinent.
"Those interested have the assurance of incoming
officials of the A. M. A. that the establishment of a
section on Anaesthesia will be given consideration at a
meeting of the Committee of Scientific Work in Chi-
cago during November. It is hoped that many State
Societies will follow the example of the Ohio State
Medical Association and the Medical Society of the
District of Columbia and instruct their delegates to
vote favorably on this matter now and also at the Bos-
ton meeting in June, 1921.
"Will you kindly inform the N. A. R. S. of what-
ever action is taken and oblige,
"Yours very sincerely,
"F. H. McMechan.
"Chairman Research Committee N. A. R. S.; Sec-
retary American and Interstate Association of
Antesihetists.
"Resolution
"Whshkas, The safety of patients, the advance of surgery
and the demands of hospital service necessitate the rapid ex-
tension of the specialty of anaethesia; therefore, be it
"Resolved. That the Medical Society of the State of Penn-
sylvania hereby instructs its delegates to secure a Section on
Anaesthesia in the Airierican Medifal Association at the Boston
meeting, June, 1931."
Dr. Baldy moved that the communication and reso-
lution be referred to the Reference Committee on
Scientific Business. Seconded and carried.
The. secretary read a communication from the Ohio
State Medical Association, with a resolution adopted
by that body at its last annual meeting, as follows :
Resolution adopted by the House of Delegates of
the Ohio State Medical Association, at its last annual
meeting, held in Toledo, June i, 2 and 3, 1020:
"WuxuSAS, In our forty-eight states there are as many sepa-
rate medical examining boards, and
"Whereas, Licensed physicians in one state. may not always
practice in other commonwealths without vexatious examina-
tions and expense, and
"Whikxas, The government in time of war frequently sent
physicians into army camps in other states, and therefore dis-
regarded state boundaries, and
''Whirsas, There is practically homogeneity in the anatomical
and psychological makeup of the people in the various states,
and
"WhIreas, Tbe same may be said of the physicians through-
out the land;
"Then fare. Be It Resolved , That it is the opinion of the
House of Delegates that the rtf ht to practice in one state should
be extended to include the right to practice medicine in any
part of the United States.
"Be It Further Resolved, That a copy of this resolution be
sent to the proper officials of all medical societies, and to na-
tional and quasi-national medical associations, and that the
American Medical Association be especially urged to perfect a
plan by which interstate medical practice be made as easy as
interstate commerce."
Dr. Baldy moved that the communication and reso-
lution be referred to the Reference Committee on
Scientific Business. Seconded and carried.
The secretary presented a communication addressed
to President-Elect Jump from The Pennsylvania-
Delaware Division of the American Red Cross, as fol-
lows :
THE AMERICAN RED CROSS
Pbnnsylvania-Delaware Division
Philadelphia, Pa., Aug. 28, 1920.
To Dr. Henry D. Jump, President Pennsylvania State
Medical Association, 2019 Walnut Street, Phila-
delphia, Pa.
From Charles Scott, Jr.
Subject: National Recruiting Campaign for Stu-
dent Nurses
My Dear Dr. Jump:
The country is face to face with a critical shortage
of graduate nurses for all types of work, and this con-
dition will rapidly grow worse if the hospital training
schools, the only sources of supply from which quali-
fied nurses may be obtained, are not kept filled to their
utmost capacity. Recruiting for these schools must
therefore be immediately stimulated.
Realizing the seriousness of the situation, the three
National Nursing Associations have joined with the
Red Cross in developing a national movement for the
recruiting of student nurses. The Nursing Associa-
tions and the Red Cross cannot do this atone. In
order to secure the fullest measure of accomplish-
ment the active cooperation will be required of indi-
vidual physicians, medical associations and all other
organizations utilizing the services of nurses, either in
the private home, the hospital, or institution, or in the
general community.
To facilitate the distribution of the plans and the
publicity material for this recruiting work, it was de-
cided to use the Red Cross machinery, which, through
the Division, Chapter and Branch organization, ex-
tends to every part of the country.
Attached will be found a copy of the plan outlining
the movement, additional copies of which may be ob-
tained through local Red Cross Chapter office, 218 S.
Nineteenth Street, or from this office.
Will you urge your association not only to endorse
and support this movement, but to stimulate your
county and local associations to assist in the develop-
ment of active recruiting committees. It is not o»r
job alone. Hospitals and members of the medical pro-
fession are among the chief sufferers from the short-
age of nurses. _ I feel sure, therefore, that I can count
upon your active assistance in putting over this cam-
paign. Dr. Martin is keenly interested and is lining
up all of his Health Department. It is at his sugges-
tion that I am writing to you for your advice and as-
sistance.
I do not know how you would propose to bring this
campaign to the attention of the members of your As-
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106
THE PENNSYLVANIA MEDICAL JOURNAL Novembbr, 1920
sociation, but if we can be of any help to you in the
matter please call upon us.
Yours sincerely,
(Signed) Charles Scorr, Jr.,
Division Manager.
Dr. Baldy moved that it be referred to the Refer-
ence Committee on New Business. Seconded and car-
ried.
The secretary read the following communication,
which was addressed to_ President Stevens, relative to
stopping forest devastation :
"You recently, through Dr. William Sharpless, of
West Chester, requested me to represent the Medical
Society in an organization of men representing the
principal business interests of the state, formed for
the purpose of 'restoration of Pennsylvania's timber
production.' Representatives of these interests met in
Harrisburg on September 14th, and permanent organi-
zation was effected. I doubt very much whether a
stronger committee, representing more business, has
met in Harrisburg within recent years.
"In order that the State Medical Society might be
officially recognized in the conference, I introduced
a resolution (copy of which herewith) which was
'unanimously adopted,' and I was directed to forward
it to the Medical Society of the State of Pennsylvania,
hoping for concurrent adoption at the Pittsburgh
meeting.
_ "I regret that my presence there will be hardly pos-
sible. I have, therefore, handed it to Dr. Joseph Scat-
tergood, of West Chester, for presentation. And also
written to Dr. Lewis Taylor, of Wilkes-Barre, re-
questing his active interest in it.
"I may safely say that any help you can give in this
matter will be welcomed by the State Department of
Forestry and by the Governor. Of course, any addi-
tional strength you may put into it, will be all to the
good.
"May I invoke your powerful assistance?
"Faithfully yours,
"(Signed) J. T. Rdthrock."
"Whukeas, Abundance of pure water i< an absolute necessity
tor public health; and
"Whxreas, Our timberlesa, unproductive, abandoned high-
lands of the state are a nursery of floods which transport germs
of disease through the breadth of the commonwealth, and by
such floods disturb the even flow of water which is so necessary
for a production of water power; and
"Whmeas, There are in Pennsylvania to^Jay five million
acres of such timberless areas^ which are a menace to individual
health and to public prosperity, which land once produced a
crop of timber of immense value to the state, and which, under
state control, can be restored to a productive condition; there-
fore, be it
"Resolved, The Medical Society of the State of Pennsylvania
cordially approves of the wish of His Excellency, the Honorable
William C. Sprout, Governor of the Commonwealth, that these
acres be taken under control of the Pennsylvania Forest Com-
mission by purchase, that further impoverishment of the soil
be stayed; that the water power of the State be increased to
supplement the growing demand for coal which, as the supply
becomes more limited, the price becomes higher, and the needs
of our population grow greater.
^ "Resolved, In order that this beneficent purpose be made pos-
sible, the Medical Society of the State of Pennsylvania earnestly
urges upon the incoming Legislature that sufficient funds be
appropriated for the purchase, by the State, of the said land,
and their protection against destructive forest fires. Under
State Forest control, streams heading in our mountain ranges
and higher ridges would insure an abundant supply of pure
water to a large portion of our population."
The secretary also read a communication which em-
bodied the same subject-matter as that contained in
the previous communication.
Dr. Baldy moved that these communications be re-
ferred to the Reference Committee on Scientific Busi-
ness. Seconded and carried.
Dr. Wilmer Krusen, Philadelphia, presented the fol-
lowing resolution at the request of the Pennsylvania
Society for the Prevention of Tuberculosis :
Whkuas, There exists a lack of provision for the care and
treatment of advanced cases of tuberculosis in Pennsylvania,
and
Whe«eas, These sufferers are a distinct menace to the other
members of their own families and the public; therefore, be it
Resolved. That it is the sense of the Medical Society of the
State of Pennsylvania that General Hospitals receiving financial
aid from the state should be requested to set apart a wing or
ward for the reception and treatment of cases of advanced
tuberculosis.
Resolved, That this association endorses the plan of erecting
a hospital for each county or group of counties for the care of
indigent persons suffering from advanced tuberculosis.
Resolved, That a copy of these resolution* be published in
Thk Pimnsylvania Mzdical ^ou»nal, and that a copy be sent
to every general hospital witbm the state, to the State Commis-
sioner of Health, as well as to Dr. Frederick h. Van Sickle, the
executive secretary, with the request that he urge the adoption
of their provisions by the Legislature.
Dr. Baldy moved that this resolution be referred to
the Reference Committee on New Business. Seconded
and carried.
Dr. Miller, Clearfield, presented the following com-
munication asking for cooperation of the County Med-
ical Societies in regard to State Sanatoria :
Resolved, That the State Medical Society ask the active and
cordial cooperation of each of the constituent organizations, the
County Societies, in the plan of collective consultations pre-
pared by the State Department of Health. That each Medical
Society, after having discussed the Sute Health policies as set
forth to it in monthly communications, forward to the State
Department their approval or the reverse with such constructive
criticism as shall make the joint action of the State Sanatarians
and the individual members of the medical profession more
efficient for the public good; and_ moreover, that these com-
mentations and constructive criticisms be furnished by each
Society to that submerged one-third who never attend meetings.
It was moved that it be referred to the Reference
Committee on Scientific Business. Seconded and car-
ried.
Dr. F. Hurst Maier, Philadelphia, presented the fol-
lowing in regard to compulsory health insurance :
Resolved. That it is the opinion of the members of the Med-
ical Society of the State of Pennsylvania, that the passage of an
enactment, providing for Compulsory Health Insurance, would
be imposing a heavy and unnecessary financial burden upon
the people of this Commonwealth, would result in inefficient
medical service to industrial workers and would lower the pres-
ent high standards of medical education and practice.
Dr. Krusen moved that it be referred to the Refer-
ence Committee on New Business. Seconded and car-
ried.
The secretary read a communication from the Med-
ical Legislative Conference of Pennsylvania, which
was addressed to the secretary of this Society.
Dr. Baldy moved that it be referred to the Board of
Trustees inasmuch as it iijvolved the expenditure of
money. Seconded and carried.
The communication is as follows :
Resolved, That the SecreUry of the Medical Legislative Con-
ference of Pennsylvania be authorized to write the proper au-
thorities of the Pennsylvania Medical Society, asking for a
contribution from the above mentioned Society, in the sum of
twenty-five hundred dollars, for the use of the Medical Legisla-
tive Conference of Pennsylvania.
The secretary presented the following resolutions,
which were adopted by the Board of Trustees, and
were recommended to the House of Delegates for ap-
proval :
WhIKCas, Under the opinion of the legal counsel of this So-
ciety that portion of Section s. Chapter V of the By-Laws, read-
ing, "It shall further be his duty to organize the machinery for
and conduct the prosecution of illegal practitioners of the heal-
ing art in the Commonwealth," conflicts with the charter rights
and powers of this Society; therefore, be it
Resolved, That the By-Laws be amended by changing that
sentence to read, "It shall further be his duty to organize the
machinery for the investigation of illegal practitionera of the
healing art in the Commonwealth of Pennsylvania."
The following resolution was also adopted by the
Board of Trustees, and is recommended to the House
of Delegates for approval :
B* it Resolved, That the Executive Secretary be authorized
to orjianize the machinery for obtaining evidence against illegal
practitioiurs, and present the same to the Bureau of Medical
Education and Licensure for action as provided by the law of
the Commonwealth of Pennsylvania.
The president stated that as the first resolution was
an amendment to the By-Laws, it would_ lie over for
one day before action could be taken on it.
Regarding the second resolution, Dr. Baldy moved
that it be referred to the Reference Committee on Re-
ports of Officers and Standing Committees. Seconded
and carried.
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OFFICIAL TRANSACTIONS
107
Dr. William H. Mayer, Pittsburgh, asked permis-
sion, which was granted, to prepare and present a
resolution in regard to the Harrison Narcotic Law tax
at a subsequent meeting of the House of Delegates.
As there was no further business to come before the
meeting at this time, Dr. Baldy moved that the House
of Delegates adjourn until eight o'clock this evening.
Seconded.
Dr. Krusen moved to amend that the House of Dele-
gates meet at three p. m. Tuesday.
The amendment was seconded and accepted.
It was further moved to amend that the House of
Delegates adjoiun until nine o'clock this evening.
Seconded.
The amendment to the amendment was put to a vote
and declared lost
The original motion as amended was then put and
carried.
The House of Delegates thereupon adjourned until
the time designated.
CL. Stevens, President:
Walter F. Donaldson, Secretary.
October s, 1920, Tuesday Afternoon — Second
Meeting op the House of Delegates
The House of Delegates met at 3: 15 p.m., and was
called to order by the president, Dr. Henry D. Jump,
Philadelphia.
A quorum being present, the calling of the roll was
dispensed with.
The minutes of the previous meeting were read by
the secretary and approved.
Dr. John M. Thome, Chairman, presented the fol-
lowing report of the Reference Committee on Reports
of Officers and Standing Committees:
The Reference Committee on Officers and Standing
Committees begs leave to submit the following report :
After reviewing the several reports handed to this
committee, we have approved of all of them and
recommend that the suggestions therein contained, be
discussed and acted upon by the House of Delegates.
The suggestions in the main are presented in the
following reports :
1. Report of Secretary : We wish to urge the gen-
eral adoption of the suggestions in the secretary's re-
port pertaining to the increase in membership; to
comment favorably upon work done for medical de-
fense, and to urge the continuation of the campaign
of education in the matter of social insurance — to point
out its dangers to the profession.
2. Report op the Executive Secretary: We en-
dorse the plans of the executive secretary to build up
an executive and publication center in Harrisburg, as
a matter of business efficiency.
3. Report of Trustees: the question of the legal
status of our executive secretary in the role of prose-
cutor of quacks is an important matter considered by
the trustees. We believe that the advice of our legal
counsel should be followed, which will require altera-
tion of our By-Laws, Section 5, concerning the duties
of executive secretary.
We recommend the adoption of the entire report, in-
cluding the adoption of the following resolution :
"Be it Resolved. That the Eneciitive Sfcretary be authorized
to orxanize the machinery for obtaining evidence against illegal
practitioners, and presentin«r the same to the Bureau of Medical
^ucation and Licen^ire for action as provided by the law of
the Commonwealth of Pennsylvania.'*
4. Report op Committee on Public Health Legis-
lation : We approve of the combination of Homeo-
pathic, Eclectic and Regular forces in legislative
matters.
5. The three subsidiary committees, though inactive,
may properly be continued, namely. Committee on De-
fense of Medical Research, Committee on Conserva-
tion of Vision, and Committee on Efficient Laws on
Insanity, the membership of the latter to be increased
by one member.
6. Report of Committee on Society Comity and
Policy: We recommend the adoption by each county
society of a minimum fee bill, as suggested.
7. Report of Committee on Health and Public In-
struction: We recommend the continuation of open
meetings for public instruction, with special work on
the cancer question.
We also recommend enlargement of the Commission
on Cancer, by two members, making a total of seven
members.
8. Report of Committee on Medical Benevolence:
We recommend that this commendable work be con-
tinued.
9. This Committee also wishes to express its ap-
proval and appreciation of the reports of the editor of
the Journal, of the committee representing this So-
ciety at the session of the U. S. Pharmacopeial Asso-
ciation at Washington, and of the Committee on
Archives. We recommend that this latter committee
be given power to act in the matter of procuring and
preserving a complete set of copies of the Pennsyl-
vania Medical Journal.
10. We also approve of the report of the Joint Re-
construction ' Committee. As this committee has ful-
filled its function, we recommend that it be dismissed.
11. We recommend that in reports of Councilors
the use of names or initials be not used in connection
with reports on malpractice suits.
The recommendations of these several committees
merit consideration and adoption by the House of
Delegates.
Respectfully submitted,
(Signed) J. M. Thorne, Chairman ;
J. W. West,
J. L. Lenker.
Dr. Theodore B. Appel, Lancaster, moyed that the
report be received and considered section by section.
Seconded and carried.
Sections I to 11 of the report were read by the chair-
man, and each section, on a separate motion, which
was duly seconded and carried, was adopted.
Dr. Appel moved that the report be adopted as a
whole. Seconded and carried.
Dr. Walter S. Brenlioltz, Chairman of the Commit-
tee on Credentials, made a supplementary report for
this committee, stating that eighty-five delegates had
registered.
Dr. Wilmer Krusen, Chairman of Reference Com-
mittee on Scientific Business, presented the following
report:
Retort op the Reference Committee on Scientific
Business
1. On the resolution from the Pennsylvania State
Department of Health asking for the cooperation of
all County Societies in the plan of collective consulta-
tion prepared by the State Department of Health, your
committee recommends favorable action.
2. The communication from the Pennsylvania For-
estry Department through Dr. J. C. Rothrock, in which
he as a member of a special organization of business
interests of the state for the purpose of "Restoration
of Pennsylvania's Timber Production" represented
our Society, was unanimously approved by your com-
mittee and we recommend the adoption of the resolu-
tion contained therein and urge our executive secre-
tary and Committee on Public Health Legislation to
foster the enabling legislation.
3. The communication from the Ohio State Medical
Society recommending interstate medical reciprocity
was considered by your committee. It is our opinion,
that although we are in sympathy with the general
principles of the reciprocity resolution passed by the
Ohio State Medical Society, we recognize the intrinsic
legal difficulties of enforcing the same except through
moral influence. We therefore do not advise favora-
ble action.
4. Communication from the National Anaesthesia
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108
THE PENNSYLVANIA MEDICAL JOURNAL
November, 1920
Research Society asking for endorsement of an ef-
fort to secure a Section on Anaesthesia in the A. M.
A. Your committee doubts the wisdom or advisa-
bility of increasing the number of sections and reports
against favorable action on this resolution.
(Signed) Wilmer Krusen, Chairman;
Aux. Armstrong,
J. H. WasoN,
Committee.
It was moved that the report be considered section
by section. Seconded and carried.
Sections I to 4 were read, and each section, on a
separate motion, which was duly seconded and carried,
was adopted, although Dr. Henry P. Ashe, of Alle-
gheny County, and Dr. Victor P. Chaapel, Lycoming
County, desired to go on record as voting in the nega-
tive on Section 3.
It was then moved that the report be adopted as a
whole. Seconded and carried.
Dr. Herbert B. Gibby, Chairman of the Reference
Committee on New Business, presented the following
report:
Report of the Reference Committee on New
Business
The Reference Committee on New Business have
carefully considered the various resolutions and com-
munication's referred to this committee, and submit the
following report :
1. We submit the following resolution, which em-
bodies the suggestion of the Council on Health and
Public Instruction of the American Medical Associa-
tion:
Reiolvtd, That the President of the Medical Society of the
State of Pennsylvania appoint a committee of five members to
attend the next meeting of the State Teachers' Association, to
cooperate with the sub-committee on Health Problems of the
American Medical Association in pronding better health condi-
tions in our Public Schools.
2. The resolution in regard to the care and treat-
ment of advanced cases of tuberculosis, is approved
and recommended for adoption, with the exception of
the portion which reads :
"Resolved, That it is the sense of the Medical Society of the
State of Pennsylvania that General Hospitals receiving financial
aid from the state should be requested to set apart a wing or
ward for the reception and treatment of cases of advanced
tuberculosis;" and the addition of the words: "to the State
Commissioner of Health" in the last paragraph, so as to make
that paragraph read as follows:
"Resolved, That a copy of these resolutions be published in
Thx PiEnnsylvania Medical Joukhal, and that a copy be sent
to every General Hospital within the state, to the State Com-
missioner of Health, as well as to Dr. Frederick L. Van Sickle,
the Executive Secretary, with the request that he urge the adop-
tion of their provisions by the Legislature."
3. The National Recruiting Campaign for Student
Nurses, now being inaugurated by the American Red
Cross, in conjunction with the American Nurses As-
sociation, the National League of Nursing Education,
and the National Organization for Public Health
Nursing, is approved, and we offer the following
resolution :
Resolved, That the Medical Society of the Sute of Pennsyl-
vania heartily endorse the effort of the American Red Cross
and the three National Nursing Associations to aid in securing
student nurses for the various Hospital Training Schools of the
State, and that the Secretary be instructed to urge the com-
ponent county societies to actively cooperate in the establishment
in each community represented in the Society, of a Student
Nurse Recruiting Committee, as outlined in the National Plan
for Recruiting Student Nurses, and a copy of this resolution be
forwarded to Charles Scott, Jr., Division Manager of the
Pennsylvania-Delaware Division.
4. The request of the Medical Legislative Confer-
ence of Pennsylvania for a contribution of $2,500.00
from the State Society for the use of the conference,
was referred to this committee and later to the Board
of Trustees. Some members of the board have re-
quested that the House of Delegates indicate their
wishes in this matter.
Sections i to 3 were read, and on separate motions,
which were duly seconded and carried, were adopted.
Section 4 was read, when Dr. J. M. Baldy, Phila-
delphia, moved as a substitute that the House of Dele-
gates recommend 'to the Board of Trustees that they
make an appropriation for the Public Health Legisla-
tion Committee of the Medical Society of the State of
Pennsylvania, to be used by said Public Health Legis-
lation Committee in its activities in conjunction with
the Medical Legislative Conference at Harrisburg. _
The substitute was seconded, accepted, and on being
put to a vote, was adopted.
It was moved that the report be adopted as a whole
as amended. Seconded and carried.
Dr. John D. McLean, Philadelphia, moved that the
secretary note that this action designates the Medical
Legislative Conference as officially recognized by the
Medical Society of the State of Pennsylvania. Sec-
onded and carried.
Dr. Herbert B. Gibby, chairman of the Reference
Committee on New Business, further reported that a
resolution was referred to the committee regarding
the enactment of Compulsory Health Insurance, and
that it was suggested that this resolution be materially
changed. The committee was not ready to report on
this resolution until the next meeting of the House of
Delegates.
No objection being made, the committee was granted
further time.
Dr. John W. Croskey, Philadelphia, presented the
following resolution, which was referred to the Refer-
ence Committee on New Business :
Resolved, That a committee of five be appointed to study the
needs of various localities in the state for hospitals for diagnosis
and treatment and to recommend methods for the establishment
and management of such by groups of physicians in this So-
ciety; that this committee be directed to confer with the Com-
mittee on Society Comity and Policy before making its report;
that this committee be directed to report to the Board of Trus-
tees at its February meeting, and that the Board of Tnutecs
be requested to appropriate $soo for its expenses.
Dr. Charles A. E. Codman, Philadelphia, presented
the following resolution:
Resolved, That the Committee on Archives of ^ the Medical
Society of the State of Pennsylvania work in conjunction with
similar committees of the County Societies, and the data ob-
tained be published in the Journal of the Medical Society of
the State of Pennsylvania, in a series of articles, and subse-
quently be reproduced in a single volume. Seconded by Dr.
Baldy, and carried.
Dr. J. Morton Boice, Philadelphia, after referring
to the report of the Committee on Society Comity and
Polic.v, published in The Pennsylvania Meoical
Journal for September, iczo, and concerning which
the Reference Committee on Reports of Officers and
Standing Committees, made a report on the question
of fee bills, offered a resolution on the subject, which
was seconded.
After discussion, which was participated in by Drs.
Victor P. Chaapel, J. M. Baldy, Jay B. F. Wyant,
Frederick Fisher, Joseph G. Steedle, John D. McLean,
William H. Mayer, Christian B. Longenecker, John W.
West, Secretary Donaldson called attention to the fact
that the House of Delegates had approved the follow-
ing resolution through its proper Reference Commit-
tee, whereupon Dr. Boice withdrew his resolution with
the consent of the seconder.
"Resolved, That the fees charged insurance companies and
employers, individual or corporate, for compensation cases under
the Act of 1915 of Pennsylvania, as amended in 1919, should be
the same as that which the doctor is accustomed to charge for
the treatment of patients in similar circumstances, physical and
financial, in the locality, and that the same spirit of honesty and
fairness which has guided the profession in the past should be
exhibited by the doctors in the present instance."
Dr. J. Morton Boice, Philadelphia, offered the fol-
lowing resolution, which was referred to the Refer-
ence Committee on New Business :
Resolved, That it is the sense of the House of Delegates that
a judicial interpretation of Clause E, Section 306, Article III,
of the Workmen's Compensation Act of 1915 a* athended in
1919, be speedily secured and that^ the executive sccreury be
directed to give what aid lies in his power in the preparation
of or presentation of such a case as may be needed to get such
interpretation.
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109
The secretary read the amendment to Chapter V,
Section S, of the By-Laws, which was introduced at a
previous meeting of the House of Delegates, which
could now be acted on.
Dr. John W. West moved that the amendment be
adopted.' Seconded and carried.
Under "New Business," Drs. Christian B. Loiige-
necker and J. Morton Boice, Philadelphia, offered the
following amendment to Article IV, Section 2, as fol-
lows.
Omit the last paragraph reading as follows :
"The per capita assessment fpr new members elected
and reported during November and December shall
cover the assessment for the following calendar year."
Substitute therefor the following:
"The per capita assessment for new members elected
and reported after July 1st, shall be one-half the
yearly per capita assessment." (To take effect in
1921.)
On motion of Dr. Christian B. Longenecker, which
was duly seconded and carried, the House of Dele-
gates adjourned to meet at 9 a. m., Wednesday, Octo-
ber 6, 1920.
HeNRY D. Jump, President.
Walter F. Donauison, Secretary.
Wednesday, October 6, 1920 — Third Meeting op the
House op Delegates
The Hou$e of Delegates met at 9 : 20 a. m., and was
called to order by President Jump.
Dr. Walter S. Brenholtz, Chairman of the Commit-
tee on Credentials, made a supplementary report, stat-
ing that up to this time one hundred and three dele-
gates had registered and were entitled to seats in the
House of Delegates.
The secretary called the roll.
The president announced a quorum present, and said
the House would proceed with the transaction of its
business.
The minutes of the previous meeting were read by
the secretary and approved.
The first order of business being the election of of-
ficers, nominations for president-elect were called for.
Dr. J. Paul Roebuck nominated Dr. Frank G. Hart-
man, Lancaster, for president-elect.
The nomination was seconded by Dr. John W. West,
Dr. William F. Bacon, and Dr. Spencer M. Free, after
which it was moved that nominations be closed. Sec-
onded and carried.
It was moved that the secretary be instructed to cast
one ballot for the election of Dr. Hartman as presi-
dent-elect. Seconded and carried.
The secretary cast the ballot as instructed, and Dr.
Hartman was declared duly elected.
The chair appointed Dr. Wilmer Krusen a commit-
tee of one to find and escort the president-elect to the
platform.
Dr. Hartman, in accepting the presidency, said :
"You have selected as your president-elect a plain
country physician. How well I am fitted for the honor
you have conferred upon me, or how well I am
equipped to carry out the duties of the office, will re-
main to be seen by the results of the work that I do.
I realize the importance of the task that has been im-
posed upon me. I likewise realize the high standard
of work of those who have preceded me. I know that
I cannot accomplish what has been done in the past
without the assistance of you men who have seen fit to
confer this high honor upon me._ I trust I shall, when
I come to occupy this high station, have the support
of each and every one of you in my efforts to carry
on a successful year. I thank you. (Applause.)
The following officers were nominated, and declared
duly elected :
First Vice President, Harold A. Miller, Pittsburgh;
Second Vice President, Spencer M. Free, Dubois;
Third Vice President, David Funk, Harrisburg;
Fourth Vice President, Anthony F. Myers, Blooming
Glen; Secretary, Walter F. Donaldson, Pittsburgh;
Assistant Secretary, Christian B. Longenecker, Phila-
delphia ; Treasurer, John B. Lowman, Johnstown.
Trustees and Councilors: (Full term),' Jay B. F.
Wyant, Kittanning; Harry W. -Mbertson, Scranton;
and Walter S. Brenholtz, Williamsport, to fill the un-
expired term of Dr. G. Franklin Bell, deceased. _
Delegates to the American Medical Association:
George A. Knowles, Philadelphia; J. B. McAlister,
Harrisburg; C. A. E. Codman, Philadelphia; John D.
McLean, Philadelphia.
Alternates: J. H. Wilson, Beaver; Victor P.
Chaapel, Williamsp<>rt ; _ Edward B. Heckel, Pitts-
burgh ; D. N. Dennis, Erie.
Alternates at Large: Alexander Armstrong, White
Haven; F. C. Stahlman, Charleroi ; T. Lemar Wil-
liams. Mt. Carmel ; Frank P. Lytle, Birdsboro ; Wal-
ter F Donaldson, Pittsburgh, (to fill unexpired term
of Dr. J. H. Wilson, ending in 1921).
Dr. Christian B. Longenecker, Philadelphia, read an
invitation from the Chamber of Commerce of that
city, inviting the Association to hold its next meeting
ill Philadelphii^.
Secretary Donaldson read an invitation from the
Chamber of Commerce of Harrisburg inviting the So-
ciety to hold its 1921 session in that city.
Dr. Longenecker moved that Philadelphia be chosen
as the place of meeting for the 1921 session. Seconded
and carried.
Dr. Herbert B. Gibby, Chairman of the Reference
Committee on New Business, presented the following
supplementary report :
SUPPI.EMENTARY REPORT OP THE REFERENCE COMMITTEE
ON New Business
The following resolutions are approved and recom-
mended for adoption :
Resolved, That the Medical Society of the Sute of Pennsyl-
vania, while deeply interested in all measures that will aid in
solving the problem of providing proper care and treatment for
the sick and injured, especially among the working classes, in
the light of our present knowledge, places itself on record as
opposed to the enactment of a statute providing for Compul-
sory Health Insurance, believing that it would not only fail of
accomplishing the desired end, but would also impose a heavy
and unnecessary financial burden upon the people of this com-
monwealth, and would lower the present high and eflficient
standards of medical service.
Resolved, That it is the sense of the House of Delegates that
a judicial interpretation of Clause E, Section 306, Article III,
of the Workmen's Compensation Act of 1015 as amended in
1919, be speedily secured and that the Board of Trustees
through its executive secretary be directed to give what aid lies
in its power in the preparation of or presentation of such a
case as may be needed to get such interpretation.
Resolved. That a committee of five be appointed to study the
needs of various localities in the state for hospitals for diagnosis
and treatment and to recommend methods for the establishment
and management of such, by groups of physicians in this So-
ciety; that this committee confer witn the Committee on
Society Comity and Policy before making its report; that this
committee be directed to report to the Board of Trustees at
its February meeting; and that the Board of Trustees be re-
quested to appropriate $500 for its expenses.
Resolved, That the House of Delegates hereby expresses its
sincere thanks to both the Allegheny County Medical Society
and the various officers and committees whose hearty coopera-
tion has brought to a most successful issue the seventieth
annual session of the Medical Society of the State of Pennsyl-
vania,
Respectfully submitted,
Herbert B. Gibby, Chairman;
Perley N. Barker,
Frank P, Lytle.
The report of this committee was considered section
by section, and on separate motions, duly seconded and
carried, was adopted.
Dr. Paul J. Pontius, Philadelphia, presented the fol-
lowing :
"It is requested that the Medical Society of the State
of Pennsylvania have introduced at the next session
of the legislature, an act whereby the proper visual
requirements will be demanded of all persons licensed
to drive mechanically propelled vehicles in the Com-
monwealth of Pennsylvania.
Dr. J. M. Baldy, Philadelphia, moved ihat this corn-
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110
THE PENNSYLVANIA MEDICAL JOURNAL
November, 1920
munication be referred to the Reference Committee
on New Business with instructions to take up not only
the question of vision, but all other features concern-
ing it which it might be advisable to introdtKe, in con-
nection with such legislation. Seconded.
Dr. Edward B. Heckel, Pittsburgh, moved as an
amendment that the communication be referred to the
Committee on Public Health Legislation, with power to
act.
The amendment was seconded, accepted, and the
original motion as amended was put to a vote and car-
ried.
Dr. Samuel M. Wolfe, Wilkes-Barre, presented the
following resolution, which was referred to the Refer-
ence Committee on New Business:
"Resolved, That the president is hereby authorized to ap-
point a committee of five to take up with the various state in. -
stitutions the abuses complained of m the resolution introduced
last jrear, and the Board of Trustees be requested to appropriate
suflicient money to carry on this work. (Resolution introduced
last year.)
"WrIeeas, There have been established or taken over by the
state certain hospitals whose distinct purpose was, when
founded, the care of those injured in industrial pursuits; and
"Whcrius, The trustees of these institutions have extended
th^ scope of their operations to take care of all classes of cases
and have accented patients who are abundantly able to pay for
their hospital services as free patients or paying only a small
fee. thus abusing the expenditure of the taxpayers* money,
fostering a spirit of dependency, and coming into direct com-
petition with private and semi.private institutions, depriving
them of a revenue which is largely depended on to help take
care of their charity cases; therefore, be it
"Resolved, That the Medical -l,egislative Conference be re-
quested to consider carefully this matter and take such steps as
may be necessary to correct by legislative action the abuse here-
with cited."
The secretary read the following resolutions, which
were offered by Dr. William H. Mayer, Pittsburgh,
and which were referred to the Reference Committee
on Scientific Business:
"Whexsas, The Harrison I<aw for the control of narcotic
drugs was devised for the furtherance of the public health ; and,
"WHKRCAS, The original tax of one dollar annually levied
upon the members of the medical profession was generally un-
derstood as merely a nominal tax, congress ^being unable to
exercise jurisdiction save through the suoterfuge of a revenue
measure; and,
"Wherius, The recent enactment for the control of narcotic
drugs has increased the tax imposed u|>on the members of the
nicdtcal profession to three dollars; be it
"Resolved, That the Medical Society of the SUte of Penn-
^Ivania hereby protest against the unjust discrimination against
the members of the medical profession in imposing upon them
the financial support of a measure distinctly in the interest of
the public at large, which the general public in true equity
should financially sustain;
"Resolved, That the Medical Society of the Sute of Pennsyl-
vania urges the expeditious removal of this unjust, inequitable
tax by an amendment of the present law, which shall expunge
therefrom the registration fee levied upon the members of the
niedical profession.
"Resolved, That these resolutions be printed in The Pekn-
SYLVAHiA Medicai, Journai. and that copies of these resolutions
be forwarded to the members of the National House of Repre-
sentatives from Pennsylvania, and to the American Medical As-
sociation.
Dr. J. M. Baldy, Philadelphia, offered the following
amendment to Chapter V, Section 5, of the By-Laws:
"and shall be ex -officio a member of this Cbmmittee."
The secretary read an amendment to Article IV,
Section 2, of the By-Laws, offered by Drs. Christian
B. Longenecker and J. Morton Boice, at a previous
meeting of the House, and after considerable discus-
sion, Dr. Longenecker moved as an amendment, which
was accepted, that the amendment become effective
January i, 1921. Seconded and carried.
The amendment as amended was voted on and car-
ried.
Dr. J. Morton Boice, Philadelphia, moved that the
secretary be authorized to investigate the matter of
special railroad rates to and from the meetings of the
Medical Society of the State of Pennsylvania. Sec-
onded and carried.
On motion, which was duly seconded and carried,
the House of Delegates adjourned until i p. m., Thurs-
day, October 7, 1920.
Henry D. Jump, President.
Walter F. Donaldson, Secretary.
October 7, 1920, Thursday Afternoon— Fourth
Meeting op the House of Delegates.
The House of Delegates convened at i : IS P- m.. Dr.
S. M. Free, second vice-president, presiding. Dr. J.
M. Boice was asked to act as secretary pro tem.
The minutes of the previous meeting were read and
iapproved.
Dr. Jefferson H. Wilson, Beaver, a member of the
Reference Committee on Scientific Business, presented
the committee's report in which they recommended the
approval of the resolution urging the removal of the
registration fee ($3.00) levied upon the members of
the medical profession by the Harrison act. A motion
by Dr. H. B. Gibby, Wilkes-Barre, seconded by Dr. T.
R. Currie, Philadelphia, to accept the committee's re-
port prevailed.
Dr. C. L. Stevens, Athens, having called attention to
the fact that there was a vacancy among the alternates-
at-targe to the American Medical Association elected
for 1921, the name of Dr. T. P. Simpson, of Beaver
Falls, was placed in nomination to fill this vacancy.
Upon motion duly seconded, the nominations were
closed and the secretary cast the ballot declaring Dr.
Simpson elected.
A communication from the Genito-Urinary division
of the State Department of Health to Dr. Van Sickle
was upon motion, which prevailed, referred to the
Committee on Public Health Legislation of the State
Society.
The secretary read the following names presented
by component covmty medical societies to the House
of Delegates for its consideration as District Censors :
Adams Coimty, T. C. Miller, Abbottstown ; .Allegheny
County, George W. McNeil, Pittsburgh; Armstrong
Coimty, Albert E. Bower, Ford City; Beaver County,
J. J. Allen, Monaca ; Bedford County, W. P. S. Henry,
Everett; Berks County, C. W. Bachman, Reading;
Blair Cotmty, Joseph D. Findley, Altoona; Bradford
County, Nelson S. Weinberger, Sayre; Bucks County,
James F. Wagner, Bristol; Butler County, J. M.
Dunkle, Butler; Cambria County, Clarence B. Mill-
hoff, Johnstown; Carbon County, Clinton J. Kistler,
Lehighton ; Center County, C. S. Musser, Aarons-
burg; Chester County, Charles E. Woodward, West
Chester; Clarion County, Joseph Aaronoff, Shippens-
ville; Clearfield County, W. W. Andrews, Phillips-
burg; Clinton County, John M. Dumm, Mackeyville;
Columbia County, Luther B. Kline, Catawissa ; Craw-
ford County, M. B. Best, Meadville; Cumberland
Coimty, H. A. Spangler, Carlisle; Dauphin County, J.
Wesley Ellenberger, Harrisburg; Delaware County,
J. C. Starbuck, Media ; Elk County, Augustus C. Luhr,
St. Marys ; Erie County, J. W. Wright, Erie ; Fayette
County, J. S. Hackney, Uniontown ; Franklin County,
L. M. Kauffman, Chambersburg ; Greene County, T.
B. Hill, Waynesburg; Huntington County, John M.
Keichline, Jr., Petersburg; Indiana County, W. B.
Ansley, Saltsburg; Jefferson Coimty, John H. Mur-
ray, Punxsutawney ; Juniata County, Benjamin H.
Ritter, McCoysville; Lackawanna County, Fred J.
Bishop, Scranton; Lancaster County, Walter J. Lea-
man, Lancaster; Lawrence County, R. G. Miles, New
Castle; Lebanon County, William M. Guilford, Leb-
anon; Lehigh County, George F. Seiberling, Allen-
town ; Luzerne County, C. W. Prevost, Pittston ;
Lycoming County, Edward Lyon, Williamsport ; Mc-
Kean County, B. H. Hall, Bradford; Mercer County,
F. M. Gleakney, Grove City; Mifflin County, F. A.
Rupp, Lewistown ; Monroe County, Alvine A. Wert-
man, Tannersville ; Montgomery County, William
McKenzie, Conshohocken ; Montour County, R. S.
Patten, Danville; Northampton County, William L.
Estes, Jr., South Bethlehem ; Northumberland County,
L. M. Holt, Shamokin; Perry County, A. Russell
Johnston, New Bloom field ; Philadelphia County, M.
B. Hartzell, Philadelphia; Potter County, Nathan W.
Church, Ulysses; Schuylkill County, Christian Gruh-
ler, Shenandoah; Snyder County, G. E. Hassinger,
Middleburg ; Somerset County, Bruce Lichty. Meyers-
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OFFICIAL TRANSACTIONS
111
dale; Sullivan County, J. L. Christian, Lopez; Sus-
quehanna County, George W. Newman, Birchardville ;
Tioga County, S. P. Hakes, Tioga; Union County,
Oliver W. H. Glover, Laurelton; Venango County,
George B. Jobson, Franklin ; Warren County, George
T. Pryor, Sheffield ; Washington County, J. W. Hun-
ter, Charleroi; Wayne County, Harry B. Ely, Hones-
dale ; Westmoreland County, L. B. R. Smith, Jeanette ;
Wyoming County, George M. Kinner, North Mehoop-
any; York County, William F. Bacon, York. They
were upon motion declared elected.
Chairman H. B. Gibby, Wilkes-Barre, for the Refer-
ence Committee on New Business, recommended that
the resolution regarding State Hospitals and the ap-
pointment by the president of a committee of five to
study same be approved. Upon prevailing motion by
Dr. Gibby, seconded by Dr. J. W. West, Philadelphia,
the report of the committee was adopted.
A motion by Dr. C. L. Stevens that the president
and secretary be empowered to furnish credentials to
members as delegates to sister societies was seconded
by Dr. V. P. Chaapel, Williamsport, and carried.
Under new business the following announcement
presented by Dr. Theodore Diller, Pittsburgh, was re-
ceived and on motion ordered published in the Jour-
nal:
"Governor Sproul has appointed a commission to
revise and codify the laws . relating to the insane and
feeble-minded. The personnel of the commission is as
follows : Honorable Isaac Johnson, Media ; Dr. Owen
Copp, Philadelphia ; Dr. Theodore Diller, Pittsburgh ;
Dr. D. C. Herr, Harrisburg ; and Dr. Charles Frazier,
Philadelphia.
"The commission is actively at work at its task.
Between now and January it expects to hold some pub-
lic hearings.
"In the meantime,- any member of the State Society
who has any suggestions to offer regarding our law
relating to the insane or feeble-minded, is invited to
write to the secretary. Dr. Charles Frazier, 1724
Spruce Street, Philadelphia, with the assurance that
his communication will receive careful attention."
Dr. J. M. Baldy, Philadelphia, called for action upon
the amendment to the By-Laws, Chapter V, Section 5,
presented on Wednesday. It was moved by Dr. West,
seconded by Dr. Chaapel, that the amendment which
reads as follows "and shall be ex-officio a member of
this committee" be adopted. Carried.
On motion, the 1920 House of Delegates adjourned
sine die.
S. M. Free, President pro tern.
Walter F. Donaldson, Secretary.
MEMBERS OF THE HOUSE OF DELEGATES
ANSWERING ROLL CALL
Allegheny County Society — ^John J. Buchanan, presi-
dent; Edward B. Heckel, Samuel Ayres, Stewart L.
McCurdy, Adolph Koenig, John Purman, Clement R.
Jones, I. Hope Alexander, Henry P. Ashe, John G.
Burke, John A. Hawkins, Joseph G. Steedle, Jojin M.
Thome.
Armstrong County Society— Jay B. F. Wyant, sec-
retary; Thomas N. McKee.
Beaver County Society — Walter H. Herriott, presi-
•dent ; Jefferson H. Wilson.
Bedford County Society— William C. Miller, presi-
•dent ; Harry I. .Shoenthal.
Berks County Society— Frank P. Lytle.
Blair County Society— Albert S. Oburn.
Bradford County Society — Cyrus Lee Stevens, sec-
retary; Perley N. Barker.
Bucks County Society — Anthony F. Myers, secre-
tary; James F. Wagner.
Cambria County Society — Harry M. Stewart, presi-
dent; Guy R. Anderson.
Carbon County Society — ^Jacob A. Trexler, secre-
tary; Alexander Armstrong.
Center County Society— Peter H. Dale.
Chester County Society — ^W. Wellington Woodward,
president; Lanan T. Bremerman.
Clarion County Society — ^Joseph Aaronoff.
■ Clearfield County Society — John M. Quigley, secre-
tary; J. Paul Frantz.
Clinton County Society — ^John B. Critchfield.
Cumberland County Society — J. Bruce McCreary.
Dauphin County Society — Hewett C. Myers, presi-
dent; J. Wesley Ellenberger, Jesse L. Lenker.
Delaware County Society — C. Irvin Stiteler.
Elk County Society — Andrew L. Benson, secretary.
Erie County Society — Katherine H. Law-Wright,
president; Fred Fisher.
Fayette Coimty Society — Robert H. Jeffrey, George
Robinson.
Franklin County Society — Samuel ShuU, James H.
Swan.
Huntingdon County Society — John M. Keichjine, Jr.
Indiana County Society — Frank F. Moore, president.
Jefferson County Society — Spencer M. Free.
Juniata County Society — Benjamin H. Ritter.
Lackawanna County Society — Arthur E. Davis,
president ; Leo P. Gibbons, John J. Price.
Lancaster County Society — Horace C. Kinzer, sec-
. retary ; J. Paul Roebuck, Samuel W. Miller.
Lawrence County Society — William L. Steen.
Lebanon County Society — W. Horace Means.
Luzerne County Society — Herbert B. Gibby, presi-
dent; Charles L. Shafer, Lewis Edwards, Samuel M.
Wolfe.
Lycoming County Society — Victor P. Chaapel, presi-
dent; Walter S. Brenholtz, Harry J. Donaldson.
Mercer County Societv — Frank M. Bleakney, presi-
dent; M. Edith MacBride.
Mifflin County Society — ^J. A. C. Clarkson, secretary ;
Benjamin R. Kohler, Reedsville.
Montgomery County Society — Edgar S. Buyers, sec-
retary ; Herbert A. Bostock.
Montour County Society — Robert A. Keilty.
Northampton County Society — Paul H. Kleinhans,
secretary; Paul H. Walter, William L. Estes.
Northumberland County Society — Clay H; Weimer.
Philadelphia County Society — ^J. Morton Boice, sec-
retary; John D. McLean, J. Montgomery Baldy, F.
Hurst Maier, John W. West, Harriet L. Hartley, C. B.
Longenecker, Addinell Hewson, Paul B. Cassidy, Meyer
Solis Cohen, William A. Steel, John Welsh Croskey,
Thomas R. Currie, J. Allen Jackson, D. Randall Mac-
Carroll, Wilmer Kruseu, Arthur C. Morgan, William
S. Newcomet, Paul J. Pontius, Seth Brumm, Charles
A. Codman.
Schuylkill County Society — Arthur B. Fleming,
Charles D. Miller.
Tioga County Society — Silas D. Molyneux.
Union County Society — Oliver W. H. Glover.
Venango County Society — John F. Davis.
Warren County Society — George T. Pryor.
Washington County Society — Frederick C. Stahl-
man, president ; Charles B. Wood, W. D. Martin.
Westmoreland County Society — John S. Anderson,
Charles E. Taylor.
Wyoming County Society — William W. Lazarus,
president.
York County Society — William F. Bacon.
GENERAL MEETING. TUESDAY, OCTOBER 5,
1920
The Seventieth Annual Session of the Medical So-
ciety of the State of Pennsylvania was called to order
in general meeting at 10 : 20 a. m., Tuesday, October S,
1920, in the ballroom of the William Penn Hotel,
Pittsburgh, by the president. Dr. Cyrus L. Stevens, of
Athens.
President Stevens invited the ex-presidents and vice-
presidents present to the platform.
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THE PENNSYLVANIA MEDICAL JOURNAL November. 1920
Prayer by Reverend Maitland Alexander, Pastor
First Presbyterian Church, Pittsburgh.
Almighty, who hast declared Thyself to be the light
and life of man, we ask that Thy blessing may rest
upon this organization which has gathered together here
to-day, that all the Hght of the knowledge which Thou
possessest may be turned toward the life of man. We
beseech Thee that they may be given such wisdom
throughout this profession throughout the world that
those diseases which have defied the knowledge and
the power of man may be conquered. Grant, we be-
seech Thee, that there may be raised up or may be con-
tributed that which is necessary for all research, and
that the time may come when the power of evil as
manifested in disease may be conquered and when
there may be that glory given to Thee, the source of
all wisdom, because of Thy blessing. Grant that these
deliberations may be done in honor of Thy name
through Jesus Christ our Lord. Amen.
Presentation of Ga.vel to Retiring President
Stevens by Dr. William L. Estes,
South Bethlehem
President Stevens, I have been commissioned at the
last moment to act for this Society in presenting this
token of affection from this organization which we'
who have been so long working with you feel toward
you. I trust, Mr. President, that in using this gavel,
which we present to you in the name of this Society,
you will regard that authority given you with greatest
affection, esteem and honor, and we feel honored in
showing how much we honor our President.
President Stevens: Dr. Estes, it is peculiarly
pleasing to me to have you represent the Board of
Trustees. Our associations have been pleasant. More
and more I have learned to appreciate the honor and
the pleasure of serving this organization. This gavel is
accepted as a token of the respect ever shown to the
individual who is so fortunate as to be selected as the
President of this honorable body. Whatever the So-
ciety may have accomplished during last year has been
due largely to the systematic efforts of Secretary
Donaldson, the faithful efforts of Dr. Van Sickle and
the watchful care of the Board of Trustees. We had
already learned to appreciate the ability of Secretary
Donaldson. For the last eight months we have had
the full time services of an Executive Secretary, and
moreover the Trustees and Councilors have given very
faithful attention to the work of the Society. This
beautiful memento is accepted; for it, for the many
courtesies and for the active support of our officers
and members I am truly thankful.
Address op Welcome
Edward Vose Babcock, Mayor, Pittsburgh: Mr.
President, Ladies and Gentlemen: I am very pleased
indeed to be in your midst this morning and have any
part of this function to perform. I am grateful for
the opportunity as the Mayor of this city to comply
with the request of your Committee and come here
and bid you a welcome this morning. I am used to
addressing conventions that come to Pittsburgh, but I
must confess an embarrassment this morning in com-
ing here without study and preparation to say a word
to this body of distinguished educators, uplifters and
helpers of mankind, the doctors of Pennsylvania.
You did well in selecting Pittsburgh as your con-
vention city. We are proud of Pittsburgh, we know
her, we hope you know her as well. She stands out
conspicuously ainong the list of cities of the entire
world. Many cities have a greater population and
lead us in the number of persons in the city, but no
city in the world leads us when it comes to doing
things. I say that you did well in selecting her as
your convention city and I am proud and happy to
give you a welcome in our midst. Whatever your
committee does not do I, as Mayor, will command the
officials of the city to do, to see that you have a rich,
warm welcome and a happy stay, in our midst. I say
that because I know your committee has done its part,
but anything they fail in, command us, and we will see
that it is well done.
I see a good many ladies here, I do not know
whether they are the wives of the doctors and dele-
gates here, or are themselves delegates, but it matters
not to me. Ladies, turn your men loose in Pittsburgh
and let them go as far as they will. They are abso-
lutely safe. I noticed this convention was opened with
prayer and to prove my statement that they are safe
here I can go back a few years to conventions opened
in Pittsburgh, they were opened with a corkscrew,
while now they are opened with prayer.
I am glad to be here because I have a wholesome
respect for your organization, your profession. You
are so necessary to mankind, you have a real serv-
ice to humanity to perform and it is a pleasure
to be associated with you in any kind of a way. I
admire, too, and respect this team work that you doc-
tors have. We see it on all hands. Only yesterday I
was in a doctor's office and I was accusing him of
robbing me in the charges to my family. He replied,
"Oh no. Mayor, I didn't rob you. You want to go to
a mental specialist." He was passing the buck so the
other fellow could get a whack at me, too. I love your
team work, you are doing well. You go to one doctor
with some ailment, by the time you get through and
find out what is the matter you have been through the
whole category of experts. Fine team work I How-
ever, it is part of the profession, we need them all.
The study of anatomy is something that appeals to us
laymen as necessary and we depend upon you to do it
I suppose we are all ready and anxious to pay you for
doing it, too. I notice on your program all the dignita-
ries of the state, all the medical tights that I ever heard
of and a lot I never had heard of before, and they even
went outside of the medical profession and brought the
heads of the State Departments, Dr. Finegan, head of
one of the most potent parts of the State Government
So I excuse myself for trying to make an address to
you. I want you to have a good time in Pittsburgh
and I want the welcome I am extending you on the
part of Pittsburgh to be real and sincere. I want
everything that Pittsburgh has to give to anybody to
be extended to you, and when I say everything that
Pittsburgh has, I say that we have everything that any
city in the land has to extend to you. Our educational
activities, religious activities, industrial activities all
down the line are yours. Partake of them any way you
can. We will see that you are safe in Pittsburgh.
The police department will be authorized to watch
every one of you and see that you do not go wrong. I
myself have not the time to be on the street comers
and see what you are doing and I do not know that
the Director of Public Safety or the Chief of Police
will have time, but to make sure that you are safe-
guarded in our midst, both ladies and men, I have
here courtesy cards of the Police Department is-
sued to your officers. Dr. Stevens, Dr. EUenberger
and Dr. Jump. That name Jump makes me think of
a story I heard once. A man was standing on the
street comer and he was exceedingly bow legged, a
man watched him for a while and came up to him and
said, "For heaven's sake, jump." Now I am going to
say to your President, Dr. Jump, to go ahead and
jump. I now clothe him with all the authority of the
Police Department of the great city of Pittsburgh, to-
take care of you in . everything you want to do while
in our city. If you are not entertained and your safety
looked after it will be the fault of your officers, for 1
now appoint them Assistant Directors of the City of
Pittsburgh and hereby clothe them with alt the au-
thority of the City of Pittsburgh. Now ladies and
gentlemen, in all seriousness if there is anything the
city can do for you let your wants be known.
I hope that your stay in Pittsburgh will be profitable,,
that you will go away enlightened, you will go away
entertained. "That when you leave our city — a city
that we love as life itself, a good city, a real city
among cities — ^you will take away from us^with yotu a.
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OFFICIAL TRANSACTIONS
113
small percentage of the affection and regard for the
city of Pittsburgh and her great people that we home
folks have. Welcome, thrice welcome to our midst I
Address of Wei.come
Dr. John J. Buchanan, Pittsburgh, President of
the Allegheny County Medical Society:
Mr. President, Ladies and Gentlemen: Members of
the Medical Society of the State of Pennsylvania:
I have been asked by the Committee of Arrange-
ments to say a few words of welcome to you in behalf
of the Allegheny County Medical Society.
I am deeply grateful to the committee for giving me
the opportunity to tell you how much the members of
our Society appreciate your attendance at this meeting.
I have some hesitation in following the mayor of
our city, whose eloquent address of welcome you have
just heard. The hospitality which he has extended to
you is part of his daily life, not only in his capacity as
head of this great city, but also as a private citizen.
When he says you are welcome, I say you have the
keys of the city in your hands.
When I scan the magnificient program of this ses-
sion, prepared for your entertainment and instruction
by men who have no superiors in the profession of
medicine, and when I compare it with the program of
an earlier meeting of which I shall speak, I am
astounded at the advance of scientific medicine.
If you will bear with me a moment I would like to
recall the first meeting of this Society that I ever at-
tended. It was held in this city the year I began the
study of medicine.
The meetings were held in the auditorium of what
was then called "Library Hall."
When I name but a few of the great men who at-
tended that meeting, I am sure you will exclaim with
me that "There were giants in those days" : D. Hayes
Agnew, Samuel W. Gross, William Pepper, Charles
T. Hunter, William Goodell, William S. Foster, Hora-
tio Wood, James McCann, A. M. Pollock, John Dick-
son, William H. Daly, Traill Green. With one ex-
ception all have gone to their reward.
I was then a medical student and had not attended
even my first course of lectures, but with what en-
thusiasm I listened to the papers read at that meeting
and with what veneration I gazed on those leaders of
the profession.
In those days there were no motors cars, no electric
cars ; even the cable car had not yet made its appear-
ance.
Every ordinary physician had his one-horse buggy.
If his practice was unusually large, he drove two
horses, while the extremely prosperous men who could;
be counted on the fingers of one hand, had their closed
carriages with drivers to attend.
In such vehicles, the visiting members were trans-
ported to the various points of interest* in the city.
These did not include the present system of parks, the
suburban districts, the Public Libraries, Art Galleries,
University Buildings, Technological School, Conserva-
tories, modern hospitals and the many other objects
of interest to which we now give you the most cordial
welcome.
There is doubtless within reach of my voice a med-
ical student who will in years to come look back at
this meeting as his first and say :
"Then for the first time I Vheld Edward Martin,
Charles H. Frazier, John B. Deaver, John B. Roberts
and William L. Estes, men who loomed large in the
medical history of their time. This young n)?Hi .wh^en
he grrows old, will say as I have said: ^herc were-
giants in those days."
I sincerely Ijope that before any of you leave this
city you will ascend to Duquesne Heights by the lower
incline plane. You will there see the convergence of
the Allegheny and Monongahela Rivers t{), forni,4K
Ohio. . ^ ;.. , ,') <)viiuo':y.3. ">..".
Down the, valley of 4he/Alleg.b^j^ cjy^'>vPelipr9i^
planting his lead plates at intervals to claim this en-
tire country for the king of France.
Just a few miles up the Monongahela was the ford
crossed by Braddock's army in that ill-fated expedition
in which he lost nearly his whole army and also lost
his life.
You will look down the Ohio and almost see the
site of Logtown, the Indians' village from which war
parties set out to ravage this and the western settle-
ments.
And all this was not much more than a hundred
and fifty years ago 1
I will detain you no longer with reminiscences of
the past, but will extend again a hearty welcome to
Pittsburgh and express the earnest desire of the pro-
fession of Allegheny County that every one of you
honor us by remaining throughout the week to attend
the scientific sessions and public meeting of the Penn-
sylvania Section of the Clinical Congress of Surgeons.^
You may be assured that we will all do our very'
best to make it interesting to you and creditable to the
surgeons of this community.
Presentation at Program
Dr. John F. Culp, Harrisburg, Chairman of the
Committee on Scientific Work : Mr. President, Ladies
and Gentlemen: I simply have a few words to say in
reference to this program, it has been prepared with
the usual care. We will have the ustial meetings in
the Genial Section and special sections on Medicine,
Surgery, Eye, Ear, Nose and Throat, and Pediatrics.
There will be three sessions of the General and three
sessions of the Sections, one each day. I am sure you
will find in this program something of interest to each
and every one of you. In reference to the last day of
the General program I would say that we made a de-
parture this year and we will have our meeting with
the Interstate Association of Anaesthetists and also the
National Anaesthesia Research Society. I am sure that
those of you who can will find something of great in-
terest in this joint meeting.
Announcement op Entertainments
Dr. Harold A. Miller, Pittsburgh: In behalf of
the Allegheny County Medical Society I wish to ex-
tend to you and hope that you will avail yourselves of
the opportunities that we are going to offer for a so-
cial time. At 1 : 30 the ladies will be taken for an
automobile ride through the residence section of Pitts-
■ burgh, leaving the city at the east side for the Oakmont
Country Club, where they will have tea at 4 p. m.
and return to the city this evening in time for dinner.
After dinner they will be our guests at the Nixon
theatre. The tickets will be given to all the ladies,
wives and daughters of those who have registered as
members of the Pennsylvania State Medical Society.
The tickets are in the hands of Dr. Walter Donaldson
and application to him for a ticket will be promptly
complied with.
To-morrow, Wednesday, there will be an automobile
trip to the Allegheny Country Club, at Sewickley, Pa.
That takes you through the southern and western resi-
dence sections. Tea will be served there. The party
will leave the William Penn hotel promptly at 2 p. m.
At 9 p.m. the President's Reception will be given at
the William Penn Hotel.
On Thursday, feeling something distinctive should
be done in showing you part of our city, ladies will be
taken to the Duquesne Steel Works, leaving the Wil-
liam Penn hotel at I p. m. Tea will be served at the
mills. The gentlemen at 9 o'clock will be the guests
of the Allegheny County Medical Society at a Smoker
to be held in this hotel as near as we can get to the old
barroom. We cap all see it and mourn its passing.
Those of you who wish to play golf and can arrange
little foursomes, it will be a great privilege to give you
the opporliunity. We cannot have a regular tourna-
mjsnt bec^i^. you are here primarily to. attend the
sci^jfic; ipee^g^, but those who wish to remain over.
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THE PENNSYLVANIA MEDICAL JOURNAL November, 1920
it will give us great pleasure to give you the oppor-
tunity. Thank you I
President Stevens introduced and extended the privi-
leges of the floor to the following accredited delegates
to this meeting: Dr. W. H. Donaldson, from the
Connecticut State Medical Society; and Dr. F. E.
Stewart, Philadelphia, and Messrs. Richard H. Lackey,
Philadelphia, and Oliver F. Wolfe, Pittsburgh, from
the Pennsylvania Pharmaceutical Association. He
also called for remarks from Secretary A. R. Craig
of the American Medical Association.
Dr. Alexander R. Craig, Secretary of the American
Medical Association, Chicago : Mr. President and Fel-
low Members ai the Medical Societies of the Counties
of Pennsylvania, of the American Medical Association
and the guests of this State Society: Someone
said this was so sudden. It is to me in a way. I want
to make a trifling correction, that may not go on the
.record. My old and esteemed friend, the president of
this Association, ought to remember a trite joke that
my good father used to have. His name, too, was
Alexander Craig. He always said I was Alexander
Righter Craig and I always had to be a little bigger
than he. I do not think I have succeeded in this
mentally, physically or morally. Be that as it may,
I always have a peculiar feeling in attending the meet-
ings of the Medical Society of the State of Pennsyl-
vania, it is like going home. When I go to other
State Associations I go to try to get team work, and
that is part of my object in coming to you, but there
is a imique, peculiar feeling of homeliness and of
hominess where I meet so many of you who have
wound yourselves so intimately into the affections
which make up life. I have nothing particularly new
to say to . you, but perhaps I may try to emphasize
after the old method of teaching of line upon line and
precept upon precept something that is very dear to
the heart of those of us who are trying to devote our
lives to the uplift of the medical profession of the
country, and I want you to feel that one of the ideals
of the medical profession that must be emphasized
particularly at this time is that our profession is pri-
marily one of service; that fee and reward, while
important, must be secondary; and that that service
may be what it should be to the public, is the province
of the American Medical Association, of its component
State Associations, its component county societies.
Primarily our purpose is making better doctors of us
all. The great fundamental purpose of the American
Medical Association is to bring together and to make -
one, all branches and specialties of the profession.
Let us say God speed to everything that develops any
particular specialty, but let us emphasize with all our
being and all the power we have that first of all we
are doctors and then specialists. I thank you for your
welcome and I know this meeting is to be a success..
Installation op President Jump
Retiring President Stevens: Members of the
Medical Society of the State of_ Pennsylvania : In
bringing to a close my official relations with you it is a
peculiar pleasure to introduce to you my friend, your
President, Dr. Henry D. Jump, of Philadelphia.
Dr. Henry D. Jump, Philadelphia: Mr. President,
Ladies and Gentlemen: I have particularly appre-
ciated the welcome which the mayor of the city has
extended to us. I have more particularly appreciated
being clothed with authority and office on his part, for
while I feel that it is not necessary that anybody shall
watch over my behaviour, I have known Dr. Stevens
and Dr. Ellenberger long enough to feel that they ought
to be watched, and as an assistant director — I have
been constituted to-day — of public safety I shall make
it my business to see that they shall not belong to the
Joint Reconstruction Committee of our House of
Delegates. I appreciate most deeply the honor which
you conferred upon me last year when you made me
president of your Society. (Dr. Jump then proceeded
to read his Presidential Address. See page i, October,
1920, Journal.)
MINUTES OF THE SECTION ON MEDICINE
Tuesday, October 5, 1920
The meeting was called to order by the chairman.
Dr. M. Howard Fussell. Dr. Howard G. Schleiter.
secretary.
Opening address was delivered by Chairman Fussell.
A paper on "Practical Points in Heart Diagnosis"
was delivered by Dr. S. Calvin Smith, Philadelphia.
Discussion on the above paper was opened by Dr.
William H. Mercur, Pittsburgh, Pa. The same paper
was afso discussed by Dr. Samuel Stalberg, Glen
Richey, Clearfield County, Pa., and the discussion
closed by Dr. S. Calvin Smith.
A paper on "Errors and Oversight in the Use of
the Blood Pressure Apparatus" was delivered by Dr.
Gordon E. Hein, of Pittsburgh, Pa.
Discussion of the above paper was opened by Dr.
Andrew P. D'zmura, Pittsburgh, Pa., and closed by
a few remarks from Dr. Hein.
A paper on "Transient Auricular Fibrillation" was
delivered by Dr. James D. Heard, Pittsburgh, Pa.
Discussion on the above paper was opened by Dr.
Howard G. Schleiter, Pittsburgh, Pa., followed by Dr.
Irwin J. Moyer, Pittsburgh, Pa.
Dr. Moyer introduced Dr. Alex Wedd, of the Ohio
State Medical Society, who also discussed the paper
by D^. Heard.
Dr. Arthur C. Morgan, Philadelphia, discussed Dr.
Heard's paper, after which the discussion was closed
by Dr. Heard.
Dr. Joseph H. Barach, Pittsburgh, Pa., delivered a
paper on "Nocturia."
A paper on "Pericarditis" was delivered by Dr.
George E. Holtzapple, York, Pa., and discussion on
the same by Dr. Arthur C. Morgan, Philadelphia, Pa.
A paper on "Some Suggestions for the Treatment
of Thyrotoxicosis" was delivered by Dr. Frederick B.
Utlcy, Pittsburgh, Pa.
Discussion on the above paper was opened by Dr.
Lawrence Litchfield, Pittsburgh, Pa., followed by Dr.
Utley, in closing.
_ In announcing the next paper, "A Method of Dis-
tinguishing from Among Various Micro-Organisms
Present in a Patient Those That are and Those That
are Not Acted on by that Patient's Whole Blood," by
Dr. Myer Solis-Cohen, Philadelphia, and Dr. George
D. Heist, Philadelphia, the chairman said:
I am reminded by the names of the writers of the
paper that the president has the melancholy duty to
tell the Society that Dr. George D. Heist died during
the last few weeks of an infectious disease. He was a
very valuable man to the Society and to the medical
profession; a man who has done great work, par-
ticularly in the bacteriological field.
The above paper was delivered by the co-author. Dr.
Myer Solis-Cohen, Philadelphia, Pa.
The meeting adjourned until Wednesday, October
6th, at 2 p. m.
Wednesday, October 6, 1920, 2 : 00 p. m.
After calling the meeting to order, the chairman an-
nounced the first business was to receive the report
of the Executive Committee. .
Dr. Irwin J. Moyer, chairman of the Executive
Committee, asked on behalf of_ the committee for a
few minutes time to prepare their report.
A paper on "Constitution and Disease" with lantern
demonstration was delivered by Dr. George Draper,
New York.
The above paper was discussed by Dr. Joseph Sailer,
Philadelphia.
The Executive Committee, by its chairman, Dr. Ir-
win J. Moyer, reported its recommendation of the
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November, 1920
OFFICIAL TRANSACTIONS
115
nomination of the following gentlemen for chairman
and secretary of the Section :
For Chairman, Dr. Howard G. Schleiter, Pittsburgh,
Pa.
For Secretary, Dr. J. G. Beardsley, Philadelphia, Pa.
On motion regularly made and seconded, the secre-
tary was instructed to cast the ballot for the above-
named nominees, who were then declared elected.
A paper on "The Effect of the Influenza Epidemic
on Tuberculosis" was delivered by Dr. Charles H.
Marcy, Pittsburgh, Pa.
A paper on "Postinfluenzal Chest" was delivered by
Dr. Arthur C. Morgan, Philadelphia, Pa.
Discussion of the above two papers was opened by
Dr. George M. Piersol, Philadelphia, Pa., followed by
Dr. Joseph Sailer, Philadelphia; I>r. A. J. Simpson,
Chester, Pa.; Dr. J. W. Boyce, Pittsburgh, Pa., and
Dr. Henry R. M. Landis, Philadelphia, Pa.
A paper on "Ejid Results of Sanatorium Treatment
for Tuberculosis" was delivered by Dr. Henry R. M.
Landis, PUladelphia, Pa.
A paper on "Psycho-Therapy of Tuberculosis" was
delivered by Dr. Henry K. Neale, Upper Lehigh, Pa.
Dr. John A. Lichty, Pittsburgh, Pa., discussed the
above two papers.
A paper on "Gastric Disease in Relation to the
Glands of Internal Secretion" was delivered by Dr.
Truman G. Schnabcl, Philadelphia, Pa. Discussion on
the above paper was opened by Dr. John A. Lichty,
Pittsburgh, Pa., followed by Dr. John J. Gilbride,
Philadelphia, Pa.
A paper on "The Analysis of Chronic Gastritis"
with lantern demonstration was delivered by Dr. Mar-
tin £. Rehfuss, Philadelphia, Pa.
Discussion of the above paper was given by Dr.
Joseph Sailer, Philadelphia, Pa.
A paper on "The Diagnosis of the Functional Ca-
pacity of the Kidneys in the Various Types and Stages
of Nephritis" was delivered by Dr. Roy R. Snowden,
Pittsburgh, Pa.
A paper on "Some Aspects of the Plague Question"
was delivered by Dr. Edward B. Krumbhaar, Philadel-
phia, Pa.
The above paper was discussed by Dr. Edward Mar-
tin, Commissioner of Health, and closed by Dr.
Krumbhaar.
The meeting adjourned until Thursday, October ^th,
at 9 : oo a. m.
Thursday, October 7. 1920, 9: 00 a. m.
The meeting was called to order by Chairman Fus-
sell.
A paper on "Encephalitis Lethargica" was delivered
by Dr. Daniel J. McCarthy, Philadelphia, Pa.
A paper on "An Analysis of the Mental Symptoms
Associated with Epidemic Encephalitis" was delivered
by Dr. ComeUus C Wholey, Pittsburgh, Pa.
A paper on "Autopsy Findings in Six Cases of Acute
Encephalitis" was delivered by Dr. William W. G.
Madachlan, Pittsburgh, Pa.
'Discussion of the three preceding papers was opened
by Dr. Max H. Weinberg, Pittsburgh, Pa., followed
by Dr. George J. Wright, Pittsburgh, Pa. ; Dr. George
E. Holtzapple, York, Pa.; Dr. John A. Lichty, Pitts-
burgh, Pa., and closed by Drs. Wholey and Maclachlan.
A paper on "Observations on the Treatment of
Tabes" was delivered by Dr. George J. Wright, Pitts-
burgh, Pa.
A paper on "Apoplexy" was delivered by Dr. Charles
S. Potts, Philadelphia.
A paper on "Meningococcic Infection" w-ith lantern
demonstrations was delivered by Dr. William W. Her-
rick, New York.
The above paper was discussed by Dr. Myer Solis-
Cohen, Philadelphia, and Dr. Lawrence Litchfield,
Pittsburgh, Pa.
Chairman Fusseu. : In closing this session the of-
ficers wish to thank the members and the speakers for
what we believe to be the unusual success of this
meeting. It is not often that we see so large an
audience for the last paper and the last discussion. To
Dr. Schleiter is due much of the greatness of the suc-
cess.
The meeting adjourned.
members registered in section on medicine
Allegheny County Society— H. M. Hall, Adah (Fay-
ette County) ; W. J. McGeary, Allison Park ; W. N.
Marshall, W. F. Ross, Aspinwall; A. H. Elliott, J. C.
Gamble, J. S. Kelso, Avalon; J. S. Donaldson, T. A.
Miller, D. W. Seville, J. C. Welch, Bellevue; J. C.
Nicholls, J. Zeok, Braddock; H. G. Clark, Bridgeville;
J. C. Caldwell, Butler (Butler County) ; L. L. Brown,
H. H. Permar, Castle Shannon; F. R. Braden, E. M.
Hand, H. B. Speer, Coraopolis; H. P. Crawford, J. S.
Morgan, C. A. Orr, E. E. Taylor, Crafton; A. C.
Davis, Creighton; W. T. Hall, Dixmont; R. D. Good-
win, A. R. Trevaskis, East Pittsburgh; J. L. McBride,
Emsworth; H. H. Rittenhouse, Federal; E. L. Er-
hard, Glassport; L. C. Fausold, W. W. Sturgis, Glen-
shaw; W. Witherspoon, Harmarville; J. L. Foster,
Hoboken ; H. D. Cassett, W. E. Lawson, O. B. Stein-
metz. Homestead; E. B. Henry, Ingomar; L. C. Bot-
kin, J. S. Crawford, W. C. Wallace, Ingram; H. S.
Ballard, C. W. Cowan, A. A. Guffey, J. F. Haben, R.
S. Hinchman, J. Read, A. R. Snedden, F. G. Unger-
man, McKeesport; G. S. Bubb, C. W. Page, McKees
Rocks; G. B. C. ElKott, A. K. Lyon, Millvale; C. C.
Leydic, Natrona ; H. T. Elliott, E. H. Parkin, A. S.
Kaufman, G. T. L^mon, New Kensington; C. B.
Denny, F. W. Mathewson, Oakdale ; J. C. Edgar, Oak-
mont; C. J. Aaron, S. H. Adams, N. Albrecht, I. H.
Alexander, V. Z. Allison, V. L. Andrews, C. S. Apgar,
H. P. Ashe, L. F. Ankrim, S. Ayres, J. A. Baird, M.
H. Baker, H. A. Earnhardt, H. L. Barr, T. M. Barrett,
O. J. Bennett, H. J. Benz, H. Bernstein, A. Bianco, L.
C. Bixler, D. G. Black, E. L. Blair, D. A. Boggs, R. H.
Hoggs, A. J. Boucek, F. C. Boucek, J. W. Boyce, J. A.
Boyd, W. A. Bradshaw, F. W. Bremier, P. C. Bruce,
D. N. Bulford, J. G. Burke, W. T. Burleigh, R. F.
Bums, P. W. Bushong, J. F. Calvert, M. C. Cameron,
G. H. Camp, C. L. Campbell, R. J. Campbell, W. J.
Cavanagh, H. E. Clark, R. W. Clark, W. A. Clark,
J. J. Clarke, R. C. Clarke, B. A. Cohoe, G. Conti, J.
M. Conway, V. B. Callomon, A. R. Cratty, A. W.
Crozier, A. S. Daggette, F. Davis, I. Davis, T. Diller,
B. E. Dombush, J. M. Douthett, A. W. Duff, J. P.
Duggan, A. P. D'Zmura, O. N. Eisaman, J. E. Eisen-
hart, K. Emmerling, J. W. Elphinstone, D. R. Evans,
W. Felker, S. K. Fenollosa, J. McE. Fetterman, A.
Fisher, H. C. Flood, E. N. Foster, W. S. Foster, O.
Fouse, A. C. Frank, W. Frederick, R. S. Freed, J. W.
Frey, E. M. Frost, E. R. Gardner, S. George, J. B. Gold,
M. Goldsmith, H. R. Goldstein, M. A. Gould, T. W.
Grayson, B. Greenberger, T. G. Greig, G. W. Grier,
P. B. Grogin, J. P. Hall, C. E. Harris, R. H. Har-
rison, C. C. Hartman, S. R. Haythom, J. D. Heard,
J. P. Hegarty, C. H. Henninger, C. C. Hersman, A. J.
Hesser, R. T. Hood, A. J. Hopkins, C. H. Ingram, H.
D. Jew, S. H. Johnson, J. I. Johnston, C. R. Jones,
H. L. Jones. H. D. Jordan, A. F. Kamens, N. P. Kel-
ler, F. S. Kellogg, D. D. Kennedy, I. K. King, D. I.
Kirk, T. T. Kirk. H. Klinzing. O. Klotz, A. Koenig,
A. H. Kraft, L. E. Lacock, L. Lasday, J. P. Laughlin,
G. Leibold, J. A. Lichty, J. A. Lindsay, L. Litchfield,
C. B. McAboy, R. K. McConeghy, B. J. McCormick,
J. C. McCormick, M. S. McKennan, T. M. T. McKen-
nan, A. McKibben, S. H. McKibben, T. M. McLena-
han, G. C. McMaster, S. McNaugher, G. W. McNeil,
W. W. G. Maclachlin. M. B. Magoffin, C. B. Maits, C.
H. Marcy, C. S. Marshall, H. O. Mateer, E. E. Mattox,
W. W. Maxwell, E. E. Mayer, W. H. Mayer, W. H. Mer-
cur. G. Metzger, G. B. Meyers, L. O. Miller, A. McL.
Milligan, A. D. Mitchell, W. M. Mitchell, T. F. Moore,
A. F. B. Morris, C. M. Morton, I. J. Moyer, S. S. Moyer,
J. A. Munster, H. L. Murphy, F. C. Narr, E. E. Neely,
F. Neely, H. G. Noah. J. R. Owens, C. L. Palmer. H.
B. Patterson. A. Pettit, I. M. Pochapin, A. D. Price,
C. R. Price. E. O. Pearson, G. W. Rail, S. H. Ratner,
Digitized by
joogle
116
THE PENNSYLVANIA MEDICAL JOURNAL Novembsr, 1920
W. B. Ray, DeW. G. Richey, S. M. Rinehart, N. L.
Rosenberg, C. Rowan, W. K. T. Sahm, E. P. Schatz-
man, J. J. Schill, H. G. Schldter, F. M. Schrack, W.
G. Shallcross, H. A. Shaw, A. W. Sherrill, T. G.
Sitnonton, S. C. Simpson, L. A. Monier Smith, H. M.
SniUer, R. R. Snowden, C. Sohn, C. J. Steim, W. J.
Sterrett, C. J. Stybr, J. S. Stybr, J. M. Thorne, H. J.
Treshler, F. B. Utley, C. J. Vaux, G. H. Vaux, M. E.
Wadsworth, W. K. Walker, A. W. Wallis, J. O. Wal-
lace, J. Weber, L. Wechsler, M. H. Weinberg, H. C.
Westervelt, J. H.Whitcraft, I. B. Whitehead, M.Wiant,
E. W. Willetts, I. Williams, R. Williams, V. A. Wil-
liams, J. M. Wilson, J. V. Wilson, J. Wolf, W. A.
Woodburn, J. W. Worrell, G. J. Wright, W. A. Wycoflf,
V. J. Yorty, E. Zugsmith, Pittsburgh ; S. D. Jennings,
DeW. B. Nettleton, Sewickley; G. E. Cramer, N. R.
Graham, Sharpsburg; H. W. Morrow, Swiss vale; C.
W. Allen, F. S. McCombs, C. L. Leydic, J. C. Smith,
J. A. Weamer, Tarentum; A. L. Trevaskis, Turtle
Creek; A. M. Pierce, West Elizabeth; D. A. Atkin-
son, A. E. Torrens, West View ; R. W. Allison, J. W.
E. Ellenberger, G. S. Engle, W. M. Findley, J. P.
Harvey, J. D. McClure, H. S. McClymonds, E. S.
Warner, Wilkinsburg; S. E. Nowry, Wilmerdmg.
Armstrong County Society— T. J. Henry, A. H.
Townsend, Apollo; G. S. Morrow, Dayton; W. H.
McCafferty, C. M. McLaughlin, C. A. Rogers, Free-
port ; J. H. Hargreaves, Kelley Station ; T. W. Mc-
Kee, F. C. Monks, Kittanning; C. C. Parks, Leech-
burg; J. G. Allison, McGrann; S. E. Ambrose, Rural
Valley; H. A. Holland, -Sagamore; J. A. Kelley,
Whitesburg; J. Ward, Yatesboro.
Beaver County Society — P. C. Smith, Ambridge; M.
L Cornelius, C. B. Daugherty, U. S. Strouss, Beaver;
G. J. Boyd, J. F. Gilliland, Beaver Falls ; N. C. Ochsen-
hirt, Enon Valley; A. B. Cloak, W. H. Herriott, Free-
dom; C. B. McGogney, Midland; M. L. McCandless,
Rochester.
Bedford County Society— W. Ayres, W. F. Enfield,
Bedford; W. C. Miller, Harrisburg (Dauphin County) ;
H. I. Shoenthal, New Paris.
Berks County Society — F. P. Lytle, Birdsboro; J.
L. Bower, Philadelphia (Philadelphia County) ; I. G.
Shoemaker, Reading.
Blair County Society— R. T. Eldon, A. G. Kcach, C.
F. McBumey, E. B. Miller, A. S. Obum, Altoona.
Bradford County Society— C. L. Stevens, Athens;
W. T. Davison, Canton; W. E. Lundblad, Sayre; P.
N. Barker, Troy.
Bucks County Society — A. F. Myers, Blooming Gtem
Butler County Society— W. A. McCall, J. D. Purvis,
H. P. St. Clair, Butler; R. L. Allison, Eau Claire; L.
H. Stepp, Mars; C. H. Ketterer, Pittsburgh (Alle-
gheny County) ; W. B. Campbell, Prospect.
Cambria County Society— W. E. Matthews, H. H.
Penrod, H. M. Stewart, H. F. Tomb, Johnstown; E.
P. Dickinson, St. Michael.
Carbon County Society— J. A. Trexler, Lehighton;
W. P. Long, Weatherby.
Center County Society- D. Dale," J. L. Seibert, Belle-
fonte; P. H. Dale, State College.
Chester County Society — L.- T. Bremerman, Dow-
ington; J. Scattergood, West Chester.
Clarion County Society— C. V. Hepler, New Beth-
lehem ; • C. W. Hoffman, Rimersburg ; J. .\aronoflF,
Shippensville ; F. K. Booth, Tarentum (Allegheny
County).
Clearfield County Sodety— J. P. Frantz, J. M. Quig-
ley, <J. B. Yeaney, Clearfield ; H. O. King, Curwens^
ville; S. Stolberg, Glen Richey; R. L. Williams,
Houtzdale; S. J. Miller, Madera. •
Clinton County Society— J. B. Critchfield, Lock
Haven; A. P: Painter, Mill Hall.
Columbia County Society— J. R. Gemmill, Millville.
■'Crawford County Society- D. C. Mock, Cambridge
SpHngs;' C. L. Williams, Linesville; M. B. Best, O.
H,'-J^ckibn, G. D. Thomas, Meadville.
Cumb'eriilnd County Society— J. B. McCreary, Ship-
pensburg;
Dauphin County Society— J. W. Ellenberger, D. S.
Funk, J. L. Good, J. B. McAlister, A. L. Page, Har-
risburg; W. P. Evans, Middletown; H. C. Myers, J.
R. Plank, Steelton.
Delaware County Society — A. J. Simpson, Chester.
Elk County Society— A. C. Luhr, St. Marys.
Erie County Society— N.T. Gillette, Corry; J. Acker-
man, E. G. Weibel, J. W. Wright, Erie.
Fayette County Society — J. W. Gordon, A. J. Mars-
ton, Belle Vernon ; H. J. Coll, E. B. Edie, L. P. Mc-
Cormick, Connellsville ; A. L. Eddy, Greensboro; C.
B. Johnson, Mount Braddock; J. E. Van Gilder,
Uniontown; J. H. Hazlett, Vanderbilt.
Franklin County Society — ^J. H. Swan, St. Thomas.
Greene County Society — E. W. Laidley, Carmichaels ;
L. S. McNeely, Kirby.
Huntingdon County Society — G. G. Harman, Hunt-
ingdon.
Indiana County Society — M. A. Sutton, Avonmore
(Westmoreland Co.) ; W. E. Dodson, Indiana; E.
Onstott, Saltsburg.
Jefferson County Society — W. C. Newcome, Big
Run; H. P. Thompson, Brookville; J. H. Murray,
Punxsutawney ; J. A. Newcome, Vandergrift (West-
moreland County).
Juniata County Society — B. H. Ritter, McCoysville.
Lackawanna County Society — F. L. Van Sickle, Har-
risburg (Dauphin County); J. J. Price, Olyphant; J.
D. Butzner, C. Falkowslor, J. D. Lewis, Scranton.
Lancaster County Society — H. B. Roop, Columbia;
F. G. Hartman, H. C. Kinzer, Lancaster; W. J. Lea-
man, Leaman Place; E. B. Bricker, Lititz.
Lawrence County Society — C. M. Dumm, Ellwood
City; J. R. Cooper, L. H. Gageby, C. F. McDowell, H.
W. McKee, W. L. Steen, R. A. Wallace, H. R. Wilson,
W. A. Womer, New Castle.
Lebanon County Society — E. H. Gingrich, Lebanon.
Lehigh County Society — W. C. Troxell, J. M.
Weaver, Allentown.
Luzerne County Society — H. M. Neale, Upper Le-
high ; J. I. Roe, Wilkes-Barre.
Lycoming County Society — E. Everett, Masten; A.
P. Hull, W. E. Turner, Montgomery; I. T. Gihnore,
Picture Rocks; W. S. Brenholtz, W. E. Glasser, Wil-
liamsport
McKean County Society — ^J. Johnston, Bradford.
Mercer County Society — W. B. Campbell, Grove
City; J. W. Elliott, P. P. Fisher, O. A. Jones, Sharon;
J. C. Bachop, Sheakleyville; J. A. Hunter, West Mid-
dlesex.
Montgomery County Society — E. S. Buyers, Norris-
town.
Montour County Society— R. A. Keilty, R. S. Pat-
ten, Danville.
Northampton County Society — E. M. Green, Easton.
Perry County Society — F. Patterson, Huntingdon
(Huntingdon Cotmty).
Philadelphia County Society — ^J. A. Jackson, Dan-
ville (Montour County) ; J. M. Anders, J. H. Arhett,
L. N. Boston, C. A. E. Codman, M. S. Cohen, T. R
Currie, D. Donnelly, M. H. Fussell, H. D. Jump, E. B.
Krumbhaar, J. D. McLean, A. C. Morgan, W. S. New-
comet, G. M. Piersol, C. S. Potts, M. E. Rehfuss, J.
Sailer, T. G. Schnabel, S. C. Smith, J. W. West, Phila-
delphia; T. B. L. Jordan, Pittsburgh (Allegheny
County).
Schuylkill County Society — D. Taggart, Frackville;
A. B. Fleming, Tamaqua.
Somerset County Society — R. P. Pollard, Garrett;
C. P. Large, B. Lichty, Meyersdale; F. B. Shaffer,
Somerset; G. C. Berkheimer, Windber.
Union County Society — O. W. H. Glover, Laurel-
ton.
Venango County Society — C. S. Braidenbaugh, W.
G. Gilmore, Emlenton; H. F. McDowell, Franklin;
H. H. Lamb, P. J. McLain, J. P. Strayer, Oil City;
J. M.Murdoch, Polk.
Warren County Society — A. Ellsworth, H. W.
Digitized by
Cnoogle
November, 1920
OFFICIAL TRANSACTIONS
117
Mitchell, F. G. Weston, Warren; R. H. Knapp,
Youngsville.
Washington Cotmty Society — D. D. Haines, Allen-
port; H. A. Snodgrass, Buffalo; A. O. Hindman,
Burgettstown ; D. M. Bell, A. V. Donaldson, E. L.
Hazlett, A. L. Runion, Canonsburg; J. W. Hunter, H.
J. Repman, Charletoi; J. N. Sprowfs, Claysville; C.
B. Lamp, Courtney; W. D. Martin, Dunns Station;
B. A. Emery, Eighty-Four; E. M. Ellis, Ellsworth;
R. E. Conner, Hickory; W. L. Scott, Joffre; W. R.
Dickson, W. A. LaRoss, McDonald; W. D. Gemmill,
Morganza; L. N. Braden, Ten Mile; E. M. Hazlett,
G. W. Ramsey, J. M. C. Reynolds, A. A. Ruben, L. D.
Sargent, R. A. Stewart, T. D. M. Wilson, Washington ;
H. M. Lacock, West Finley.
Westmoreland County Society — R. M. Alexander,
Bolrvar; D. C. Jordan, Derry; E. L. Piper, Export;
J. S. Anderson, W. M. Bortz, C. F. Pierce, D. R. Mur-
doch, C. E. Snyder, W. J. Walker, Greensburg ; J. D.
Caldwell, R. P. McClellan, Irwin; H. N. Prothero,
U. H. Reidt, H. J. Stonffer, J. H. Wilson, Jeanette;
C. D. Ambrose, E. B. Dunlap, E. E. McAdoo, Ligon-
ier; E. G. Ankney, Pleasant Unity; W. H. Fetter,
A. W. Strickler, J. P. Strickler, Scottdale; D. A.
Walker, Southwest; T. P. Painter, United; R. H.
Speer, Vandergrift.
Wyoming County Society — ^W. W. Lazarus, Ttmk-
hannock.
York County Society — B. E. Gamble, Manchester;
W. F. Bacon, G. E. Hohzapple, R. C. Rasin, York.
UEMBERS KEGISTERED IN SECTION ON SURGERY
Allegheny County Society — W. M. Anderson, Aspin-
wall; W. J. K. Snyder. Avalon; A. H. Gross, Belle-
vue;_ A. W. Colcord, Clairton; H. M. Meanor, Cora-
opohs; S.A. Norris, John Purman, Homestead; C.
G. Eicher, C B. Keebler, G. R. Wycoff, McKees
Rocks; J. C. Kelly, C. F. King, D. P. McCune, W. M.
Woodward, McKeesport; A. P. Fogleman, E. V. Mc-
Cormick, Munhall; J. A. Huth, Natrona.; P. A.
Brown, R._C. Johnston, F. J. Pessalano, M. Snyder,
New Kensington; F. B. Craig, Pitcaim; G. Alvino,
C. O. Anderson, R. L. Anderson, H. Arthurs, C. H.
Aufhammer, F. R. Bailey, T. Baker, M. E. Baldwin, W.
M. Beach. R. J. Behan, N. H. Bennett, G. F. Berg, C. A.
Bicking, C. F. Bietsch, W. Blick, A. A. Bomscheuer, C.
F. Boucek, R. E. Brenneman, E. P. Buchanan, J. J.
Buchanan, J. C. Burt, D. W. Cameron, W. M. Camp-
bell, T. B. Carroll, B. Z. Cashman, W. A. Caven, S. A.
ChaHant, G. Conti, A. A. Cross, N. P. Davis, R. E.
Davison, W. A. Dearth, H. R. Decker W. B. Denslow,
B. M. Dickinson, T. L. Disque, H. H. Donaldson, W.
F. Donaldson, C. A. Duff, G. W. Ely, R. M. Entwisle,
T. Evans, H. L. Farquhar, E. W. Fiske, J. W.
Fredette, R. J. Frodey, J. L. Gilmore, W. H. Glynn,
W. G. Goehring, L. R. Goldsmith, J. P. Griffith, S. M.
Hankey, F. A. Hartman, W. B. Harvey, E. B. Ha-
worth, G. L. Hays, W. B. Hetzel. R. C. Hibbs, H. C.
Hieber, J. Hodgkiss, G. A. HoUiday. W. M. HoUz,
J. J. Horwitz, R. R. Huggins, R. W. Hughes, J. M.
Jackson, J. M. Jamison, L. W. Johnson, G. C. Johnston,
H. J. Kalet, F. M. Kern, J. P. Kerr, S. V. King, H. P.
Kohberger, W. E. Kramer, L. H. Landon, H. M. Long,
D. E. Ludwig, C. W. Lurting, E. C. McAdams, E. J.
McCague. W. H. McCombs. A. H. McCreary, J. F.
McCullough, S. L. McCurdy, J. F. McGrath, H. E.
McGuire, W. B. McKenna, J. W. Macfarlane, J. S.
Mackrell, S. J. Marcus, A. R. Matheny, C. C. Mech-
ling, E. W. Meredith, H. A. Miller, R. T. Miller, E.
S. Montgomery, A. I. Murphy, W. A. Nealon, L L.
Ohlman, J. J. Rectenwald, J. M. Reed, F. A. Rhoades,
J. W. Robinson, W. H. Robinson, J. A. Rubem, J. P.
Baling, K. L Sancs, C. B. Schildecker, M. Schonfield,
T. Schubb, J. H. Seipel, W. O. Sherman, N. Shillito,
P. R. Sieber, H. M. Sigal, D. L. Simon, J. D. Singley,
M. A. Slocum, M. Spire, J. G. Steedle, A. Stewart, C. A.
Stillwagen, M. E. Stover, L. W. Swope, C. M. Thomas,
V. D. Thomas, E. J. Thompson, L. L. Thompson, P.
Titus, F. L. Todd. C. M. Watson, W. S. Watson, B. B.
Wechslier, G. C. Weil, E. A. Weiss, H. L. W. Wignall,
C. W. Wirts, B. B. Wood, C. E. Yoho, C. E. Ziegler,
Pittsburgh; M. W. Heilman, F. W. Silsby, F. W.
Wohlwend, Tarentum; L. D. Cratty, J. W. Dixon,
A. S. Hains, C. A. Lauffer, Wilkinsburg.
Armstrong County Society— J. M. Cooley, A. J. Sed-
wick, Kittanning.
Beaver County Society — C. B. Forcey, Ambridge;
J. H. Wilson, Beaver; R. M. Patterson, T. P. Simp-
son, Beaver Falls; W. F. Beitsch, B. C. Painter, New
Brighton; B. B. Snodgrass, Rochester.
Blair County Society— J. D. Findley, J. H. Gal-
braith, Altoona; W. A. Nason, Roaring Spring.
Bradford County Society — D. Guthrie, Sayre.
Bucks County Society — ^J. F. Wagner, Bristol.
Cambria County Society — G. R. Anderson, A. F.
Dunsmore, Barnesboro; J. B. Lowman, C. B. Mill-
hoff, A. Miltenberger, J. L. Sagerson, R. J. Sagerson,
Johnstown; W. S. Wheeling, Windber (Somerset
County.)
Carbon County Society — A. Armstrong, White
Haven.
Center County Society— M. W. Reed, Bellefonte.
Clarion County Society — ^J. B. Miller, Sligo.
Chester County Society — W. W. Woodward, West
Chester.
Clearfield County Society— L. F. Stewart, S. J.
Waterworth, W. O. Wilson, Clearfield; A. C. Lynn,
Philipsburg.
Clinton County Society— G. D. Mervine, T. E. Teah,
D. W. Thomas, Lock Haven.
Crawford County Society — H. C. Winslow, Mead-
ville.
Delaware County Society— G. S. Armitage, H. M.
Armitage, Chester.
Elk County Society — A. L. Benson, Ridgway.
Erie County Society— F. Fisher, J. R. Smith, Erie.
Fayette County Society— W. M. Lilley, Brownsville;
V. P. Pisula, Everson- S. H. Baum, A. E. Crow, R.
H. Jeffrey, W. A. McHugh, G. H. Robinson, Union-
town.
Franklin County Society— S. D. Shull, Chambers-
burg.
Greene County Society — S. A. Hoge, Rice's Land-
ing; R. E. Brock, T. N. Millikin, H. C. Scott, Waynes-
burg.
Huntingdon County Society — ^H. C. Frontz, J. M.
Johnston, Huntingdon; W. J. Campbell, Mount Union.
Indiana County Society — F. F. Moore, Homer City;
G. E. Simpson, J. W. Carson, Indiana; C. M. Smith,
Plumville. •
Jefferson County Society— J. K. Brown, Brookville;
S. M. Free, Dubois (Clearfield County).
Lackawanna County Society — H. W. Albertson, A.
E. Davis, L. P. Gibbons, D. A. Webb, Scranton.
Lancaster County Society — ^J. P. Kennedy, Colum-
bia ; T. B. Appel, S. W. Miller, Lancaster.
Lawrence County Society — H. E. Helling, Ellwood
City ; J. Foster, R. G. Miles, S. W. Perry, T. M. Shaf-
fer, E. U. Snyder, New Castle.
Lebanon County Society — W. H. Means, Lebanon.
Lehigh County Society— F. J. Schaeffer, R. L.
Schaeffer, Allentown; C. A. Haff, Northampton
(Northampton County).
Luzerne County Society — W. Lathrop, Hazelton; L.
Edwards, M. C. Rumbaugh, C. L. Shafer, Kingston;
H. G. Gibby, S. P. Mengel, W. S. Stewart, S. M.
Wolfe, Wilkes-Barre.
Lycoming County Society— J. W. Albright, Muncy;
H. J. Donaldson, G. B. Klump, R. F. Trainer, Wil-
liamsport.
McKean County Society — E. O. Kane, Kane.
Mercer County Society — C. W. McElhaney, Green-
ville; F. M. Bleakney, Grove City; P. T. Hope,
Mercer; W. M. Writt, New York City; J. C. Weide-
man, Pittsburgh (Allegheny County) ; C. C. Marshall,
Sharon.
Mifflin County Society — ^J. A. C. Clarkson, Lewis-
town.
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THE PENNSYLVANIA MEDICAL JOURNAL Novembbr, 1920
Montour County Society — H. L. Foss, Danville.
Montgomery County Society— J. E. Porter, Potts-
town; J. O. Bower, Wyncote.
Northampton County Society — W. L. Estes, W. L.
Estes, Jr., Bethlehem.
Northumberland County Society — G. W. Reese, C.
H. Weimer, Shamokin.
Philadelphia County Society— A. R. Craig, Chicago,
Illinois; J. M. Baldy, Devon (Chester County); E.
G. Alexander, W. W. Babcock, M. Behrend, W. L.
Clark, H. C. Deaver, M. M. Franklin, C. H. Frazier,
J. J. Gilbride, F. C. Hammond, L. J. Hammond, A.
Hewson, W. S. Higbee, R. H. Ivy, W. Krusen, C. B.
Longenecker, F. H. Maier, G. B. Massey, D. B.
Pfeiffer, J. J. Reichy, J. B. Roberts, J. S. Rodman, W.
A. Steel, E. A. Schumway, J. E. Sweet, T. T. Thomas,
J. R. Wells, A. C. Wood, Philadelphia.
Schuylkill County Society— R. W. Montelius, Mt-
Carmel.
Somerset County Society — H. C. McKinley, Meyers-
dale.
Tioga County Society — S. D. Molyneux, Blossburg.
Venango County Society — F. M. Summerville, Oil
City.
Warren County Society— G. T. Pryor, Sheffield; J.
W. Hamilton, Warren.
Washington County Society — C. L. Harsha, J. W.
Ildza, J. C. Kelso, Canonsburg; J. H. Corwin, J. F.
Donehoo, J. C. Knox, W. D. Teagarden, A. E. Thomp-
son, Washington.
Westmoreland County Society — G. M. Dickson,
Adamsburg; B. Haughwout, Derry; L. J. C. Bailey,
T. P. Cole, C. C. Crouse, J. J. Singer, Greensburg;
R. E. L. McCormick, C. E. Taylor, W. J. H. Taylor,
Irwin; B. R. Smith, Jeanette; A. B. Blackburn, La-
trobe; M. E. Griffith, E. B. Sloterbeck, Monessen;
M. W. Homer, W. A. Marsh, F. C. Mauk, Mt. Pleas-
ant; L. T. Gilbert, Scottdale; F. C. Katherman,
Whitney.
York County Society— F. V. McConkey, York
MINUTES OF THE SECTION ON EYE, EAR,
NOSE AND THROAT DISEASES
TUESDAY AFTERNOON SESSION
The Tuesday afternoon session was called to order
at twg o'clock by the chairman. Dr. George B. Jobson,
of Franklin.
The chairman. Dr. George B. Jobson, read his ad-
dress.
Dr. William Blair, Pittsburgh, read a paper written
by Dr. Blair and Dr. Jay G. Linn, Pittsburgh, entitled
"School Myopia; Its Prevention, Importance and
Early Recognition and Treatment." This paper was
discussed by Drs. J. Ferdinand Klinedinst, York;
Michael V. Ball, Warren; William Campbell Posey,
Philadelphia, and Harry O. Mateer, Pittsburgh.
Dr. Frederick Krauss, Philadelphia, read a paper
entitled "Acute Mastoiditis in Children." This paper
was discussed by Drs. John R. Simpson, Pittsburgh;
H. H. Fisher, Pittsburgh; Matthew S. Ersner, Phila-
delphia, and the discussion closed by Dr. Frederick
Krauss, Philadelphia.
Dr. George M. Coates, Philadelphia, read a paper
entitled "Discussion of the Blood Clot Dressing for
the Mastoid Operation." This paper was discussed
by Drs. Matthew S. Ersner, Philadelphia; Myer Solis-
Cohen, Philadelphia; John F. Culp, Harrisburg, and
in closing by Dr. George M. Coates, Philadelphia.
Dr. J. Homer McCready, Pittsburgh, read a paper
entitled "Intranasal Operation for Dacrocystitis."
This paper was discussed by Drs. William Campbell
Posey, Philadelphia; George W. Stimson, Pittsburgh;
Luther C. Peter, Philadelphia; George H. Cross,
Chester, and the discussion closed by Dr. J. Homer
McCready, Pittsburgh.
Dr. William Hardin Sears, Huntingdon, read a
paper entitled "Practical Use of the Barany Tests
Away from Medical Centers." This paper was dis-
cussed by Dr. Seth A. Brumm, Philadelphia.
The Section adjourned until Wednesday at two
o'clock.
WEDNESDAY AFTERNOON ^SESSION
Pursuant to adjournment, the Wednesday afternoon
session was called to order at 2 : lo by Dr. John F.
Culp, Harrisburg, acting chairman.
The Executive Committee of the Section made its
report announcing the following names as officers of
this Section for the ensuing year:
Chairman, Luther C. Peter, Philadelphia.
Secretary, William H. Sears, Huntingdon.
It was moved by Dr. Edward B. Heckel, Pittsburgh,
that the report of the Executive Committee be accepted
and approved. Motion seconded by Dr. George M.
Coates, Philadelphia, and carried.
Dr. Breese M. Dickinson, Pittsburgh, read a paper
entitled "A Phase of Accessory Sinus Disease."
This paper was discussed by Drs. George M. Coates,
Philadelphia; George W. Stimson, Pittsburgh; John
F. Culp, Harrisburg, and in closing by Dr. Breese M.
Dickinson, Pittsburgh.
Dr. William Campbell Posey, Philadelphia, then
made the following brief report for the Committee on
the Conservation of Vision.
Dr. Posey: I would like the Section to know that
last night the Commission on the Conservation of
Vision at its annual meeting put into activity a move-
ment looking to the physical examination of those who
operate automobiles in the city — the examination of
their eyes and ears and perhaps other physcial tests.
This of course will be a work of great magnitude and
will require the cooperation of every member of this
Section. Steps will be taken in the House of Dele-
gates to-day looking to some action during the ooming
year along this line and this is simply a brief pre-
liminary statement at this time.
Dr. William H. Wilder, Chicago, read a paper en-
titled "A Consideration of Some of the Problems of
Glaucoma." This paper was discussed by Drs. William
Campbell Posey, Philadelphia; Edward B. Heckel,
Pittsburgh; William W. Blair, Pittsburgh; Edward
Stieren, Pittsburgh; J. Ferdinand Klinedinst, York;
William H. Sears, Huntingdon, and by Dr. William
H. Wilder in closing.
It was moved by Dr. Edward B. Heckel, Pittsburgh,
that a vote of thanks be given Dr. Wilder for his
address. Motion seconded and carried by risihg vote.
Dr. William Campbell Posey, Philadelphia, read a
paper entitled "Some Observations on the Muscle
Advancement Operation." This paper was discussed
by Drs. Edward B. Heckel, Pittsburgh; William H.
Wilder, Chicago; Luther C. Peter, Philadelphia, and
the discussion closed by Dr. William Campbell Posey.
Dr. Edward Shumway, Philadelphia, read a paper
entitled "Traumatic Paralysis of the Left Superior
Oblique Muscle, Relieved by Tenotomy of the Right
Inferior Rectus." This paper was discussed by Dr.
William Campbell Posey, Philadelphia, and in closing
by Dr. Edward A. Shumway.
Dr. J. Milton Griscom, Philadelphia, read a paper
entitled "The Relation of Intranasal Pressure to Heter-
ophoria." This paper was discussed by Drs. William
W. Blair, Pittsburgh, and David I. Giarth, Ford City.
The Section adjourned until Thursday morning at
nine o'clock.
THURSDAY MORNING SESSION
Pursuant to adjournment the Thursday morning
session was called to order at 9 : 35 by the chairman,
Dr. George B. Jobson, Franklin.
Dr. Clarence M. Harris, Johnstown, read a paper
entitled "The Pharyngeal Tonsil, Important Con-
siderations in Its Treatment." This paper was dis-
cussed by Drs. George M. Coates, Philadelphia;
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OFFICIAL TRANSACTIONS
119
Watson 'Marshall, Pittsburgh; Matthew S. Ersner,
Philadelphia; George B. Jobson, Franklin, and the
discussion closed by Dr. Clarence M. Harris, Johns-
town.
Dr. George W. Mackenzie, Philadelphia, read a
paper entitled "Lenticonus, With Report of Three
Cases." This paper was discussed by Drs. Edward
Stieren, Pittsburgh; Waid E. Carson, Pittsburgh, and
the discussion closed by Dr. George W. Mackenzie,
Philadelphia.
Dr. Edward Stieren, Pittsburgh, read a paper en-
titled "Melanosarcoma of the Choroid." This paper
was discussed by Drs. Edward A. Shumway, Phila-
delphia; Luther C. Peter, Plyladelphia, and George
W. Mackenzie, Philadelphia.
Dr. Russell H. Boggs, Pittsburgh, read a paper en-
titled "Treatment of Malignant Growth of the Mouth
and Throat." This paper was discussed by Charles
H. Viol, of the Radium Research Laboratory, Pitts-
burgh; by Drs. George M. Coates, Philadelphia;
Richard E. Brenneman, Pittsburgh; William L.
Clark, Philadelphia, and the discussion closed by
Russell H. Boggs, Pittsburgh.
Dr. Thomas W. Stahlman, Pittsburgh, read a paper
entitled "The Use of Paraffin and Wax in Ear and
Nose Surgery." This paper was discussed by Drs.
George W. Mackenzie, Philadelphia; Clarence M.
Harris, Johnstown; William H: Sears, Huntingdon;
Luther C. Peters, Philadelphia, and the discussion
closed by Dr. Thomas W. Stahlman, Pittsburgh.
Dr. George B. Jobson, the retiring chairman, then
introduced the incoming chairman. Dr. Luther C.
Peter, who thanked the Section for the honor of the
chairmanship and emphasized the fact that the suc-
cess of the Section rests, not alone with the officers,
but on the cooperation and work of the individual
members.
The Section then adjourned sine die.
MEMBERS REGISTERED IN SECTION ON EYE, EAR, NOSE AND
THROAT DISEASES
Allegheny County Society — E. H. Sloan, Ben Avon ;
A. Hunter, A. T. Zeller, McKeesport; T. E. McCon-
nell. New Kensington ; C. S. Hunter, North Bessemer ;
W. L. Allison, C. A. Arnold, W. W. Blair, W. E.
Brown, W. E. Carson, N. B. Craighead, G. E. Curry,
S. A. Dawson, J. S. DeMuth, J. J. Dickinson, G. A.
Dillinger, S. I. Eber, A. B. Ferguson, N. A. Fischer,
D. W. Fyre, J. E. Gross, A. J. Guerinot, A. R. Hamp-
sey, R. M. Heath, E. B. Heckel, S. F. Hogsett, W. H.
Kirk, G. C. Kneedler, A. Krebs, J. G. Linn, G. M. Mc-
Cain, J. H. McCready, G. J. McKee, A. A. MacLach-
lan, R. S. Major, J. C. Markel, W. Marshall, S. C.
Milligan, E. L. Neff, C. S. Orris, E. J. Patterson, D.
M. Perkins, J. Porter, M. S. Redmond, C. L. Reed, N.
J. Resmer, C. N. Schaefer, S. Seegman, A. S. Sigman,
J. R. Simpman, S. Smith, T. M. Stahlman, E. Stieren,
G. W. Stimson, S. A. Sturm, M. C. Taylor, T. Turn-
bull. H. H. Turner, V. E. VauWn, F. J. Walz, N. J.
Weill, E. S. Weimer, H. Weiss, E. A. Weisser, E. E.
Wible, J. E. Willetts, C. A. Wishart, Pittsburgh; T.
H. Manly, Tarentum.
Armstrong County Society — D. 1. Giarth, Ford City ;
J. B. F. Wyant, Kittanning.
Beaver County Society — H. E. Moore, Ambridge;
W. C. Meanor, J. J. Scroggs, Beaver.
Blair County Society — S. P. Glover, Altoona.
Bradford Couiity Societv — N. S. Weinberger, Sayre.
Butler CAunty Societv— J. C. Boyle, L. L. Doane, L.
R. Hazlett, Butler.
Cambria County Society — O. G. A. Barker, C. M.
Harris, Johnstown.
Carbon County Society — C. J. Kistler, Lehighton.
Crawford County Society — W. W. Shaffer, Mead-
ville.
Dauphin County Society — ^J. F. Culp, Harrisburg.
Delaware County Society— G. H. Cross, C. 1. Stite-
ler, Chester.
Erie County Society— D. N. Dennis, K. L. Wright,
Erie.
Fayette Coimty Society— J. P. LaBarre, Uniontown.
Franklin County Society— F. N. Emmert, Chambers-
burg.
Huntingdon County Society — W. H. Sears, Himt-
ingdon.
Lackawanna County Society — L. G. Reeling, Scran-
ton.
Lancaster Coimty Society — J. P. Roebuck, Lancaster.
Lawrence County Society— J. C. B. Douthett, D. C.
Lindley, New Castle.
Lycoming County Society — ^J. C. Brown, W. F.
Kunkle, Williamsport
Mercer County Society — C. H. Bailey, M. E. Mac-
Bride, Sharon.
Montour County Society — R. Nebinger, Danville.
Northampton County Society — P. H. Kleinhans, P.
H. Walter, Bethlehem.
Northumberland County Society — L. E. Schoch,
Shamokin.
Philadelphia County Society — S. A. Brumm, G. M.
Coates, J. W. Croskey, M. S. Ersner, J. M. Griscom,
F. Krouss, H. C. Masland, L. C. Peter, P. J. Pontius,
W. C. Posey, E. A. Shumway, Philadelphia; G. H.
Shuman, Pittsburgh (Allegheny County).
Schuylkill County Society— T. L. Williams, Mt
Carmel.
Venango County Society — G. B. Jobson, E. V.
Thompson, Franklin; C. Cooper, Titusville; C. Y.
Detar, Oil City.
Warren Coimty Society — M. V. Ball, Warren.
Washington County Society — F. C. Stahlman, Char-
leroi ; H. P. Lvnch, Monongahela ; G. B. Dunkle, J.
W. McKennan, J. B. McMurray, C. E. Tibbens, Wash-
ington.
Westmoreland County Society — H. B. Barclay, E.
M. Clifford, Greensburg; W. P. Gemmill, Monessen.
York County Society— J. F. Klinedinst, York.
MINUTES OF THE SECTION ON PEDIATRICS
Tuesday Afternoon, October 5, 1920
The Section on Pediatrics was called to order Tues-
day, October 5, at 2 : 10 p. m., by William N. Bradley,
chairman.
An address on "Tuberculosis in Children" was de-
livered by the chairman.
"The Diet During the First Two Years of Life"
was read by Edwin E. Graham, of Philadelphia. Dis-
cussion opened by Drs. Eaton, Hand and Lowenberg,
and closed by Dr. Edwin E. Graham.
"Pyloric Stenosis in Children" was read by Henry
C. Deaver, of Philadelphia. Discussion opened by Drs.
Hand, Graham, Lowenburg and Bauer, and closed by
Dr. Deaver.
"Hypertrichosis in Childhood; the So-Called 'Dog
Face Boy,' " was read by Frank C. Knowles, of Phila-
delphia. Discussion opened by Drs. Guy, Eaton and
Bauer, and closed by Dr. Knowles.
"Pseudomuscular Hypertrophy" by Albert H. Rieth-
muller, of Pittsburgh. Dr. Riethmuller was unavoida-
bly detained, but a moving picture presenting cases in
his paper was shown to the section. Discussion opened
by Drs. Weisenburg and Price.
"The Antiscorbutic Vitamin" was read by M. H.
Givens, of Pittsburgh, and discussed by John F. Sin-
clair, of Philadelphia. Closed by Dr. Givens.
Wednesday Afternoon, October 6, 1920
The report of the Executive Committee was pre-
sented to the Section at the opening of the meeting
Wednesday, October 6, at 2:05 P-ni. Drs. Harry J.
Cartin, of Johnstown, chairman: Henry T. Price, of
Pittsburgh, secretary. Signed, Drs. P. J. Eaton and
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THE PENNSYLVANIA MEDICAL JOURNAL November, 1920
Charles J. Miner. The above men were elected as of-
ficers for the coming year.
Dr. Weisenburg was compelled to leave the city and
his paper "Convulsions in Childhood" from the Neu-
rological Viewpoint was advanced to the first paper
read at the Wednesday afternoon session. Discussion
opened by Drs. Diller, Sinclair and Lowenburg and
closed by Dr. Weisenburg.
"The Duty of the Pediatrist to the Mother of the
New Bom" was read by Orel N. Chaffee, of Erie.
Discussion opened by Drs. Ross, Sinclair, Bradley and
Cassidy, and closed by Dr. Chaffee.
"The Eradication of Diphtheria by Means of Toxin-
Antitoxin Following Schick Testing" was read by Ed-
ward L. Bauer, of Philadelphia, and "Prevention of
Diphtheria " was read by William H. Parker, of New
York City. EHsciission of these papers opened by Drs.
Edward Martin, Commissioner of Pennsylvania State
Board of Health, Gilbride, Meyers, and Cohen, Phila-
delphia.
"Etiology of Convulsions in Infancy" was read by
A. Graeme Mitchell and Wilford W. Barber, of Phila-
delphia. Discussion opened by Drs. Weisenburg and
Diller, and closed by Dr. Mitchell. Dr. Griffith was
unable to be present to discuss his paper.
Thotisday, October 7, 19201 p a.m.
"The Vaccine Treatment of 'Pfertussis" was read by
Robert K. Rewelt, of Williamsport. Discussion opened
by Drs. L. C. Bixler, of Pittsburgh ; Edward L. Bauer,
of Philadelphia; William N. Bradley, of Philadelphia;
Harry J. Cartin, of Johnstowii ; Henry T. Price, of
Pittsburgh, and closed by Dr. Rewalt.
Report of "Case of Intestinal Infantilism Associated
with Rickets" was read by D. Hartin Boyd, of Pitts-
burgh. Discussion opened by Dr. M. H. Fussell, of
Philadelphia, and closed by Dr. Boyd.
"Acrodynia" was read by Dr. Henry J. Cartin, of
Johnstown. Discussion opened by Dr. Herbert G.
Wertheimer, Dr. Hollander, of Pittsburgh; Dr. Fred
E. Ross, of Erie, and closed by Dr. Cartin.
"Necessity of More Strenuous Efforts to Reduce the
Infant Mortality Rate" was read by Dr. Z. R. Scott, of
Pittsburgh. Discussion opened by Dr. H. T. Price, of
Pittsburgh; Dr. Bentz, of Pittsburgh; Dr. P. J.
Eaton, of Pittsburgh; Dr. Wright, of Erie; Dr. Wil-
liam N. Bradley, of Philadelphia, and closed by Dr.
Scott. Dr. Hamill was not present at the meeting due
tu death in the family. ,
"Pediatrics in the Small City" was read by Dr. Her-
bert E. Hall. Discussion opened by T. Elterich, of
Pittsburgh, and closed by Dr. Hall. '
-MBMBBRS RECISTERED IN SECTION ON PEDIATRICS
Allegheny County Society — C. H, Wolfe, -Aihbridge
(Beaver County) ; S. C. McGarvey, Bridgeville ; E. H.
Parkin, New Kensington ; C. J. Bowen, D. H. Boyd, H.
B. Bums, C. L. Curll, A. A. Drang^, P. J. Eaton, T. J.
Elterich, J. K Everhart, G. J. Feldstein, H. M. Fink,
W. H. Guy, H. J. Herzstein, L. Hollander, J. D. lams,
S. I. Lebau, W. P. McCorkle, W. McCracken, E. B.
McCready, W. W. McFarland, M. A. Naylor, H. T.
Price, W. T. Pyle, E. C. Robinson, Z. R. Scott, C. K.
Waigener, H. G. Wertheimer, J. A. Williams, Pitts-
burgh; H. Schlesinger, Sharpsburg.
' Artnstrong County Society— L. F. Krbh, Rural Val-
ley.
Beaver County Society— J. D. Stevenson, Wood-
lawn.
Butler County Society— M. B. St. Clair, Butler.
Cambria County Society— H. J. Cartin, Johnstown.
Erie County Society--0. N. Chaffee, R. E. Ross,
Erie.
Fayette County Society— H. .E. Hall, Uniontown.
Huntingdon County Society— J. M. Keichline, Pe-
tersburg. . ,
Lancaster County Society— C. H. Witmer, Lancaster.
Luzerne Countv Society— W. F. Davison, Dorrance-
ton; C. H. Miner, £. L. Meyers, Wilkes-Barrc.
Lycoming Coimty Society— ^V. P. Chaapel, R. E. Re-
walt, C. E. Shaw, Williamsport ■
Montgomery County Society — H. A. Bostock, W. R.
Roberts, Norristown.
Philadelphia County Society— E. L. Bauer, J. M.
Boice, W. N. Bradley, P. B. Cassidy, C. A. Fife, E. E.
Graham, A. Hand, H. L. Hartley, F. C. Knowles, H.
Lowenburg, D. Randall MacCarroll, J. F. Sinclair, T.
H. Weisenburg, Philadelphia.
Somerset County Society — G. F. Speicher, Rock-
wood.
Washington County Society — E. McKay, Charleroi;
C. C. Cracraft, Claysville; C T. Dodd, F. I. Patter-
son, H. P. Prowitt, C,B. Wood, Washington.
Westmoreland Cotmty Society— L. J. Reese, Bolivar.
REGISTERED BUT SECTION NOT DESIGNATED
Allegheny County Society — ^A. G. Sandblad, McKees-
port; O. T. Cruikshank, C E. Fawcett, C. I. Foster,
J. V. Crahek, J. A. Hawkins, L. H. Hector, C A. Hill,
H. J. Hopkins, F. S. Luke, O. L. Marks, C. C. Moore,
C. C. Wholey, H. F. Zinsser, Pittsburgh ; C. K. Mur-
ray, Wilkinsburg; J. M. Haramett, Wilson.
Armstrong County Society— E. C. Winters, Ford
City.
Beaver County Society — L. W. Glatzau, Midland.
Cambria County Society— J. E. Sloan, Johnstown.
Dauphin County Society— J. L. Lenker, H. F. Smith,
Harrisburg.
Fayette County Society— H. J. Bell, Dawsox
Franklin County Society — Harry C. McClain, Hous-
tontown.
Greene County Society — ^J. M. Askey, Nemacolin;
F. S. Ullom, Waynesburg.
Indiana County Society — W. S. Campbell, Dilltown.
Lawrence County Society — J. O. Brown, C. M. Isc-
man, EUwood City.
Mercer County Society — ^A. P. Hyde, Sharon.
Mifflin County Society— B. R. Kohler, Reedsville.
Philadelphia County Society — ^J. D. Blackwood, Jr.,
G. W. MacKenzie, Philadelphia.
Venango County Society— J. F. Davis, Oil City; S.
G. Foster, FrankKn.
Washington County Society — R. A. Spahr, Browns-
ville ; R. S. Clark, Washington.
Westmoreland County Society — G. T. McNish,
Mount Pleasant ; S. S. Wright, Pleasant Unity.
DELEGATES FROM SISTER SOCIETIES
.Connecticut Medical Society — W. H. Donaldson,
Fairfield.
United States Pharmacopeial Association — O. F.
Wolf, Pittsburgh.
GUESTS
J. Whitridge Williams, Baltimore, Maryland; Wil-
liam H. Park, George Draper, James T. Gwathmey. J.
E. Lumbard, New York City; Rea Proctor McFee,
Denver, Colorado ; Crum Epier, • Pueblo, Colorado ;
Walter E. Sistrunk, Rochester, Minn.; Frederick R.
Green, Chicago, 111.; E. A. Peterson, Deborah B.
Richter, Washington, D. C; Thomas E. Finnegan,
Harrisburg; Mary B. Newell, Crawfordsville, Indi-
ana ; Arthur £. Guedel, Indianapolis, Indiana ; Samuel
Johnston, Toronto, Canada; A. H. Miller, Providence,
R. I.; William C. Dansforth, Evanston, Illinois;
Gaenor Jennings, Milton, O.; J. Frank Kahler, Can-
ton, O.; Clyde W. Kirkland, Bellaire, O.; W. S.
Jones, Columbus, O.; C. C McLean, Dayton, O.; T.
T. Church, Salem, O.; E. S. McKesson, Ira O. Den-
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CURRENT MEDICAL TOPICS
121
man, Toledo, O.; William C. Autenreith, Colin R.
Clark, H. E. Patuch, Youngstown, O.; Samuel W.
Dinsmore, S. K. Hall, Irvin D. Meteger, Pittsburgh;
Rev. Maitland Alexander, Hon. E. V. Babcock, Pitts-
biu-gh.
MINUTES OF THE CONFERENCE OF
SECRETARIES
The fifteenth annual banquet and conference of sec-
retaries of the component county societies of the Med-
ical Society of the State of Pennsylvania was held at
the Hotel Henry, Pittsburgh, Tuesday, Oct. 5, 1920.
President William A. Womer, of New Castle, called
the meeting to order at 5: 17 p.m. After two minor
corrections were made, the minutes of the preceding
meeting were approved and adopted.
The president named as a Nominating Committee,
Drs. C. L. Stevens, Athens, Bradford County; Wil-
liam H. Horner, Mt. Pleasant, Westmoreland County ;
Anthony F. Myers, Blooming Glen, Bucks County.
This committee to report later in the meeting.
There being no other business. President Henry D.
Jump, of the State Society, was called upon for a few
remarks. He spoke of each county instituting a imi-
form fee bill for compensation cases, and to influence
its members not to accept less than this fee bill pro-
. vides. Other guests speaking were Dr. J. B. F. Wyant,
trustee; Dr. J. Morton Boice, secretary of the Phila-
delphia Society; Dr. Walter F. Donaldson, state sec-
retary, and Dr. Alexander Craig, secretary of the
American Medical Association, Chicago.
Following this the regular program of the meeting
was taken up, which consisted of a symposium on the
question of "How May We Increase the Mfembership
of the Component County Medical Societies?" This
subject was first taken up by Dr. J. B. F. Wyant, of
Armstrong County, followed by Dr. J. Morton Boice,
of Philadelphia, after which two-minute talks were
had from the secretaries of each society present; 23
secretaries responding on call. Having thoroughly
discussed the various phases of the question as applied
to each of our counties, the meeting adjourned to the
dining hall, where dinner was served to 39 of the sec-
retaries and their guests.
At the close of the banquet the Nominating Com-
mittee reported as follows: For Chairman, J. B. F,
Wyant, Kittanning, Armstrong County; Vice-Chairr
man, Elmer L. Myers, Wilkes-Barre, Luzerne County ;
Secretary, Joseph Scattergood, West Chester, Chester
County; Executive Committee, Boyd B. Snodgrass,
Rochester, Beaver County; J. Morton Boice, Phila-
delphia; John M. Quigley,' Clearfield County. The
report of the Nominating Committee was accepted and
the conference adjourned to meet next year.
CURRENT MEDICAL TOPICS
the after-war public health program of the or-
ganization.
This program, decided on after the signing of
the armistice, aims to concentrate Red Cross ef-
fort on public health work in this country.
Much has already been done. . Last year more
than 30,000 disaster victims were given assist-
ance, more than 26,000 men, still in hospitals as
the result of the war, had Red Cross service,
92,000 women and girls completed courses under
Red Cross nurses in home care of the sick.
Community nurses have been appointed, First
Aid and Dietetic courses given, Health Centers
established — in short, the Red Cross has en-
deavored in every way possible to carry out a
nation-wide campaign against disease.
But to continue, it naturally needs the con-
tinued support of its members. Last year, when
the organization was in the transition stage be-
tween war and peace .work, ten millions, exclu-
sive of the fourteen million Juniors, renewed
their memberships. This year, with the peace
work in full swing, the Red Cross asks each of
these members to pay his dollar and join for
another year. It asks all those who, for what-
ever reason, did not join last year, to become
members now. For it desires to have the whole
American people standing solidly behind it in
the fight for a healthier and happier America.
AMERICAN RED CROSS
THE. FOURTH KED CROSS ROLL CALL
The Fourth Roll Call of the American Red
Cross will be held during the two weeks from
the 1 1th to the 25th of November. During that
time all of the ten million, meinbers who joined
last year will be asked to renew their member-
ships, as an expression of- their faith in the ideal
of service for which the Red Cross stands, and
as an evidence of their desire to help carry out
FROM EDITORIAL NOTES AND COMMENT
Of the recently sdected committee of fifty for
the revision of the U. S. Pharmacopoeia analy-'
sis shows it to include seventeen physicians and
thirty-three pharmacists. Most of the physi-
cians are in active practice of their profession,
while of the pharmacists but three, if we are
correct, operate drug stores, the other thirty
being teachers, research chemists or in related
lines. The committee appears to be very well
balanced, indeed, not from the standpoint of
geographical distribution, but because of the at-
tainments and experience of its members, who
are eminently fitted for the task they, are called
upon to discharge. — American Druggist, Jul^j
lp20.
SEND ON TH5:NEWS
We are anxious to have the medical news of the
state for publication each month in the JdUPMl!'
Marriages, deaths, the removal of physiciatis fromr
one address to another, the electidn ■ of 'ofRcofs 'to'
coimty societies are items that sh6old' bt'< for*r«d«)d>
promptly. Members of the sodety sirtWto'fbrget'lhat.
the Journal is the ofljcial organ i'f'thtf SW«fe Society?-
that each mefnber oWn's as' niiUfeTf' d< vfhfr"/(>«fno/ 'a**
his fellow member.' They fail alio t<» rimembtrttfart •
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122
THE PENNSYLVANIA MEDICAL JOURNAL NoveMBBR, 1920
what they get out of the Journal is what they put
into it.
So far we have received comparatively little as-
sistance from members of the society. We would like
a variety of expression from the members rather than
being obliged to accept several articles each from a
comparatively few physicians.
Doctor, you should take a lively interest in your
own medical Journal; remember it is trying to help
solve your problem. Read every copy carefully and
if you have something for the next or succeeding issue,
don't fail to send it in at once. We want you to take
active interest in the Journal. We want to serve you
and we want you to help us serve the other fellow. —
Illinois Medical Journal, October, 1920.
ANOTHER FALLACY OVERTHROWN
At the request of the Council on Pharmacy and
Chemistry, John F. Norton, of the Department of Bac-
teriology of the University of Chicago, has made an
investigation of the disinfecting value of the so-called
"antiseptic" and "germicidal" soaps.
As a result of an extended research Dr. Norton
comes to the conclusion that, while sterile hands may
not be obtained by the use of the much lauded "anti-
septic" and "germicidal" soaps, a considerable portion
of the bacteria that are found on the hands may be
removed by their use. However, he comes to the con-
clusion that an ordinary toilet soap or the green soap
of the pharmacopeia is more eflScient in germ-remov-
ing properties than these "antiseptic" and "germi-
cidal" soaps, for the reason that the addition of the
antiseptics or germicides is likely to interfere with
the lathering qualities of the soap. In other words,
it is the soap and not the antiseptic or germicide which
accomplishes the removal of bacteria from the exter-
nal surfaces of the human body.
While the great value of substances that kill germs
and of substances that prevent the growth of germs is
appreciated more and more, it is also being recognized
more generally that under many conditions they cannot
be used successfully on' or in the human body. Anti-
septic washes, gargles and lotions had their day with
an ever credulous medical profession until there came
the appreciation that the water used in connection with
these agents deserved the credit for any observed
beneficial effect. As a result. Liquor Antisepticus of
the U. S. Pharmacopeia was "demoted" to the Na-
tional Formulary and, as the latter work is now in
process of revision, it may expect to be "dishonor-
ably discharged."
In the same way, most physicians have come to the
conclusion that intestinal antiseptics are of no avail.
Though scientific proof of the inefficiency of intestinal
antiseptics is still lacking, there is a grawing convic-
tion on the part of physicians that any beneficial ef-
fect that has been observed from the use of intestinal
antiseptics is due to the cathartic that had wisely been
combined with the antiseptic.
As the eflfectiveness of attempts to hinder or stop
the growth of undesirable bacteria becomes more ap-
parent, the question becomes increasingly insistent:
how much harm is done by the use of ineffective anti-
septics and germicides? i. There is the false sense of
security that comes from the use of a "germicidal"
soap that fails to get rid of germs that might have
been removed by a more thorough use of an ordinary
cleansing soap. 2. There is the exposure to infection
which may come through the removal of protecting
mucus by the persistent use of mouth washes and
gargles. An illustration of the second kind was re-
centiy furnished by R. H. Major, in a study of the
reation of bacius influenzae in pneumonia. Major's re-
searches indicate that the invasion with influenza
bacilli injected intravenously or intratracheally. Ma-
jor's experiment suggests the thought that inefficient
medicines may do harm more often than is realized. —
The Journal of the Missouri State Medical Associa-
tion, October, 1920.
AN ALL-AMERICAN HEALTH CONFERENCE
The first of a series of regional health conferences
authorized by the International Health Conference in
Cannes is to be held in Washington, D. C, December
6-13. It will be devoted to a consideration of venereal
diseases which, according to conservative estimates,
constitute one of the world's most terrible plagues.
The conference is being organized under the joint
auspices of the U. S. Interdepartmental Social Hygiene
Board, the U. S. Public Health Service, the American
Red Cross and the American Social Hygiene Asso-
ciation. Prof. William H. Welch of Johns Hopkins
has consented to serve as president, and already as-
surances have been received that some of the fore-
most physicians and sociologists will participate.
Prominent health officers and sociologists from all
parts of North and South America will attend.
The conference will review past experiences and ex-
isting knowledge as to the causes, treatment and pre-
vention of venereal diseases, and will formulate rec-
ommendations relating to a practicable three-year pro-
gram for each of the North and South American
countries participating. In addition it will make sug-
gestions for putting such programs into effect.
In speaking of the proposed conference, Surgeon
General Hugh S. Cumming, of the U. S. Public Health
Service, said : "The United States is in the front rank
of the countries which have organized against the
Great Red Plague, and a consideration of the various
measures which have proved of value in different
communities will tmdoubtedly contribute much to fur-
ther progress in the countries represented at the con-
ference. More than any other important communi-
cable disease, the spread of the Great Red Plague is in-
extricably bound up in a mass of social, economic, edu-
cational and recreational problems. The success thus
far attending the campaign against the venereal dis-
eases is due largely to the fact that this interrelation
has been recognized and that the campaign has enlisted
the cooperation not only of physicians and sanitarians,
but of sociologists, judges, probation officers, educa-
tors, the clergnr and good citizens generally." — October,
1920, The Journal of the Missouri State Medical As-
sociation.
OBJECTION TO MEDICAL SOCIETY DUES
We recently have heard from a county medical so-
ciety secretary in Indiana who says that two or three
well-to-do doctors in his county resigned from the
local medical society when the dues were raised to $5,
and have steadfastly refused to reaffiliate with their
professional brethren ever since. It seems remarkably
strange to us that any member of the regular medical
profession can have the nerve to object to the payment
of $5 a year toward the support of an organization
that is absolutely necessary for the perpetuation of the
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November, 1920
CURRENT MEDICAL TOPICS
123
traditions and present position of the medical profes-
sion as a whole. Purely selfish interests alone should
encourage the medical man to associate himself with
the state medical association, and pay any assessment
that may be asked when he knows that the money so
paid will be for his own as well as the general good
of the profession. The medical defense feature of
our Association alone is worth double what member-
ship costs, and we believe that every member of the
Association will admit that The Journal is worth
the membership fee.
One of the reasons why we never have been able to
accomplish all that should be accomplished in the way
of protective medical legislation and the suppression
of incompetents and quacks, has been because doctors
do not hold together, and many of them are forever
complaining about an insignificant expense which
must be assessed on the individual members in order
to keep up the organization. Even the chiropractors
pay from $io to $15 a year membership dues, and they
cheerfully subscribe from $10 to $100 each toward a
legislative fund for the purpose of paying expenses in
securing the legislation that is favorable to them.
Certainly the members of the regular medical pro-
fession ought to adopt a new spirit of liberality, to-
ward the support of their medical societies, and just
now there is every reason why they should "cut the
belt" and donate to a ftmd to be used in promoting
the right kind of medical legislation, and they are
"cheap skates" if they go at it in a niggardly fashion.
— The Journal of the Indiana State Medical Associa-
tion, September, 1920.
THE NATIONAL RESEARCH COUNCIL.
A -site for the new building in Washington which is
to serve as a home for the National Academy of
Sciences and the National Research Council has re-
cently been obtained. It comprises the entire block
botmded by B and C Streets and Twenty-first and
Twenty-second streets. Northwest, and faces the Lin-
coln Memorial in Potomac Park. The Academy and
Council have been enabled to secure this admirable site,
costing about $200,000 through the generosity of the
following friends and supporters: Thomas D. Jones,
Harold F. McCormick, Julius Rosenwald, and Charles
H Swift, Chicago; Charles F. Brush, George W.
Crile, John L. Severance, and Ambrose Swasey, Cleve-
land; Edward Dean Adams, Mrs. E. H. Harriman,
and the Commonwealth Fund, New York City;
George Eastman and Adolph Lomb, Rochester ; E. A.
Deeds and Charles F. Kettering, Dayton ; Henry Ford,
Detroit; Arthur H. Fleming, Pasadena; A. W. Mel-
lon, Pittsburgh; Pierre S. duPont, Wilmington;
Raphael Pumpelly, Newport; Mr. and Mrs. H. E.
Htmtington, Los Angeles; Coming Glass Works,
Corning, New York. Funds for the erection of the
building have been provided by the Carnegie Corpora-
tion of New York.
PUBLIC HEALTH SERVICE TAKES OVER
ARMY HOSPITALS.
Washington, October, 1920. — Two army hospitals,
one in North Carolina and the other in New York
Harbor, will be taken over by the U. S. Public Health
Service during the present week.
The North Carolina hospital (O'Reilly hospital),
which is at Oteen, eight miles from Asheville, will be
continued as a tuberculosis hospital with about 1,000
beds. Dr. W. M. Foster will be in temporary charge.
The location of the hospital is beautiful and the
institution is admirably adapted to the treatment of
tuberculosis disease. The buildings were erected by
the army for that particular purpose and are superior
to_ most of those in base camps. Two of the wards
will be remodeled; and some additional buildings will
be erected for the use of the staff, especially the mar-
ried staff, for whom no accommodations now exist
The present patients will probably remain, if the
hospital equipment can be taken over with them. The
nurses, except those who wish to take accrued leave,
will remain.
The hospital in New York, variously known as the
Hoff General hospital and the U. S. Debarkation hos-
pital, is at Fox Hills, about ten minutes' walk from the
New York City ferry station at Stapleton, Staten
Island. It will be continued as a general hospital with
a capacity of about 500 beds. Dr. J. O. Cobb, recently
in charge of all Public Health Service activities at
Chicago, will be in charge. By reason of its proximity
to New York City this hospital has available the best
consultation facilities in the country.
.WAR DEPARTMENT SELLS REMAINING
SURPLUS OF HOSPITAL BANDAGES
AND ABSORBENT COTTON.
The War Department authorizes publication of the
following from the office of the Director of Sales :
The Surplus Property Branch, Office of the Quar-
termaster General of the Army has sold to TThomson
& Kelly Co., of Boston, the remaining surplus of ban-
dageis and absorbent cotton, purchased for the use of
the army during the war. The sale netted the gov-
ernment more than $1,000,000. The bandages alone
represent a quantity sufficient to supply the hospitals
and surgeons of the United States with all their needs
for at least eighteen months. The Boston firm was
the highest of a number of bidders for these items.
Included in the sale were a million dozen roller and
between two and two and one-half million compressed
bandages, and approximately two million two hundred
and fifty thousand one-ounce packages of absorbent
cotton.
A NEW DEPARTMENT.
Begmnmg with the January issue, the Medical Re-
tnew of Reviews of New York will inaugurate a new
department for the advancement of the science of
Chemo-Therapy. ^
In order to develop the theories as set forth by the
various investigators who have thus far entered this
field, we mvite the cooperation of all physicians,
chemists, bacteriologists and pharmacologists who are
doing or contemplate doing work along these lines.
It IS our purpose to stimulate a more thorough fun-
damental knowledge of this subject, which so far is
little known to a great number of practicing ohv-
sicians. " f ■>
Believing Chemo-Therapy to be a rich field for the
development of products of great therapeutic value,
and that we have so far neglected to give it the im-
portance that past researches would warrant, we are
placing this department at the disposal of all those who
may find an interest in the subject, as an open forum
where contributions dealing with this science will be
welcomed.
THE BABIES' CHANCE
If the babies of the United States were to hold a
vote as to their favorite cities, tiiey would probably
select Brooklme, Mass.; Berkeley, Calif.; Aberdeen.
Wash.; Mannette, Wis. ; Everett, Mass.; Madison,
\yis.; Piqua, Ohio, or Alameda, Calif.; for these
eight cities, each with an infant mortality rate under
50, give the baby the best chance for its life./ Of cities I
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124
THE PENNSYLVANIA MEDICAL JOURNAL
November, 1920
under 50,cwo population, Burlington, Vt., Paducah;
Ky., and Hannibal, Mo., have the highest death rates,
varying from 145 to 150, giving the baby just one-
third the chance that it would have in any of the eight
cities mentioned above. Of cities from 50,000 to
100,000, Berkeley, Calif., with a rate of 44, Fort Wayne,
Ind., 51, and Topeka, Kan., 59, lead while El Paso,
Texas, with 245, Knoxville, Tenn., 135, and Racine,
Wis., 123, have the ignominy that goes with careless-
ness for the baby's health. Of cities from 100,000 to
250,000, Houston, Texas, with a. rate of 61, Oakland,
Calif., 62, and Cambridge, Mass., 64, compare with
New Bedford Mass., 124, Camden, N. J., 121, and
Nashville, Tenn., n6. Of cities over 250,000, Seattle,
with a rate of 54, Minneapolis, 61, and San Francisco,^
65, compare with Pittsburgh, 115, Buffalo, 107, and
Kansas City, 103. These figures were based on the
reports of 520 health officers in cities of more than
100,000 population. The figures, of course, are ob-
tained only when the number of reported births was
furnished. Chicago, the second largest city in the
United States, failed to give this information on three
requests, and hence is omitted from the table. New
York, with a population of 5,500,000, has a rate of 82,
as compared with an average of 102.2 from 191 1 to
1915. Philadelphia, with almost 2,000,000 population,
had a rate of 90, as compared with an average of
1 17.4 for the period mentioned. The states of Ala-
bama, Colorado, Florida, Georgia, Illinois, Louisiana,
Missouri, Montana, Nebraska, New Jersey, Tennes-
see, Texas and West Virginia are not in the birth
registration area. The American Child Hygiene As-
sociation, which has conducted this investigation,
points out, in a footnote to the large statistical chart
which it has published, the importance of regristration
of every birth. Citizenship and the right to inherit
property, to mention only a few things, may depend
on the fact of the baby's birth having been registered.
The baby ought to have the best chance that his parents
and the state can give him. — Jour. A. M. A., Oct. 16,
1920.
THIS JOURNAL PROTECTS ITS
READERS
The advertising pages of this. Journai, are believed
to be free from all questionable advertisements. No
speculative announcements or unethical products are
admitted to these paiges.
Subscribers may rely on the quality of the goods ad-
vertised in this JouRNAt. The firms are believed to be
financially and ethically reliable. We aim to protect
our readers.
This Is Your Journal
It becomes, therefore, a privilege, as well as an obli-
gation, of our readers to patronize our advertisers.
Let us be consistent as joint owners in our Journal,
and buy goods from our patrons.
THE PENNSYLVANIA MEDICAL JOURNAL
TABLE OF CONTENTS— Continued
(Oontlnned from PMT* U)
structlon, CommisBlon on Cancer, Report of Commit-
tee on Medical Benevolence, Report of the Reference
Committee on Scientific Business, 107 ; Report of
Reference Committee on New Business, 108 ; Elec-
tion of OfBcers, Supplementary Report of the Refer-
ence Committee on New Business, 109 ; District Cen-
sors, 110.
Members of the House of Delegates Answering Roll Call 111
Minutes of the General Meeting Ill
Minutes of the Section on Medicine 114
Members Registered in Section on Medicine 115
Members Registered in Section on Surgery 117
Minutes of Section on Bye, Bar, Nose and Throat Dis-
eases 118
Members Registered in Section on Eye, Ear, Nose and
Throat 11»
Minutes of the Section on Pediatrics 119
Members Registered in Section on Pediatrics 120
Registered But Section Not Designated 120
Delegates from Sister Societies 120
Guests 120
Minutes of the Conference of Secretaries 121
OTniRENT MEDICAL TOPICS 121
INDEX TO ADVERTISERS
Armour & Company cover p. *
B. B. Culture Laboratory cover p. 2
Bauer & Black t
Betz, Frank 8., Company Tl
Brady, Geo. W., A Company il
Bume Brae xvUi
Dental & Surgical Supply Co xU
Deutsch, Max, The Gravid Shoe ziz
Devltt's Camp xi
Feick Brothers Company xil
Horllck's 'Malted Milk Company x
Hynson, Westcott A Dunning It
Intra Products Company xii
Jacobl, Prescription Blanks zlr
Jefferson Medical College xvii
Kenwood Sanatarium zvlii
Kraus, A. H., Prescription Blanks zIt
Lea A Feblger x
Lowy Laboratory, Inc xl
McDonald, Joseph, J Ii
Maltbie Chemical Company It
Manhattan Bye Salve Company xtr
Marshalltown Laboratories xiil
Massey Hospital, The xir
Mayo Foundation, The xii
Mead Johnson A Co xxl
Medical Protective Company vii
Mercer Sanitarium xvili
Metz, H. A., Laboratories, Inc xix
Mosby, C. v., Company Ix
Mutual Pharmacal Company, Inc Ix
Parke. Davis A Co. cover p. 4
Physicians Supply Company xii
Physicians and Surgeons Adjusting Association xli
Pomeroy Company It
Quaker Oats Company Til
Radium Company of Colorado xlx
Rsdlum Laboratory , ... .It
Saunders, W. B., Company cover p. 1
Scherlng A Otatz, Inc xri
Stprm, Katherlne L., M.D. xl
Sunnyrest Sanitarium xvlll
Superior Specialty Company ill
Takamlne Laboratory, The xvl
United Synthetic Chemical Corporation xlr
University of Pennsylvania xrll
Victor X-Ray Corporation it
Winthrop Chemical Co., Inc xx
Woman's Medical College of Pennsylvania xrll
Zemmer Company, The xU
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The Pennsylvania Medical Journal
Owned, Controlled and Published by the Medical Society of the State of Pennsylvania
Issued monthly under the supervision of the Publication Committee
VOLUM? XXIV
NuUBEIt 3
212 North Third St., Harrisburg, Pa., December, 1920
Subscription:
$3.00 PgR YtktL
ADDRESS
THE relationship OF ANATOMY TO
• SURGERY*
WITH SPECIAL REFERENCE TO THE WORK OF THE
LATE PROFESSOR G. G. DAVIS
T. TURNER THOMAS, M.D.
PHILADELPHIA
This is an old subject and has been coming up
for discussion periodically, probably, since the
beginning of anatomy and surgery. The impor-
tance of a knowledge of anatomy to the surgeon
is so obvious that it is fair to assume the needs
of surgery were chiefly responsible for the early
development of our knowledge of gfoss anat-
omy. The great obstacles to dissection of the
human body were slowly overcome, the secrets
of gross anatomy have largely been exhausted
and the subject has become the most definitely
established and unalterable, of the fundamental
branches in medicine. Perhaps nothing in the
history of our profession has shown more clearly
the importance of anatomy in surgery than the
practice, long continued, particularly in England,
of making the same man Professor of Anatomy
and Surgery. The inference is that the best
anatomist made the best surgeon.
But progress required new fields and compara-
tive anatomy, embryology and histology were
developed. These with other laboratory studies
left less time for gross anatomy, and the ten-
dency to ignore it has become pronounced at
times, which neglect sooner or later was fol-
lowed by a protest. It has received scant atten-
tion in surgical literature during the past twenty
years or more, which is a fair indication that sur-
geons generally were not very keen for cadaver
dissection. There are some signs, however, that
the pendulum is swinging in the opposite direc-
tion and that the tide of protest is again rising
against too much purely scientific anatomy in our
curricula and too little practical anatomy. Some
years ago the late Maurice Richardson, in dis-
cussing the surgery of the gall bladder region,
said that we shall never know how many lives
have been lost because of the operating surgeon's
lack of knowledge of the anatomy of this part of
the body. Lane said that if your knowledge of
'The Chairman's address delivered before the Section on
Surgery of the Medical Society of the State of Pennsylvania,
Pittsburgh Session, October s, 1930.
the anatomy is faulty, your knowledge of pa-
thology and surgery based upon it is faulty.
Wm. J. Mayo said recently that the surgeon
of the future must follow in the footsteps of
such men as Deaver. No one could sit under
Beaver's teaching long without learning that he
obtained his working knowledge of anatomy in
the dissecting room, and without becoming im-
bued with the importance of this kind of anat-
omy to the surgeon.
The word anatomy means "to cut up or dis-
sect," and every graduate in medicine knows this
is the most time-consuming, most interesting and
impressive method of studying gross anatomy,
and by the same tokens he knows why the anat-
omy learned in this way stands by him the long-
est and serves him the best in an emergency.
But however well he comes to know the cadaver,
the surgeon soon realizes that the most difficult
feature is to apply that knowledge in practice.
The facts of anatomy are rather definite and
fixed, i. e., there are so many bones, muscles,
etc., but the applicati.->ns of these facts are with-
out limit. For example, the anatomical field ex-
posed by one operative incision will differ very
much from that exposed by another incision only
a short distance from the first one. It therefore
becomes difficult or impossible for any surgeon
to know his anatomy perfectly. We have for
this reason developed methods of studying anat-
otny from different angles.
The term, practicd anatomy, has come to
mean that obtained by dissection, and none is
more practical. Topographical, is usually re-
stricted to surface anatomy or the location of
parts beneath the surface by means of land-
marks, which is of great interest and value to the
surgeon but of limited application. He must
know his anatomy regiondly also, i. e., he must
know a part as a whole and the individual struc-
tures in it in their relations to each other. He
must know-how to expose certain structures and
avoid others which can not be seen. What is
perhaps more difficult is to recognize important
structures which have been pushed out of their
normal positions by abnormal conditions, as
new growths, displaced fragments of fractured
bones, etc.
A disappointing phase of ordinary cadaver
dissections is that in exposing the deeper struc-
tures we must separate or remove the overlying
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THE PENNSYLVANIA MEDICAL JOURNAL December, 1920
structures so that the normal relations are soon
lost and the specimen has then little value for
such study. Special dissections must be prepared
and preserved and this can be done only in an
institution which affords proper facilities. For-
malin hardened bodies furnish material for the
best kind of dissections for the study of regional
anatomy. Improved methods of preservation
permit the gradual accumulation of a very valu-
able collection. Most surgeons must depend
upon book descriptions and illustrations which
are very inadequate. Probably the best oppor-
tunity to refresh one's knowledge of the subject
is by attendance, for a short period, at an insti-
tution where he may dissect a body in the ordi-
nary way and have the privilege of studyipg
many excellently prepared and preserved speci-
mens of special parts. He can study surface
anatomy at any time on the living. He should
first be well acquainted with the essential facts
of descriptive anatomy in order that he may
know what he is trying to locate by surface land-
marks. Cross sections of frozen or formalin
hardened bodies may be brought to the surgeon
by means of good photographs but the number
available will be very limited because of the cost
of reproduction. They will give phases of anat-
omy that can not be obtained in any other way,
but like other methods, this one has very definite
limitations. No surgeon can carry mental pic-
tures of many cross sections, and if he tries they
will become very confusing. The surgeon who
starts out to acquire a thorough knowledge of
anatomy will become dissatisfied because he is
attempting the impossible.
Descriptive and dissecting room anatomy were
first thought to satisfy all needs, but topograph-
ical, regional, surgical and applied anatoipy,
were developed more or less successively to fill
the defects which had developed. The only dif-
ference between surgical and applied anatomy
is that the former is concerned only with surgery
and the latter attempts to cover the whole of
medical practice. Probably few recognize the
deficiencies of both, especially of the latter. As
already stated, the facts of descriptive anatomy
are more or less limited, but the possible appli-
cations of these facts are without limit. This is
what discourages the average surgeon who
makes the eflfort to refresh his knowledge of the
subject. He needs to know the field of opera-
tion in any part of the body and the picture will
vary according to the site of the incision. In the
abdomen it will be complicated by the changing
positions of the viscera.
But it is these very difficulties which make the
study worth while. If we could overcome them
the field of surgery would broaden materially.
The average abdominal surgeon knows where a
few concealed structures lie. He knows that he
can safely tie the ovarian and uterine vessels
and avoid the ureter so that he may remove dis-
eased structures, but few will care to lift the pa-
rietal peritoneum, as for the removal of lymph
nodes. We do most abdominal operations ac-
cording to chart, i. e., according to the descrip-
tion of the originator of the operation or its
variation. Operations on clean joints are con-
spicuous by their inf requency. A free exposure
of any joint capsule, except that of the loiee, is
impossible and a limited exposure calls for a
good knowledge of the route of approach. With
our present methods and knowledge of anatomy
there is too much mutilation which facilitates in-
fection.
Originality in this field is not looked for. New
developments are conspicuous by their infre-
quency. Twenty-five years ago on graduating
from the medical school I was imbued with the
importance of a knowldege of anatomy in sur-
gery, but I soon learned that it was a poor field
for investigation. Then came the opportunity
of becoming associated with the late G. G.
Davis, when he becjime the Associate Professor
of Applied Anatomy in the University of Penn-
sylvania. This occasion will not permit even a
modest attempt at an appreciation of his work
in this field. After a previous five or six years'
work in routine dissection and the teaching of
operative surgery on the cadaver I felt that I
knew about all there was to learn of this kind of
anatomy. Except for a little teaching of opera-
tive surgery on the cadaver, Davis had been con-
fined for years to clinical surgery, both general
and orthopedic, and he was not burdened with
routine ideas about the teaching of practical
anatomy. It soon became evident that he had
new ideas and good ones. At first I was in-
clined to offer suggestions but soon concluded
that it would pay better to watch his work for
he was clearly ploughing new ground. He soon
furnished an abundance of new viewpoints or
new angles from which to study old surgical
problems.
The temptation here is to supply examples of
which there are many, but the time and space
will not permit. He insisted on demonstrating
what he taught, and if the subject did not fit the
demonstrative method he got rid of the subject.
He could use his time to better advantage on sub-
jects that responded to demonstration, of which
there were plenty. He was revolutionary but he
got results.
My most intimate association with his work in
applied anatomy was during his first five and
most enthusiastic years, and I saw in it a certain
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RELATIONSHIP OF ANATOMY— THOMAS
127
something which is very difficult to describe.
He was turning up rich soil for new ideas, so
that one needed only to watch and follow him
to be abundantly rewarded. The greatest diffi-
culty comes when an attempt is made to tell what
such ideas were like. They were too numerous
and indefinite and as a matter of fact required
much time for study. For fifteen years it has
been my chief purpose to prove the value of as
many as I could find time to work out. Prac-
tically everything I have written in that time has
had its origin, directly or indirectly, in anatomi-
cal suggestions picked up from Davis' work. It
has long been my desire to give some estimate of
the value of his anatomical work but have been
deterred by the realization of the fact that it can
not be measured. One of the most persistent
memories is of the acute interest aroused by my
first sensing his basic purpose in attacking his
new responsibilities as a teacher of applied anat-
omy. I had heard many teachers on practical
phases of anatomy and had come to think that
there was only one way to do the work, i. e., to
have a good dissection from which practical ol>-
servations could be made. Surface anatomy was
taught, of course, from the undissected body,
but for the most part the dissected body was the
text around which the lessons in practical anat-
omy were grouped, ligations of arteries, frac-
tures, dislocations, etc.
Davis simply reversed this formula and made
an important condition, usually a surgical one,
the text or central theme, and made the anatomi-
cal dissection secondary to it. This was radical
but very promising. He permitted anatomy to
become important only in so far as it contributed
to the teaching and the solution of the difficulties
associated with that clinical condition. Like all
other methods of making anatomy more valu-
able to the practitioner, this also has its limita-
tions, but Davis carried it as far as possible to
all parts of the body and fell back on older meth-
ods when necessary. Of course it is impossible
to give here satisfactory illustrations of his idea
but it may be permitted to make one attempt, by
taking the subject of dislocations of the shoul-
der. To cover this subject he would reserve one
side of a body undissected to demonstrate the
normal shoulder landmarks and relations, and on
the other side he would produce a typical ante-
rior or subcoracoid dislocation by hyperabduc-
tion. It is of much importance to appreciate
that a cadaver dislocation so produced will have
all the earmarks of the common dislocation in
life, the typical displacement, flattened shoulder,
humeral head under the coracoid process, etc.,
and that in all probability the lesions occurring
in the cadaver are essentially the same as those
in life. If this is true, and so far as my clinical
observations will show, it is true, then these cad-
aver dislocations gave excellent opportunities
for studying the mechanism, pathology and
treatment in the living. Most of our exact
knowledge of dislocations of the hip has come
from similar studies in the cadaver. Besides an
ordinary dissection of the normal shoulder re-
gion, he would make numerous special dissec-
tions of the important blood vessel and nerve re-
lations about the joint and similar dissected
specimens of dislocated shoulders. This meant
milch work but it also meant that Davis taught
dislocations of the shoulder as they had prob- •
ably never been taught before. I have never
seen in the literature any reference to such
teaching. The value of his teaching was not
confined to the shoulder by any means but had
a wide application which can not be further dis-
cussed here.
The following incident will illustrate my faith
in his results, and many similar ones could be re-
lated. In 1907 a friend asked if a radical cure
by operation was possible for a recurring dislo-
cation of the shoulder. He had an athletic friend
with this condition who had gone the rounds of
physicians and surgeons (the patient afterwards
told me he had counted as many as forty of
them) and had been advised by all to "let well
enough alone" and that if he submitted to opera-
tion he was liable to end up with a stiff shoulder
and shrivelled arm. In view of my work with
Davis the question was a very interesting one,
but I was compelled to admit that I had not
seen such an operation, had not read or heard of
one. I added, however, that because of my ex-
perience with dislocations of the shoulder on the
cadaver I believed such an operation could and
should be done. I took the first opportunity of
looking up the literature and found that the
operation had been done successfully through a
delto-pectoral incision sometimes with a modifi-
cation. I operated on this patient in January,
1908, doing a capsule operation for the first time
through the axilla. The patient continued his
athletic work, has never had another dislocation
and has given me a photograph of himself stand-
ing on that hand to prove his faith in the good
results of the operation. The special purpose
here is to emphasize the value of Davis' work in
applied anatomy, particularly his efforts to re-
produce surgical conditions on the cadaver and
study them. The problem presented to me by
this patient was new and to all but a few sur-
geons, most of them in Europe. A study of the
literature up to that time showed it to be very
scanty and very confusing. The pathology and
treatment was very unsettled. A half dozen or
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128
THE PENNSYLVANIA MEDICAL JOURNAL December, 1920
more causes were assigned and the operative
treatment was said to vary with the cause.
Davis' work told clearly and positively the na-
ture of the lesion and some of its most important
modifications, its exact location and the difficult
but decidedly the best route possible for expos-
ing it. There was nothing in the literature to
compare with it for reliable guidance in attack-
ing this practically new and troublesome prob-
lem in surgery. Because of my knowledge of
and faith in it I exposed the capsule through the
axilla in my first case and in the forty similar
shoulders which I have operated on since. . I
liave now no expectation of using any other ex-
posure in that kind of dislocation.
The underlying thought in his work was to
clear up the anatomical difficulties of a surgical
condition in the simplest and most direct man-
ner and he (Davis) seemed always to be think-
ing up and working out new ideas. He prepared
and preserved many beautiful and practical ana-
tomical specimens usually from formalin har-
dened bodies. The essence of his results was the
ploughing of rich soil for himself and others to
cultivate.
ORIGINAL ARTICLES
RECTAL DRAINAGE FOR PELVIC
ABSCESS*
ROBERT M. ENTWISLE, M.D.
PITTSBURGH
Vaginal section for pelvic peritonitis, although
not so frequently done as formerly, is still ai
very useful procedure. Undoubtedly many of
the pelvic abscesses so drained were appendiceal
in origin. It is for an analogous condition in men
and children that the procedure of rectal section
is reported. It is very probable that the opera-
tion was first suggested by nature as a case is
occasionally seen where there has been a spon-
taneous rupture of an abscess into the rectum
with usually the most favorable result.
The drainage of a pelvic abscess through the
anterior wall of the rectum is not meant as a
substitute in any way for the accepted approach
through the abdominal wall, but is reserved for
those cases which do not do well following
operation and in which there is found a large
bulging mass in the pelvis which obviously is
not draining through the original incision.
The operation has been done many times by
Madaren and Ritchie both as a primary pro-
cedure in cases of severe generalized peritonitis
with a large collection of fluid in the pelvis and
'Read before the Section on Surgery of the Medical Society
of the State of Pennsylvania, Pittsburgh Session, October s,
1930.
as a secondary adjunct following the abdominal
operation. It is of the latter t)T)e of case that
the two histories are presented in this paper.
The symptoms of an undrained pelvic abscess
are simply those usually found in a patient who
is not doing satisfactorily following removal of
the appendix, but who obviously has not devel-
oped a generalized peritonitis. Pain, distension,
and clinical signs of inflammation do not entirely
clear up, fullness in the lower abdomen is com-
plained of, and, in one of our cases, there was
severe rectal tenesmus.
The diagnosis is made upon doing a rectal ex-
amination. A soft fluctuating tender mass is
felt in the anterior wall of the rectum. In both
of our cases it was noted that there was con-
able relaxation of the sphincter.
The operation is extremely simple. The pa-
tient should be catheterized and put in the lithot-
omy position. The sphincter is stretched, if nec-
essary, and the index finger of the left hand put
into the rectum and used as a guide. A blunt-
nosed hemostat of any kind is then introduced
gainst the bulging walls of the abscess, pushed
through and then opened to stretch the aperature
made. Drainage material is introduced and a
dressing applied which helps to retain it in
place. In both of our cases the tube was ex-
pelled within twenty-four hours, but this had no
eflFect on the convalescence, as the opening made ■
remained patulous until the abscess became ob-
literated. A "T" tube, as advised by some, might
obviate this but it appears hardly necessary to
have any drainage as an opening in a ripe ab-
scess so placed is sufficient. We have recently
had an opportunity to observe a spontaneous
rupture of an appendiceal abscess into the rec-
tum in which the opening remained patulous,
without resort to surgical aid, until recovery en-
sued.
While very few cases of appendiceal abscess
fail to drain through the abdominal wall, the
knowledge that such things do occur should lead
us to routine rectal examinations on patients suf-
fering from all forms of peritonitis. When such
a condition as described ils found, the result of
this simple opening through the rectum will be
found very gratifying.
Case I. S. McC. Male. Age 25. Farmer. Ad-
mitted to St. Francis Hospital, Jan. 11, 1920.
C. C. Pain in lower abdomen; pain on urination.
H. P. I. Ten days before admission, following an
enema which the patient had been accustomed to tak-
ing, he noticed a slight pain in the suprapubic region.
The pain persisted during the ten days, each day be-
coming more severe, and more generalized over the
entire lower abdomen, especially on the left side. It
was not of the colicky variety.
The patient took several cathartics during this time
but a satisfactory bowel movement was not obtained,
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December, 1920
ABDOMINAL DRAINAGE— CROW
129
although he passed gas and small amounts of fecal
matter. He was nauseated but did not vomit.
From the beginning of his abdominal discomfort he
also complained of a boring pain on urination. There
was no frequency.
P. M. H. Nine months ago the patient had an at-
tack of right-sided abdominal pain with vomiting and
fever which lasted two days.
Two and one-half years ago he swallowed lye by
mistake and has been treated at intervals since then
for an oesophageal stricture.
Examination : T. loo— P. 90— R. 26. W. B. C. 7,600.
The entire abdomen was moderately distended and
slightly tender, but this was most marked below the
umbilicus, especially over the bladder and the right
iliac fossa. In this area there was moderate rigidity.
Peristalsis very feeble but present. No mass palpated.
On rectal examination a soft, very tender mass the
size of a croquet ball was fotmd presenting itself on
the anterior wall, a finger's length from thcianus.
He was catheterized at once, clear urine obtained
and no difference in the size of the mass noted.
The following day through an abdominal incision
a large pelvic abscess was drained and a gangrenous
appendix removed.
The patient had very little reaction from the opera-
tion but from the first his convalescence was a dis-
appointment. The abdominal wound drained profusely
but he continued to complain of pain and fullness in
the lower abdomen as before operation. Daily ex-
amination of the rectal mass revealed that it was not
decreasing in size.
Each day there wasr noted an increase in the ab-
dominal distension with decreasing effectiveness of
enemas. Temperature and pulse were normal during
this period but the leucocytes had risen to 10,000.
Ten days after the first operation, he was again
anesthetized and an opening made into the mass
through the anterior rectal wall. Five or six ounces
of foul smelling pus were recovered and a drainage
tube inserted. The recovery from that time was
prompt and satisfactory and he was discharged en-
tirely well three weeks later. A recent examination
has shown no recurrence of trouble.
Case II. G. P. Boy. Age 16. Admitted to St.
Francis Hospital, Feb. 10, 1920.
C. C. Pain and tenderness over entire abdomen.
H. P. I. Four days before admission he developed
a fairly severe pain around the umbilicus. During the
following night the pain became more severe and
localized itself over the right iliac fossa. He was in
bed up to the time of admission and was given two
cathartics by mouth. On the fourth day he vomited
for the first time and the pain became very severe
and was felt over the entire abdomen.
Examination: T. 102— P. 132— R. 30. W. B. C.
26,000.
Patient had the appearance of being very ill. Respi-
rations entirely costal in type. The abdomen was very
slightly distended but was tender throughout and ex-
quisitely so over the right iliac fossa. There was
marked rigidity and absence of any peristalsis.
At operation which was done at once, a diffuse per-
itonitis was encountered and a gangrenous appendix,
without gross perforation, removed. The pelvis, ap-
pendiceal and right kidney regions were drained.
The patient had an excellent convalescence for the
first thirteen days. The wound drained a small amount
of pus, the clinical signs of inflammation subsided,
there was no pain and the bowels moved without
enemas.
On the fourteenth day he complained of pain in the
lower abdomen which was promptly relieved by an
enema. The following day there was a repetition of
this but the enema did not entirely relieve him this
time. On the sixteenth day the patient noticed a se-
vere pain in the rectum and stated that there was
clear fluid being discharged all the time which burned
his buttocks.
A rectal examination was then made for the first
time. There was a moderate degree of proctitis with
a very much relaxed sphincter. Upon palpation a
soft tender mass, the size of an orange was found pre-
senting itself into the anterior wall of the rectum. ,
Under ether, an opening was made into this and
about three ounces of very foul pus obtained. A tube
was inserted. The recovery following this was also
prompt and satisfactory and the patient discharged
cured twelve days later. He has remained entirely
free from symptoms up to the present time.
ABDOMINAL DRAINAGE*
CONDITIONS MET WITH IN ABDOMINAL OPERA-
TIONS WHICH DEMAND ABDOMINAL DAINAGE
WITH SOME CONSIDERATION OF FACTORS
GOVERNING THE ADVISABILITY OF
DRAINAGE IN CASES IN WHICH
DRAINAGE IS A QUESTION
ARTHUR E. CROW, M.D.
UNIONTOWN, PA.
It affords me great pleasure to bring be-
fore you for your consideration, your delibera-
tion and your discussion a subject matter which
concerns conclusive action at a time when human
life is entrusted to your judgment. A subject
matter which has since the beginning of opera-
tive measures for the relief of trouble within the
walls of the abdomen baffled all alike. A subject
which has developed surgical thinkers and surgi-
cal actors. We can all look back over our past
and recall not one but many cases whose regret-
ful termination came as a result of the fact that
life's doors were closed and nature left to strug-
gle with a condition in which surgical interfer-
ence failed completely in its part. History is re-
plete with mistakes but I dare say the mistakes
which have been thrust upon the peritoneal cav-
ity and the peritoneum outnumber all others.
Abdominal drainage or drainage of the perito-
neal cavity invites consideration whenever it is
opened. No one knows absolutely what throw-
ing open the door is going to disclose and no one
knows absolutely what closing the door in cases
in which the question of drainage has arisen is
going to develop. The swing of the pendulum
has been and will be back and forth when the
consideration of this subject is brought before
our best surgeons, and to-day we find many of
'Read before the Section on Surgery of the Medical Society
of the Sute of Pennsylvania, Pituburgh Session, October 5,
1920.
Digitized by
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130
THE PENNSYLVANIA MEDICAL JOURNAL
December, 1920
our leading men closing the abdomen who but
a year ago made it a routine to drain and be safe.
There is no doubt but that they are getting away
with their new fashion in the vast majority of
cases but I dare say the hour of unrest has come
to them all and the regretful termination hap-
pens, all because they have established a routine
method. In this particular I refer to the gall
bladder removal more than to other conditions.
It seems to me, little, if any, danger can follow
the establishment of drainage in all our border
line cases if not all our cases of removal of the
gall bladder.
When we consider the question of leakage and
the possibility of infection from other causes we
can not help but doubt the advisability of closing
and saying to nature we have done our bit — you
finsh. I fear this is done too often. But a year
or two ago few such chances were taken by the
majority of surgeons. To-day many are clos-
ing without drain. When a cigarette drain can
be used for a day or two without any danger,
why permit that element to enter into it? We
can not compare the removal of the gall bladder
with the removal of the appendix and close the
abdomen for similar reasons ; in the one we are
able in the majority of instances to invaginate,
and in the other we are not.
Of all the pathology existing within the abdo-
men there is nothing productive of as much di-
versity of opinion as that surrounding the ap-
pendix. A study of the true range of trouble
found along the line from the simple catarrhal
to the acute suppurative form brings us face to
face with the problems which only experience is
able to fathom and foster. The question of drain
in the simple catarrhal case can be set asideand
the same can be said of a majority of the cases
in which we have pus confined within the walls
of the appendix and the technique of the opera-
tor has enabled him to remove the appendix
without its rupture and without contaminating
the peritoneum, but we are not always sure that
this has happened, and where there is that ele-
ment of uncertainty surrounding the life of the
individual it matters not what that practice or
that custom has been, let these things be set
aside. I mean by this that too often the abdo-
men is closed and the mistake closed with it when
drainage would have saved the day ; this I again
say happens more in dealing with the appendix
than with any other surgical trouble within the
abdomen.
When we cut down on an appendix blooming
with congestion and a surrounding inflammation,
with an exudation already started but the real
pus stage not reached, is it right for us to say to
nature, "This is within your scope ;" we will re-
move the source of trouble and leave the rest to
you? I believe we are in many of these cases
stopping too soon; we have not completely
shouldered the responsibility of the hour until
we have established drainage; we all want to
close the abdomen as often as it is possible to
close it, but I fear it has too often become a habit.
Any penetrating wound of the abdomen cer-
tainly demands immediate operation and drain-
age. An injury causing the rupture of the liver,
the bowel, the spleen, the kidney or any internal
viscus, should, in nearly all cases be drained, and
many of these cases will get along when drain-
age alone is resorted to.
This brings us finally to a hasty consideration
of the pelvic troubles. I believe that one can de-
cide thfe question of drain with greater ease in
<lealing with pelvic surgery than with any other
part of the peritoneal cavity. It is only the ex-
ceptional case that can not be closed without
drain when pus has not been met with, but when
pus has invaded the field of operation drainage
is certainly the proper course to pursue.
I believe that the day has come when judg-
ment says to practice, you have had your day,
you have triumphed over your successes, but you
have forgotten your failures; you have spread
upon your statistical records only the results
which have made you proud, forgetting all the
while the incidences which during your wakeful
hours haunt you. I believe that the day has
come or will soon come when the definite and
defined ways of procedure, as directed by many
as a routine, will give way to the applied judg-
ment in the individual case.
CECAL STASIS AND ITS RELATION-
SHIP TO APPENDICITIS*
RICHARD J. BEHAN, M.D.
PITTSBURGH
I feel that in presenting the subject which I
have 'taken for my paper of to-day, to you, that
I should apologize for attempting to traverse
ground which has been so ably covered by such
workers in this field, as Kelly, Deaver, Robin-
son, Hertzler, and others.
However, I believe that when you recall the
number of cases which you have had return to
you after appendiceal operations, complaining of
the same symptoms for which the appendicec-
tomy had been done, — when you recall these
cases, I feel that you will agree with me that
after all, possibly there is some need for further
discussion on the subject of appendicitis and its
related conditions.
•Read before the Section on Surgery of the Medical Society
of the State of Pennsylvania, Pittsburgh Session, October 5,
1920.
Digitized by
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December, 1920
CECAL STASIS— BEHAN
131
Symptoms for which the patient returns to the
physician after an operation for appendicitis, are
usually associated with the formation of gas.
The patient claims that after eating, or at other
times irrespective of the taking of food, he has
a considerable abdominal distention. This
causes him great distress, which is usually re-
lieved by the belching of large quantities of gas,
usually odorless, or by the passage of gas per
rectum. In some cases, however, there is neither
belching nor rectal passage, the gas being ab-
sorbed by the intestinal mucosa. In many of
these patients, the symptoms now complained of
have come on shortly after the operation, in
some instances even before the patient has left
the hospital. In other instances the symptoms
do not appear for six months or a year or even
two years after operation. After onset the ten-
dency is for them to gradually increase in se-
verity.
The usual diagnosis made of this condition is
that of abdominal adhesions, the result of the ap-
pendiceal operation. With this diagnosis I would
like to take issue, because I believe that the con-
dition which exists postroperatively, had existed
prior to operation, and that even though the
symptoms are due to the end result of adhesive
formation, this adhesive formation was present
at the time of the original operation. That these
symptoms for which the patient had been oper-
ated were not due to the appendix is self-evident
from the fact that they were not relieved by the
appendicectomy. The mere fact that the same
symptoms did persist, or did return after the re-
moval of the appendix, seems to be positive
proof that the appendix itself was not the orig-
inal cause of the trouble. If we reoperate such
a patient it is usual to find that the ceciun is en-
larged and is held firmly by broad bands of ad-
hesions, either to the lateral abdominal wall, to
the brim of the pelvis, or in some cases to the
adjacent ileum and mesentery. In some very
rare instances also the omentum is adherent to
the cecum. It is these adhesions resulting in
cecal enlargement which are the causes of the
patient's complaint, and it is necessary in order
to cure the patient of his distress, that the adhe-
sions both be separated and be hindered perma-
nently from reforming, and that the cecal
enlargement with stasis be corrected.
The cecal stasis and enlargement may be due
to either anatomical defects, such as (i) an ab-
normally large cecum, (2) a prolapse of the
transverse colon with firm union at the hepatic
flexure of the colon to the liver, thus producing
a sharp bend or kink with resulting back pres-
sure, (3) a marked Jonnesco's membrane which
is mudi thicker and stronger than usual.
Neuroses may act as causative factors. In
such cases there is a paralysis of the vagus sys-
tem with dilatation of the cecum and intestine
with the collection of flatus and resulting stasis.
Cecal stasis may also be caused reflexly by dis-
ease of the gall bladder, the kidneys, the stomach,
the appendix, and the ovaries.
Drugs also may act as causative factors; for
instance, the first effect of morphine on the in-
testine seems to be a paralysis of that portion of
the bowel where the fecal contents are of a firmer
consistency, namely, in the descending colon and
in the sigmoid. However, it is conceivable that
the paralysis may also affect the cecum so that
the propulsive force to the faeces is diminished,
jhe fecal contents remain in the cecum, and the
foxins, etc., which are generated there pass
through the wall and give rise to a low grade in-
flammation.
Mechanical factors also may cause fixation of
the cecum with consequent dilatation and en-
largement, as froni an appendix which is adher-
ent and is bound to the surrounding structures;
or from adhesions not appendiceal in origin, but
due to previous operations, either appendiceal or
gall bladder, or to peritonitis, (traumatic or
bacillary).
An enlarged cecum may also cause adhesions
between itself and the surrounding structures,
such as the psoas muscle. This is the result of
the so-called muscular trauma of Robinson, who
describes it as the effect of two peritoneal sur-
faces constantly being in forcible apposition.
When this occurs, as he says, there is a resulting
degeneration of the opposing serosal cells, so
that fusion and direct union occurs.
As the cecum enlarges and the cecal stasis be-
comes more pronounced, there is a gradual seep-
ing through of toxins, the result of the bacterial
activity of the organisms present in the contents
of the cecum. As a consequence of the presence
of this toxic material upon the serosal surface of
the cecum, a low grade, plastic peritonitis results,
with the formation of adhesions. That such ad-
hesions can be the result of bacterial influence
without direct infection may be seen in the
cholecystitis chronica, in which adhesions fre-
• quently connect the gall bladder to the omentum,
the stomach, etc., these adhesions not being the
result of developmental defects, but the result of
intraluminary, bacterial activity.
The most potent cause of cecal stasis is ob-
struction of the ascending colon at the hepatic
flexure, due to a kinking of the bowel in this
location. This kinking may follow a ptosis of
the transverse colon, or be the result of traction
by bands, either congenital or inflammatory. In
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THE PENNSYLVANIA MEDICAL JOURNAL December, 1920
any case, when kinking occurs, there results a
stasis of the cecal contents.
Adhesions in many cases connect the cecum
with the appendix, so that finally as they contract
they produce kinks and strictures of the appen-
dix, which in turn develop appropriate conditions
for the induction of inflammatory changes in the
appendix. That chronic infection in the appen-
dix is frequently secondary and not the predis-
posing factor in periappendiceal and pericecal
adhesions, is indicated, first, by the ease with
which the adhesions are stripped from the appen-
dix; second, by the fact that the adhesions are
densest in the region of the ileocecal valve;
third, by the fact that after removal of the ad-
hesions, or after stripping them away, a smooth
glistening surface of the serosa comes to view,
thus showing that the cause of the adhesive for-
mation could not primarily have been due to an
inflammation of the serosa of the appendix.
This later view is gradually obtaining converts.
Last year Brown stated that he believed the
chronically inflamed appendix . represents but
one phase of a diffused low grade peritonitis, in-
volving the ileum, the cecum and ascending
colon, and frequently the pelvic organs as well.
The symptoms resulting from cecal stasis and
pericecal adhesions, with sometimes an associated
chronic appendicitis, may be divided into the sub-
jective and the objective. By the subjective symp-
toms we mean those which rise from no apparent
exciting factor. By the objective we mean those
produced by the action of the examiner. Sub-
jective symptoms in turn may be divided into
four groups:
1. Those which are purely mechanical, arising
directly from the dilatation of the bowel without
any interference from neighboring organs.
2. The symptoms arising from the dilatation
.producing interference on neighboring organs.
3. The symptoms, the result of absorption of
toxic material from the enlarged cecum.
4. The symptoms resulting from stimuli re-
flected from the enlarged cecum and the adja-
cent affected organs.
The chief symptoms due to mechanical causes
are, i. Pain, or rather a discomfort in the right
iliac region. This pain is not localized definitely .
to a small area of the abdomen, but is more or
less diffused, and is much increased by the pres-
ence of gas in the bowel. It sometimes becomes
colicky in character, the colic likely being the re-
sult of the sudden restriction of the onward pro-
pulsive movement of the fecal masses. Reflected
pain may occur in any quarter of the abdomen,
but it is usually present in the zone of the ab-
domen enervated by the same cord segment as
that supplying the cecum. In some cases the
pain is referred across the epigastrium.
Cecal pain may be caused by hyperdistention
of the cecum, by pulling on the mesocecum, or
from increased interluminary pressure with
stretching of the muscular layers, or to the
traction of the cecoparietal bands, either those
which are normally present, or those which are
abnormal and are termed adhesions.
The pain or distress due to cecal enlargement
is modified by the mobility or fixity of the
cecum. When the cecum is free and is very mo-
bile, and is attached by a short mesocecum to the
mesocolon and mesentery, the dragging and dis-
tress are of the same character as that produced
by other viscera which are in ptosis, and is re-
lieved by measures which correct the ptosis. I
should emphasize that ptosis of the cecum alone,
as is true of other viscera, will not produce pain
unless there is obstruction to the onward flow of
the contents.
Yet in some cases there is an indefinite sensa-
tion of distress referred to the section of the ab-
domen usually associated with ileoceco disturb-
ances, that is to the region of the umbilicus.
This dragging, unpleasant sensation, sometimes
amounting to pain, is likely the result of traction
on the ileocecomesentery by the heavy, over-
weighted cecum. When colicky pain is com-
plained of it may in a minor degree be due to the
muscle tension reaction as is described by Hertz.
When adhesions bind the cecum to the parietal
wall or to other viscera, the pain is of the peri-
toneal type, and is sharper and more definitely
distressing. It is due to pulling on the perito-
neum, or to dragging on adjacent viscera by ad-
hesive bands. In this type there is frequently
found on palpation tenderness, which is localized
to the outer lateral margin of the abdomen above
the iliac crest. In this type as the cecum en-
larges, it produces traction on the ileocecal mes-
entery, and as it passes downward there may oc-
cur the dragging and distressing sensations
which we have described under the mobile cecum,
— so that in old, well-developed cases with en-
larged cecum and marked pericecal adhesions,
there is present both local tenderness and um-
bilical distress.
Constipation is also a usual accompaniment
of cecal enlargement and pericecal adhesions.
This constipation is not relieved by oil or by
magnesium sulphate, but is frequently tempo-
rarily corrected by pituitrin. Diarrhea may
alternate with the constipation. Constipation
is the result of the collection of fecal material
in the enlarged cecum, which because of its sur-
rounding adhesions is unable to force the fecal
mass onward and upward.
In the second group of symptoms, the so-
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December, 1920
CECAL STASIS— BEHAN
133
called toxic group, we find pains in the limbs,
thyroid enlargement, slight fever, and in some
cases a rapid pulse. It is peculiarly impressive
in many instances of this condition to find as as-
sociated thyroid enlargement. The exact pro-
portion of cases I have not statistically studied,
but I am sure there is a large percentage of pa-
tients with cecal stasis who have thyrotoxic
symptoms. The evident relationship is marked.
There can be no doubt that the absorption of
toxic material does produce many deleterious
changes in the body. These deleterious effects
are expressed in terms of headaches, mental and
physical exhaustion, or intellectual sluggishness.
If we closely question such a patient we learn
that he has had in years gone by, an attack of so-
called appendicitis, and further questioning may
bring out the fact that he is subject at times to
considerable abdominal distress which he attrib-
utes to gas. He usually localizes the distress in
the right iliac fossa. If we question him fur-
ther we may ilicit definite symptoms of cecal
stasis.
In the third group of cases we have many re-
flex symptoms referred to the stomach, such as
nausea, coming on at indefinite periods, some-
times associated with the taking of food, and at
other times having no such relationship. Hyper-
acidity of the stomach, as indicated by water
brash, heart burn and palpitation, may occur.
Vomiting is sometimes present following the
water brash and nausea. In other cases there is
no nausea. Vomiting comes on in the morning
and in some instances may be confused with the
morning vomiting of pregnancy.
The fourth group of symptoms are the result
of pressure upon neighboring organs, or are due
to the traction of bands which have become
united to adjacent organs such as the ovary and
fallopian tube or gall bladder on the right side,
and the sigmoid on the left. Especially is this
so if the adhesions are the result of an acute ap-
pendicitis, with resulting attachments of the ap-
pendix to the peritoneum in the region of the
mesonephron and mesosalpinx. Sometimes trac-
tion on the ovary and tube may cause a partial
obstruction of the tube and congestion and cir-
rhosis of the ovary. These changes are particu-
larly manifested at the time of the menstrual pe-
riod by increased pain and tenderness in the af-
fected area. In other instances traction by ad-
hesive bands or by pressure of the enlarged
cecum on the right ureter has produced hydro-
nephrosis of an intermittent type. This in one
or two cases has been definitely proved by
the relief which the patient obtained upon the
passage and retention of a ureteral catheter, and
also by the complete relief which followed opera-
tion. In one case an appendix passed across and
obstructed the right ureter. In another case the
freeing of a large and very adherent cecum from
its bed, so that it could easily contract without
producing pressure upon the ureter, relieved an
intermittent hydronephrosis. In other cases
pressure may be exerted upon the ileolumbar
nerve so that a referred pain is felt in the scro-
tum or may be referred directly down the thigh.
In still other cases the pain may be complained
of on the left side of the abdomen when the ap-
pendix is adherent to the mesentery. In still
other cases the pain may be present in the exter-
nal inguinal ring. In one patiefit the pain was
complained of in the right axilla. In another
. patient, pain of a cutting character was present
on the right side and radiated upwards. It be-
came less intense upon lying down.
In some cases the appendix may lie back of
the cecum and be entirely retroperitoneal. In
such instances overfilling of the cecum is apt to
distend the anterior portion and distort the area
of the ileocecal valve. When.it does so, dis-
turbances of fimction of the ileocecal valve may
result, and it either becomes incompetent and al-
lows chyme to easily regurgitate back into the
ileum, or it is so constricted that a relative
stenosis with retardation of the forward prog-
ress of the chyme results.
While subjective symptoms are of considerable
importance in making a diagnosis of cecal stasis
due to pericecal adhesions, for an absolute diag-
nosis we must rely upon the signs presented to
us in our examination of the abdomen. On ex-
amination there may be no apparent difference in
the contour of the abdomen. However, in some
instances in which the cecum is very large and is
distended with gas there may be a bulging of
the right side of the abdomen. On palpating the
bulging area there is a sense of well-defined re-
sistance.
In some, however, there may be no resistance,
although even in these cases the patient may com-
plain of a definite tenderness in the area usually
associated with appendiceal inflammation. The
tenderness generally is located slightly higher
than is the lower border of the cecum as out-
lined by auscultatory percussion.
Tenderness may also be present in other por-
tions of the abdomen ; for instance, adhesions at
the hepatic flexure give rise to tenderness in the
right hypochondrium on making pressure at the
right costal margin. Adhesions on the right .side
of the ascending colon, between it and the pa-
rietal peritoneal wall usually cause tenderness on
pressure in this location. Tenderness, both here
and under the right costal margin with enlarge-
ment of the cecum and ascending colon as out-
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134
THE PENNSYLVANIA MEDICAL JOURNAL December, 1920
lined by auscultatory percussion and the X-ray,
is rather significant of obstructive changes in the
area of the hepatic curvature.
It is my custom in every case complaining of
symptoms referable to the cecum or to the ap-
pendix, to outline the cecum, and it is surprising
the number of patients in whom the cecum is
found enlarged. In exjunining the abdomen,
the cecum is outlined first by ordinary per-
cussion and is indicated by a long continuous
line. Then I have the patient point with the
right index finger to the area of greatest tender-
ness. This area is marked with a cross. If the
area of greatest tenderness is somewhat above
the lower border of the cecum, I conclude that
the appendix is either retrocecal, or lies laterally
along the cecum, between it and the parietal
peritoneum.
On outlining an enlarged cecum we find that
the lower border has a tendency to be carried in-
ward and downward. This is so marked at
times; that the inner border of the cecum forms
practically a straight line, parallel with the mid-
line of the body. That this is so is demonstrated
at operation. The cecum is found to increase in
size in two dimensions, i. e., in length and in
width, and to be rotated inward.
Length. Because of the attachment of the
mesocolon to its inner border, the outer border
of the cecum increases in length to a greater de-
gree than does the inner border; the inner
border is shorter than the outer, consequently
stretching is not symmetrical. It will in many in-
stances be twice as much on the external border
as on the inner. To accommodate this increase
the head of the cecum will be thrown in the op-
posite direction, that is toward the middle line.
The attachment of the ileocecal portion of the
bowel to the mesocolon increases this tendency,
as it supplies a fixed point around which the
cecum rotates.
In practically every case of dilated cecum
which I have seen there is present this tendency
to inward rotation. That such rotation actually
occurs is well illustrated during autopsies, where
it is the rule to find the cecum dilated and ro-
tated towards the median line. In cases of peri-
cecal adhesions with enlargement of the cecum,
the appendix may or may not be adherent, but
usually is found free and lateral to the cecum.
Sometimes it glides under it, but is not retro-
cecal, i. e., not under the parietal peritoneum.
When the cecum and ascending colon are ex-
posed through the abdominal incision it is pos-
sible by rotating the cecum and ascending colon
outward, to define the attachment of the meso-
cecum to the mesocolon at the point where the
ileum enters the cecum. The attachment is at
the upper and inner part of the cecum, and is
such that any enlargement of the cecum will have
a tendency to rotate the lower pole of the cecum
inward.
The point where the mesentery joins the meso-
colon is the axis of the rotation, because at this
point the mesocolon is the most fixed, and any
movement of the cecum must occur around it as
a center. This tendency of the cecum to push
downward and inward is shown clinically by the
outer border of the cecum being much lower in
the abdomen than is the inner border. The
boundaries of the cecum may be exactly deter-
mined by auscultatory percussion.
When the cecum is increased in width, as is in-
dicated by the increased size of the cecum defined
by auscultatory percussion, there is usually f oimd
an associated lesion of the appendix. The ap-
pendix is bound either to the posterior abdomi-
nal wall or to the mesentery. These adhesions
inhibit the downward expansion of the cecum so
that it must increase in width. Even with this
increase in width there is a slight inward rota-
tion.
In cecal stasis with enlargement, the X-ray is
a valuable contributory agent in making a diag-
nosis. However, we must not rely implicitly
upon the X-ray in drawing conclusions as to the
presence of adhesions. I have known of several
cases in which kinks were diagnosed, but in
which at operation no kinks were found.
The treatment of pericecal adhesions with en-
largement of the cecum may be considered under
medical and surgical.
Medical treatment of this condition is insuffi-
cient because of the fact that it is not curative,
but is only palliative in its action. Laxatives or
cathartics make no very noticeable change in the
condition of the patient. The cecal stasis still
continues because of the inability, even with vio-
lent purgation, of the cecum to empty itself.
Sometimes massage may be of value, in that it
mechanically empties the cecum and ascending
colon. Also in some cases, diathermia, because
of the active peristalsis which it creates is of
value. It is of further advantage from the fact
that it produces a localized hyperemia in the area
of the adhesions, so that they sometimes do
seemingly become absorbed, at least the sypm-
toms in many cases disappear to a marked de-
gree. Use of a concentrated food, that is a
food with little residue, is of an advantage in this
condition, as well as the use of oils, such as neu-
tral mineral oil, also the repeated and constant
use of enemas. However, the condition is not
curable on a medical basis, therefore in every
case surgical interference should be considered.
When such an interference has been decided
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December, 1920 APPENDICITIS IN CHILDREN— ALEXANDER
135
upon, the usual incision for appendicectomy is
made. After opening the abdomen the cecum
is sought and the condition of the appendix
is noted. If the appendix is badly diseased,
or is held down by adhesions so that it is im-
mobile, it is resected. Then an attempt is
made to draw up the ileum and the cecum into
the wound. If this is unsuccessful it indicates
that there must be some binding down of the
cecum by adhesions. These are sought, and
when found are severed. If blood vessels run
through the adhesive mass, the vessels are tied
on the proximal side. If the adhesions do not
appear to produce any pressure or special trac-
tion upon the cecum and ascending colon, so that
no kinks are formed in the bowel, they are left
in place. However, if by traction on them it is
apparent either that they are kinking the bowel,
or else are directly obstructing it by means of
mechanical pressure, and if there is an enlarge-
ment of the cecum itself so that on traction a
dent or crease in the wall is made by these bands
or adhesions, then it is thought desirable to re-
move them. Adhesions which show a high vas-
cular structure and are red in character, and are
easily separated from the serosal surface, are dis-
sected free or pushed away by means of a gauze
sponge. After the adhesions have been separated
and the cecum is freed, it is frequently found to
be very much dilated, the dilatation being espe-
cially marked in the area between the anterior
longitudinal bands and the external longitudinal
band. After separation of the adhesions it is
surprising at times to see to what an extent the
cecum will dilate. In some cases it increases to
one and a half the original size.
After the two longitudinal bands which I have
spoken of are free, they are sutured together by
linen sutures, according to the technic of Marvel.
After this is done the entire area is covered with
a thick coating of lanolin and boric acid; 5%
boric acid in lanolin. This preparation has
proved very efficacious in all abdominal condi-
tions for which I have operated. I have used
the paste in numerous cases (I estimate about
300 or more) and have found that when there
were no complications, the patient, after the
use of the paste was practically free of pain. I
would recommend it to you for your considera-
tion and thorough trial, and hope it will meet
with your approval.
That operative interference will cure abdomi-
nal adhesions which are present around the
cecum, and will at the same time ease the symp-
toms, I have proved in the great majority of
cases which are operated for this condition.
Some few persistently have symptoms, but these
are cured or are relieved by the application of
the diathermic electric current, with the proper
diet, massage of the abdominal muscles, and per-
sistent use of weak laxatives.
APPENDICITIS IN CHILDREN— A
STUDY BASED ON FIVE
HUNDRED CASES*t
EMORY G. ALEXANDER, M.D.
PHILADELPHIA
Volumes have been written upon the subject
of appendicitis, but a study of the literature re-
veals comparatively little concerning this disease
as it occurs in children. This seems strange in
view of the fact that the differences between ap-
pendicitis in the adult and in the child are suffi-
ciently well marked to deserve separate and
careful consideration. These differences are seen
clinically and anatomically and have a corre-
sponding influence on the diagnosis and the sur-
gery of appendicitis as it appears in children.
Anatomically the infant appendix is situated
much higher in the abdomen than in the adult,
and is relatively larger. The coats of the organ
are thinner and its mouth is funnel-shaped with
a relatively larger opening, all of which make for
more perfect drainage than occurs in the adult
appendix. Deaver (John B.) gives as one of
the reasons for the comparative rarity of appen-
dicitis in infancy, the higher location of the
cecum in the abdominal cavity which reduces
the tendency to stagnation in the venous return
from the appendix to the superior mesentery
veins. Others attribute the relative immunity of
the infant to the supine position in which it lies,
.its almost exclusively liquid diet and the fre-
quent evacuation of the bowels, all of which di-
minish the opportunity for congestion and stasis
in the intestinal tract and thus reduce the chances
of inflammation of the appendix.
Age and Frequency. — The appendix \«hich has
come to occupy so prominent a place in medicine
and surgery may make its presence unpleasantly
manifest from the very hour of the infant's birth.
Thus Gloniger reports successfully operating
on an infant only forty-one hours old. At birth
the attending physician noticed an enlargement
at the base af the cord, in which a coil of intes-
tine was seen by transmitted light. The tumor
failing to yield to other measures, operation was
resorted to. The sac was found to contain the
greater part of the small intestine with the cecum
and the transverse colon; the appendix, about
one inch long, showing unmistakable signs of in-
*Read before the Section on Surgery of the Medical So-
ciety of the State of PennsjriTania, Pittsburgh Session, Octo-
ber 5, i9»o.
tThis study is based on 500 cases of annendici'is operatrd,
within the past five years, at the Mary J. Drexel Home, Phila-
delphia, by Dr. John B. Deaver, Dr. Harry C. Deaver and the
author.
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136
THE PENNSYLVANIA MEDICAL JOURNAL
December, 1920
flammation. Dixon saw a case of gangrenous
appendicitis in a baby of twenty-four days, and
Griffith one in a three months' old negro boy.
In our series the youngest child was nineteen
months of age ; the ages ran up to fifteen years;
49.2 per cent, occurring from the sixth to the
tenth year, decreasing to 42 per cent, from the
eleventh to the fifteenth year, and the remaining
(8.8 per cent.) occurring during the first five
years of life. The sudden falling off after the
"twelfth year is probably due to the fact that the
Mary J. Drexel Home is a children's hospital
and that very often girls and boys after the
twelfth year are so mature as to seek admission
to the adult wards of other hospitals.
Sex. — Our series shows the same preponder-
ance of the male sex as appears from other
studies on the subject, although the difference,
286 males and 214 females, is not so great as
noted by others and places the incidence in the
sexes nearer to equality. In Deaver's (H. C.)
published series of 500 cases there were 315
males and 185 females; and in Riedel's 1,532
cases, 955 were male and 577 female.
It has been our experience also that the dis-
ease is apt to run in groups. For example, one
group of cases will be boys from four to five
years of age, and this will be followed by a
group of girls ranging from eight to ten years.
There is no palpable explanation of this peculiar-
ity but the fact seems to me a noteworthy one.
Season. — It appears from the accompanying
tables that the greatest number of appendicitis
cases are admitted during the month of July,
and the smallest number in November. This
would seem to indicate a seasonal influence in
the incidence of appendicitis, but the indication
is more apparent than real. There is a general
consensus of opinion that appendicitis is not de-
pendent upon the seasons. The reason that more
cases arjje during the warm weather may be ex-
plained by the fact that the summer offers
greater opportunity for indiscretions in diet,
such as eating unripe fruits and vegetables. The
resultant stomachache is generally treated by the
use of a purgative such as castor oil, which is
so fraught with danger in case the attack should
turn out to be appendicitis. This undoubtedly
also accounts for the observation made in our
wards, that the cases admitted during the warm
months are more severe than at other times, that
is, are more often accompanied by peritonitis or
abscess. Another possible explanation for the
apparent seasonal incidence may be found in the
child's greater fondness and interest for play
than for work, so that often a child will suffer
considerable pain without complaining during
the vacation, while during the school term the
same child would probably instantly complain,
glad to have an excuse to stay away from
school. During this past summer I operated
upon a boy of ten, who had suffered severe ab-
dominal pain for a whole week without com-
plaining sufficiently to cause anxiety. This pa-
tient walked into the hospital and at the opera-
tion the case proved to be one of appendiceal ab-
scess.
Etiology. — Among the etiological factors of
appendicitis the role of the acute infectious dis-
eases is often emphasized. In my experience as
surgeon at the Philadelphia Hospital for Con-
tagious Diseases for the past seven years, I have
seen very few cases of appendicitis among the
many thousands of children admitted annually.
T am therefore strongly inclined to deny such a
role to the acute infections; although the ab-
sence of appendicitis during their course may
possibly be explained by the restricted and care-
ful diet that prevails in the treatment of the
acute infections.
The etiological role of dental caries cannot be
denied, especially since defective conditions of
the mouth and teeth are now known to be re-
sponsible for so many pathological states.
While external trauma hardly enters into con-
sideration as a cause of appendicitis, mechanical
irritation, as from fecal concretions, worms and
other foreign bodies, without doubt are most im-
portant causative factors in the disease. The
uric acid diathesis of children, according to
Sutherland, may also be added to the contribut-
ing causes of infantile appendicitis. He bases
his opinion on the close anatomical resemblance
between the appendix and tonsils, which latter
are so frequently affected in gout. Bland Sut-
ton is quoted by Kelly as having been the first
to call attention to this resemblance and to stress
the pathologic similarity between simple and
suppurative appendicitis and like conditions of
the tonsils.
Diagnosis. — As a rule the symptoms in the or-
dinary acute attack of appendicitis in the child
are more marked than in the adult, the pain be-
ing often very severe, vomiting prolonged, and
the temperature naturally much higher. But
very often the diagnosis in children is apt to
present somewhat greater difficulty than in
adults, because not only may the symptoms be
vague, but there is in addition the inability of
the child to give a definite indication of the loca-
tion of pain, and furthermore, even the severest
type of infantile appendicitis has been known to
fail to exhibit any of the classic symptoms, such
as nausea, vomiting, pain, local tenderness, etc.
Besides these there is also the child's natural fear
of an examination and the voluntary rigidity
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December, 1920 APPENDICITIS IN CHILDREN— ALEXANDER
137
and the ease with which it draws away from the
palpating hand, and the indefinite and often
contradictory statements with regard to the site
of greatest tenderness. It is therefore of the ut-
most importance to gain the child's confidence by
a gentle persuasive manner, this together with
"a warm hand and a light touch" will enable the
surgeon in practically every case to make a satis-
factory examination without the use of an anes-
thetic, as is advised by some authorities.
In making the diagnosis in these youthful pa-
tients it is well to remember that in the child
the appendix is often located over the brim of
the pelvis in close proximity to the bladder. In
such cases the point of greatest tenderness will
in all likelihood be in the left iliac fossa. In facrt
a left-sided location of pain and other symptoms,
either in the epigastrium, under the costal arch
or in the loin is not unusual, since an abnormal
position of the appendix is apt to be common
among children. Indeed, the greatest point' of
tenderness is always over the site of the appen-
dix. This must be borne in mind when the
valuable sign of tenderness at McBurney's point
is absent, so that the site of the appendix must
be sought elsewhere. The observation has often
been made also that flexion of the thigh due to
irritation of the psoas muscle may be suggestive
of a deep-seated appendicitis.
We also find that acute appendicitis with
localized or diffuse peritonitis, is more frequently
encountered in the child than in the adult. Ap-
pendiceal peritonitis in the child is also more
virulent and more rapidly fatal since children
become more profoundly toxic within a given
time during this stage than do. their elders. That •
more infantile cases develop peritonitis is prob-
ably largely due to the relatively thin coats of.
the infantile appendix. On the other hand, it
may also be traced to the fact that an attack of
abdominal pain in the child is often diagnosed by
the parent as one of simple stomachache and
without calling in a physician is treated by pur-
gation with the disastrous result of a perfora-
tive peritonitis. In a case of appendicitis with
diffuse peritonitis the temperature is high, the
pulse rapid, abdominal rigidity and tenderness
are generalized over the entire abdomen, and
there is more or less distension ; the latter, how-
ever, is never so uniform as in typhoid fever
and pneumonia.
Appendiceal abscess likewise is oftener seen in
the child than in the adult, the most favorite
sites for the collection of pus being at the brim
of the pelvis to the outer side of the cecum,
within the pelvis, or high up to the outer side of
the cecum beneath the liver. The first type can
readily be diagnosed by palpation and percus-
sion, the second by rectal examination, which, by
the way, should be a routine of every examina-
tion for suspected appendicitis; while the third
type is characterized by tenderness and pain in
the loin. It is this last type that presents the
greatest difficulty in differentiating between ap-
pendicitis and thoracic conditions.
In acute appendicitis the direct diagnosis rests
on the sudden onset of abdominal pain, vomit-
ing, fever, rigidity and local tenderness. But as
very often the cardinal symptoms may be ab-
sent, it is only by a careful physical examination
that a correct diagnosis can be made. Every
child complaining of abdominal pain should be
subjected to such an examination and a disease
of the appendix excluded before any treatment,
especially purgation, is advised. Urinary synip-
toms in a child should also arouse the suspicion
of appendicitis before a definite diagnosis is pro-
nounced.
We repeat that rectal examination should
never be omitted since the examining fingers can
reach high up in the pelvis of the child and it has
been shown that extension of the disease be-
yond the appendiceal region generally takes
place along the pelvic wall, and the evidence of
inflammation is thus easily felt. Examination
of the thoracic viscera likewise is essential, since
the first signs of pneumonia or pleurisy in a
child are often so suggestive of appendicitis as
to be misleading except to the experienced sur-
geon who makes a very careful study of the case.
While leucocytosis and the differential count are
of prognostic and some diagnostic value, the
clinical manifestations we believe tell the story
better than any of the laboratory tests.
Any of the acute exanthemas may oftentimes
simulate the intestinal symptoms of appendicitis
and cloud the diagnosis, but as a rule, there is
some atypical feature in the mimicry which in a
few hours develops sufficiently to clear the doubt.
Probably the most frequent differentiation that
has to be made is from gastroenteritis accom-
panied by coKc. It is well to remember that in
this condition the fever is continuously high, and
there is frequent inclination to purging. There
may be distension, pain and tenderness on pal-
pation, but marked rigidity is never present.
Occasionally the differentiation will have to be
made from other acute abdominal conditions,
such as typhoid fever, intussusception, cholecyst-
itis, duodenal ulcer, tubercular peritonitis, sal-
pingitis, and twisted ovarian cyst. Only recently
I had occasion to operate on a little girl eight
years of age, for symptoms that led to a diag-
nosis of appendicitis. It was not until the abdo-
men was opened that the true condition, twisted
ovarian cyst, was recognized.
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In fact it may well be said that there is
scarcely any condition in the realm of surgery
that calls for more careful study and examina-
tion than appendicitis in children. So many dis-
eases of childhood set in suddenly with vomit-
ing, nausea, very often associated with abdomi-
nal pain or intestinal derangement, that differ-
entiatioo presents more than ordinary difficulty
and is a matter of exact and well considered
judgment.
In differentiating from pneumonia one may
be guided by the temperature, which is higher
than in appendicitis, the respirations, which are
more rapid, indeed much more rapid than is con-
sistent with the pulse; and the distension if
present is usually uniform. Herpes is sometimes
present and also cyanosis together with nasal
breathing and an expiratory grunt; these are
points that should lead to a diagnosis of pulmon-
ary disease.
Infection of the urinary tract, as occurs in
pyelitis and cystitis, may also simulate appendi-
citis and oftentimes may be associated with the
latter and mislead the examiner. It is for this
reason that a child presenting urinary symptoms
should be considered a potential case of appen-
dicitis until careful study proves otherwise.
Among other conditions which are at times con-
fused with appendicitis and of which passing
mention can only be made at this time, are:
Potts's disease, psoas, abscess, coxalgia, cyclic
vomiting, migraine, tubercular meningitis, pneu-
moccic and gonococcic peritonitis, retention of
urine, renal colic ; ureteral stones, etc.
Prognosis. — The prognosis of acute appendi-
citis in childhood is good provided it is recog-
nized and operated on early in the disease. The
mortality ranges from three per cent, (in the
present series) to sixteen per cent., as reported
by some authors. In the Mary J. Drexel home
we have reduced our mortality i .6 per cent, from
the 4.6 per cent, reported (in 1910) in a pre-
vious series of five hundred cases by Dr. H. C.
Deaver, thus bringing it down to about the same
percentage as for appendicitis (of all types) in
the adult patient. The early tendency to peri-
tonitis and abscess formation figures largely in
the mortality and further emphasizes the danger
of temporizing and the necessity of prompt sur-
gical attention. The only type of acute appendi-
citis with diflFuse peritonitis in which delayed
operation is advisable and justifiable is when the
patient is seen after two, three or four days' ill-
ness, and presents vomiting, general abdominal
tenderness, absence of peristalsis, marked ab-
dominal distension, slight cyanosis with' rapid
pulse and a dry coated tongue. Operation in such
cases is attended with great risk, so that the bet-
ter plan is to place the little one in the Fowler
position. with an ice bag on the abdomen, with-
hold all food, liquid or solid, by mouth, and ad-
minister continuous enteroclysis. In alarming
cases where owing to the starvation there is dan-
ger of acidosis, it is well to add glucose and soda
bicarbonate to the enteroclysis. For persistent
vomiting and distension gastric lavage is indi-
cated. Under this regime the peritonitis, in the
majority of cases, will localize in a few days. It
it very important to avoid frequent abdominal
examination during this period of watchful wait-
ing, for undue palpation may light up a case that
is in a fair way of subsiding. After localization
has taken place, the abscess can be drained and
the appendix removed with little danger to the
patient's life.
Although appendicitis in children is usually of
the acute type, chronic appendicitis is sufficiently
frequent to demand consideration. It very often
manifests itself by recurrent attacks of what is
generally regarded as biliousness or liver trouble.
Every child that is subject to so-called bilious
attacks or attacks of vomiting with more or less
abdominal pain, headache, temperature, consti-
pation, etc., should be examined under the suspi-
cion of appendicitis. Nearly every surgeon, I
believe, will agree with Still's statement Ihat a
large number of so-called bilious or liver attacks
of children are slight attacks of appendicitis, and
that many a child's life has been sacrificed that
might have been saved if the true cause of the
trouble has been properly located as residing in
the appendix. In very many instances the usual
initial symptoms of pain in the right iliac fossa,
vomiting, perhaps painful micturition and ten-
derness at McBurney's point are absent or so
slight as to escape attention. Each recurrent
seizure is treated by purgation with all its in-
herent dangers in a case of appendicitis, until a
more than usually severe attack develops into
peritonitis and at the subsequent emergency
operation an inflamed or perhaps perforated ap-
pendix reveals the original malefactor in the re-
peated supposed bilious or liver attacks.
Operation. — In the early case where the disease
is confined to the appendix is a simple matter.
The McBurney incision is recommended if the
patient is a boy, but in girls it is better to make a
right rectus incision because of the possibility
of pelvic complications. In appendiceal abscesses
located to the outside of the cecum near the an-
terior superior spine the incision should be made
to the outside of the mass and an extraperitoneal
operation performed. The appendix can be re-
moved if it is easily accessible, but if this is not
the case simply drain the region and reserve ap-
pendectomy for a later period. Drainage should
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December, 1920 APPENDICITIS IN CHILDREN— ALEXANDER
139
be obtained by means of cigarette drains, rubber
or glass tubing, preferably the last, placed to the
pelvis, for the first twenty-four hours, and then
replaced by rubber tubing. In pus cases it is a
good rule to "sound" the pelvis with a glass
tube ; by this means free pus or an abscess can
frequently be discerned which might otherwise
be overlooked.
Postoperative Treatment. — This is no less im-
portant than the preoperative regime or the oper-
ation itself. The peritonitis cases should receive
the same treatment as before operation except
that the Fowler position should be maintained
for only a day or two. The crowding of the in-
testines down into the pelvis in this position fa-
vors intestinal obstruction, which together witH
subdiaphragmatic abscess and secondary abscess
(abdominal) stand out more prominently as
postoperative complications among children than
among adults. Otherwise the complications fol-
lowing operation in infantile appendicitis are the
same as those incident to any abdominal opera-
tion on the adult.
Our greatest mortality was due to diffuse peri-
tonitis and intestinal obstruction. The initial
symptoms of the latter condition — nausea, vom-
iting and paroxysmal pain — ^are sufficient to war-
rant reopening the abdomen as a possible life-
saving measure.
From this study of appendicitis in children it
is evident that diagnosis is beset with difficulties
and at the same time early diagnosis and prompt
surgical treatment are the essentials for effec-
tually reducing the mortality from the disease.
Home remedies for abdominal pain in the child
are fraught with tremendous risks, it is the
cases that have been thus mistreated, if not mal-
treated, but purgation that provide the greatest'
percentage of morbidity and mortality figures.
Peritonitis with its attendant dangers is much
more frequent in the child than in the adult and,
what has been said of the adult disease is equally
true of the infantile type of appendicitis, "it is
the peritonitis that kills."
When this fact is recognized and acted upon
by parents as well as by the general practitioner,
we can hope to see the approach of the appen-
diceal millennium — a thousand cases without a
death.
I take pleasure in expressing my indebtedness
to Dr. W. B. McKinney, resident physician of
the Mary J. Drexel Home, for the preparation
of the attached statistics on which this study is
based.
STATISTICS
Number of cases, 500
Number of deaths 15
Mortality 3%
SEX
Males 286
Females, 214
AGE
2 years, 4
3 " 6
4 20
.5 :: '4
o 32
I : 37
o 44
9 " 62
10 " 71
11 " 63
" :; 79
13 ' 40
14 " 20
15 " 8
SEASON
January 35
February, 48
March 30
April 31
May 52
June. 45
July. 57
August, 44
September, 49
October, 43
November 29
December 37
VARIETIES
Chronic, 81
Acute, 419
(a) Clean 211
(b) Drainage, 208
(i) Simple acute, 121
(2) Acute suppurative 90
(3) Acute with abscess formation, 103
(4) Acute with local peritonitis, 88
(5) Acute with diffuse peritonitis 17
DRAINAGE EMPLOYED
Gauze, 43
Glass tube, 25
Glass tube with gauze, 60
Rubber tube, lo
Rubber tube with gauze 32
Cigarette, 32
Rubber dam 6
Counter drainage, 7
POSTOPERATIVE COMPLICATIONS
Intestinal obstruction, 9
Secondary abscess, 9
Vaginitis 5
Secondary abscess (subphrenic), 3
Bronchitis, 3
Oxyuria vermicularis, 3
Pneumonia, 2
Acute endocarditis 2
Stitch abscess, 2
Fecal fistula, •. . . . 2
Other complications consisted of one case each of:
Phlebitis, parotitis, nephritis, diphtheria, scarlatina,
typhoid fever, influenza, oophoritis, salpingitis, hemor-
rhagic infarct (right ovary), volvulus (mild), leutic
fever, evisceration (7th day).
CAUSE OP DEATH
Diffuse peritonitis, 7
Intestinal obstruction, 5
Pneumonia, i
Subphrenic abscess, i
Acidosis, ^. .,. 1 f
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THE PENNSYLVANIA MEDICAL JOURNAL
December, 1920
seCONDAKY OPEKATIONS
Secondary abscess, 7th day, Recovered
8th day,
9th day,
13th day,
29th day,
37th day. Death
Secondary accumulation in pelvis, Sth day. Recovered
" 7th day,
" nth day,
" 13th day,
Intestinal obstruction, 7th day, "
9th day,
9th day,
22nd day,
" " sth day. Death
7th day, "
9th day, "
9th day, "
14th day, "
Foecal fistula, 29th day, Recovered
Badly infected wound 8th day, "
Appendix removed, 31st day, "
Appendix removed 3Sth day, "
Evisceration, 7th day, "
REFERENCES
Churchman, J. W. : Johns Hopkins Hosp. Bull.,
1909, XX, 31.
Deaver, H. C. : J. Am. M. Ass., 1910, Iv, 2198.
Deaver, John B. : Appendicitis, its Diagnosis and
Treatment. 1913. Philadelphia.
Dixon, C. H.: Ann. Surg., 1908, xlvii, 57.
Gloniger, A. : Cited by Kelly.
Griffith, J. P. C.: Univ. Penn. M. Bull., 1901, xiv, 300.
Kelly, H. A.: Appendicitis and Diseases of the
Vermiform Appendix. 1909. Philadelphia.
Riedel, B. : Munch. Med. Wchnschr., 1907, liv, 2365.
Still, G. F. : Common Disorders and Diseases of
Childhood. 1909. London.
Sutherland, G. A. : Brit. M. J., 1892, i. 856.
DISCUSSION
Dr. Silas D. Molyneux, Blossburg: I will not at-
tempt to discuss all of these papers. I think our rec-
ords in abdominal drainage are not better because we
do not drain rather than because we drain too much.
I think it is a good plan when you are in doubt to
drain. However the type of infection will help us to
determine whether we should drain or not. In cases of
tuberculosis ordinarily it is a wise thing not to drain.
In old gonococcal infections in the pelvis, or other
types of infection of long standing it is not always
necessary to drain for the reason that the pelvic peri-
toneum will take care of infections so well. I think
ordinarily we drain too much in the upper abdomen.
Peritonitis following perforation of a gastric ulcer in
the first few hours, is to a great extent chemical. To
drain these cases thoroughly as we see them some-
times, a drain at the point of perforation, and in the
pelvis increase the tendency to adhesions and obstruc-
tion. I think in the early hours after perforation one
small drain is usually sufficient. In regard to the
drainage in cases of infection in appendiceal abscess
which is a type of case peculiarly fitted to drainage, the
important point is not only to drain around the cecum,
the origin of infection, but as the doctor mentioned in
his report on appendicitis, it is important to drain the
collection from the pelvis. We find here a collection
of fluid which apparently is not infected. However, if
you wait a few days you will find that the collection
does become pus and as in the first paper it may be
necessary to drain through the rectum. When it is
necessary to drain appendix cases I somethnes think
we do not drain thoroughly enough. I think several
small tubes are better than one large, perhaps one in
the pelvis, one at the cecum and one in the right kid-
ney fossa. Two or three small tubes will carry off
more pus than one large one. I think it is better to
leave the incision without any sutures at all than it is
to close it up very tight. In placing drains it is im-
portant not to impinge upon the small bowel. A drain
here often causes bad adhesions, intestinal obstruction
or fecal fistula and consequently we should as far as
possible keep drains away from the small intestine.
In regard to the frequency with which Dr. Alexander
met cases of appendicitis in children in the summer:
that has been my experience too. I have found a great
many of these cases of appendicitis in children in sum-
mer are accompanied with diarrhea rather than con-
stipation, as we find in the adult. I have never been
able to explain satisfactorily why we have this. I
sometimes think that this condition begins as a true
ileo-colitis and extends up into the appendix rather
than as a primary infection of the appendix.
Dr. Charles A. Fife, Philadelphia : I am very glad
as a pediatrist to register against the use of castor oil
in appendicitis and heartily endorse the plank of your
platform which imposes the duty of every medical man
to report at once to the surgeon and turn over to him
every case of suspicious appendicitis in children. As
Dr. Alexander has so well said, the cases in children
advance insidiously, but often very rapidly and there-
fore operation must be done. Very clear evidence of
this rapid advance is shown by the experience of the
physicians at the Girard College. Here they have a
fixed policy of encouraging all the boys to report at
once to the infirmary for the slightest disorder, par-
ticularly so-called "stomach ache" and "bilious at-
tacks." The Spartan endurance is strongly frowned
upon. Dr. Wharton tells me that boys who have pain
early in the morning are operated upon at 11 o'clock
and in that time over 90 per cent.- of his cases require
drainage, showing the rapid advance in children, par-
ticularly in the older children. It is with the infec-
tion in the young child, as Dr. Alexander has said,
that the chief difficulties of diagnosis are presented.
Many of "them develop so insidiously that they are
thought to be suffering from some acute digestive dis-
turbance, particularly when associated with colic.
Symptoms ar« exceedingly obscure and variable and
they cannot be depended upon. Vomiting is perhaps
the most common and one that is usually present, but
this is such a common symptom in infancy that it is
misleading. However, when vomiting is accompanied
by fever, constipation, appendicitis must be excluded.
In fact in all illnesses of young children appendicitis
ought to be considered. The symptom complex is
vomiting, fever and paroxysmal crying. The pain is
apt to be of paroxysmal type in babies as shown by
crying. Definite diagnosis in the early stage may be
impossible, but it cannot be made by relying upon these
subjective symptoms. Only by careful, tactful, patient
examination can the diag^nosis be at all helpful and
then only by excluding the long list of illnesses and
diseases that he mentioned. Tenderness may usually
be elicited by sufficient persistence and patience. Ab-
dominal tenderness is extremely important as it is not
a common symptom in the diseases of early childhood.
It is not seen in digestive disturbance and not in the
infectious diarrheas. Intussusception and pneumonia
are the two diseases with which it is most likely to be
confused. Tenderness is frequently manifested by the
disinclination of the child to move its trunk or ex-
tremities or to be moved. That isx>ften the chief, or
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December, 1920 DRAINAGE AND APPENDICITIS— DISCUSSION
141
in subacute cases the diiHculty in walking through
lameness or flexed thigh and also, as Dr. Alexander
has said, the rectal examination will often elicit ten-
derness ; when there is nothing else a rectal examina-
tion should always be insisted upon. As to those two
diseases which are especially troublesome I shall only
speak of pneumonia in that it has all the symptoms of
appendicitis and with the chest signs very indefinite
and indistinct for days, not showing clearly at all the
test of crisis, when if appendicitis the favorable hour
would have been lost. The chest signs, if we wait for
them, will sometimes mislead. The most helpful signs
are the higher and persistent temperature, not waver-
ing, the respirations out of proportion to the pulse
are perhaps the most helpful, decidedly disproportion-
ate to pulse and temperature, a slow full pulse, the
superficial character of the tenderness I have noted in
a few instances and it seemed very characteristic. Ir-
ritation of the nerves, lessening of the resistance with
inspiration is suggestive. It is often difficult to deter-
mine however, the catchy inspiration and the uniform
distention which Dr. Alexander impressed and here
the leukocyte count is advisable. But, however, in
cases it is impossible to diagnose early and these cases
you must always watch and wait. Time will not per-
mit the mention of the other causes, except bilious-
ness, recurrent hyperpyrexia and cyclic vomiting.
These conditions may be more or less related and
various factors may be considered in the etiology, but
chronic inflammatory focus of some sort must be
searched for and we must not overlook the appendi-
citis, as has been so often done. In this chemical era
we must not forget our old enemy the bacteria. I
have known cases of cyclic vomiting to dear up after
removal of appendix. Here the best guide is localized
tenderness, often elicited only by rectal examination.
Dr. William L. Estes, South Bethlehem: I have
but a word to add. In hearing the paper on Appen-
dicitis, the point of frequent mistake in diagnosis in
children ought to be brought out, that is the fact that
a right side pneumonia is frequently diagnosed appen-
dicitis. It is a curious thing that those who have come
to me, most of these pneumonias are in the beginning,
central, and unless one bears in mind the cardinal facts
Dr. Alexander brought out, namely the uniform dis-
tention, and the fact that appendicitis goes so quickly
and has a varjring curve of temperature, it is very diffi-
cult to make the diagnosis. Time and tithe again cases
of so-called appendicitis have been sent to me for im-
mediate operation which I have found on more careful
investigation to be cases of pneumonia. While one
deprecates delay before an operation, in these cases, it
is important to know that one has a case of appen-
dicitis and not a right-sided pneumonia. In reference
to the drainage question, I think every case has to be
judged on its own individuality. If a case has pus one
should as a rule drain. With a very small quantity of
localized pus which can be thoroughly blocked off, the
abdomen may be closed without drainage. I have al-
ways felt if pus is present in the abdomen and there
is also a considerable adhesive inflammation in the ab-
domen, it is necessary to protect the abdomen by drain-
age, and dependent drainage where it may be procured
is the proper one. These papers are so important I
think the Section should take up the discussion gen-
erally, and I give place to someone else.
Dk. p. Hubst Maier, Philadelphia: I think one of
the best tests of a surgeon's ability is the question of
when to drain and when not to drain. The old axiom
of "when in doubt drain" should probably be substi-
tuted by the more modern axiom when in doubt don't
drain. Of course I am more inteqisted in pelvic sur-
gery than I am in general surgery, but there are very
few cases of pelvic surgery in which it is necessary to
drain. We must always remember in the question of
drainage that it carries with it a great deal of mor-
bidity. Fistula the result of fecal concretion, result
of traimia in the intestinal canal, in any place at all is
the result of drainage. One of the greatest bugbears
in surgery to-day concerning morbidity and also con-
cerning the secondary mortality is post-operative ad-
hesions and they are more frequently the result of our
drainage than any other factor. We want to be very
considerate before draining indiscriminately. In pelvic
surgery there are few cases that we have to drain. If
we have an acute septic pelvic peritonitis, we do not
operate because the individual is never in any danger
for the reason that there may be an accumulation of
pus. It is always walled off and by making frequent
examinations through the vagina and rectum even the
general practitioner is able to do this as a routine pro-
cedure. You can always determine when this is reach-
ing a point when something should be done and then
a vaginal incision can be made without any danger,
without any anesthesia so far as the patient is con-
cerned, the condition relieved for a time and subse-
quently months afterwards when no organisms in the
pelvic cavity the secondary curative operation when
necessary, frequently, it is not necessary, can be per-
formed. Concerning the gonococcal or any of the
other cases, the chronic cases it is almost never neces-
sary to drain. The only time that it is necessary to
drain is probably in those cases where there are a lot
of adhesions, where the ovaries and pus tubes are em-
bedded and in their removal you make a large, raw
surface in the pelvic cavity and in this class of cases it
is advisable to drain for this reason and you prevent
puddling with • subsequent infection and you prevent
those adhesions which we are so much afraid of. I
would rather have two large cigarette drains sticking
out through the vagina and intestines resting on a rub-
ber tissue. After all in very bad cases, suppurative
peritonitis, should be drained for one reason and that
is because we know infection takes place under ex-
treme abdominal tension. After the first 48 hours,
when the patient is making the fight for his or her
life, the drainage tube prevents abdominal tension and
with the Murphy drip we are able to tide her over this
dangerous time. In clean gallbladder cases, choleli-
thiasis or your appendiceal cases in the first 48 hours
there is some inflammation, but after all nature takes
care of it very much better than your drainage does.
Drainage often leaves a stenosis there. What do we
have as the result of it? Possibly a lot of adhesions
and the patient suffers as much following the opera-
tion as she ever did before the operation. Further-
more, in very many of these cases nature will take
care of organisms and when they come in contact by
the drainage with the raw surfaces of the wounds, we
get wound infection instead of a good union by first
intention. The best point so far as I am concerned in
Dr. Alexander's paper is that in which he recom-
mended the lateral incision m cases of appendicitis that
had gone on for three or four days. It follows that he
pays no attention to the appendix whatsoever, but
makes a low lateral incision. This holds good for
children, and for adults as well. Where you have a
mass there make your low incision and drain.
Dr. J. DeV. SiNGLEY, Pittsburgh : The purpose of a
drain, as I take it, is not principally to favor the out-
pouring or the withdrawal of the products of infection
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142
THE PENNSYLVANIA MEDICAL JOURNAL
December, 1920
from the abdominal cavity. If the primary focus of
infection has been removed or closed, the principal
thing that a drain does is to stimulate the throwing out
of an inflammatory exudate which localizes the infec-
tion. I have often said that the omentum is the best
abdominal drain which perhaps may need a little ex-
planation. The function of the omentum is very read-
ily appreciated in its ability to wall off and isolate
areas of infection. The materials used for drainage,
when drainage is absolutely demanded, is to my mind
of the greatest importance ; and, personally, I am very
strongly opposed to glass or rigid rubber tubes' as
there can be no question but that such a drain is a fre-
quent cause of pressure necrosis with occasional dis-
astrous results. Rubber dam or a soft collapsible
rubber tube is infinitely superior. Gauze of any type
I believe is one of the worst drains that anyone can
use in that it commonly results in fecal fistula. In the
perforated ulcers, duodenal or gastric, provided one
sees them within a reasonable time — within the first
24 hours, — it is rarely necessary to drain as the essayist
remarked. The abdominal cavity can take care of an
enormous amount of infection; not so the abdominal
wall ; and while I find it rarely necessary to drain an
abdomen, it is very commonly necessary to drain the
layers of the abdominal wall. As to the differential
diagnosis between pneumonia and appendicitis, I think
any medical man, if he remembers that there is a dan-
ger of confusing the two things, and takes sufficient
time to examine his patient, will rarely ever be led
astray.
Dr. a. E. Crow, in closing: I have not yet been
convinced that it is not always necessary to drain in
pus cases. We all recognize the fact I think that the
pelvic peritoneum takes care of these harmful products
better than any other part of the peritoneal cavity, but
it certainly seems to me that it is safer to drain the
pelvic condition in which pus has been found than it is
to close it. In connection with the gallbladder I be-
lieve one of the discussers mentioned closing the ab-
dominal wound in the clean cases. I do not know that
we are operating on clean cases, or whether we should
operate on the clean cases. It is true we should not
drain a clean case, but if we operate on a gallbladder
case I think the pathology there is regarded as an in-
fectious case. We do not know when we are going to
have leakage and if we have drained we have prepared
the way to take care of that leakage. I am heartily in
sympathy with Dr. Singley in the kind of rubber drain
we should use. I do not think there is any better
drainage than the cigarette.
Dr. Emory G. Alkxander, in closing: It has been
asked, why do more cases of appendicitis in children
occur in the summer months and why are they of a
more severe type ? I have thought probably it was due
to the fact that during the summer months children
take more liberties with their stomach in eating under-
ripe fruit and indigestible food. Also during the sum-
mer months children are recreating and playing and
they will persist in their play much longer before
they give up to illness than in the corresponding win-
ter months when they have their work going to school.
This summer I operated on a boy 11 years of age who
walked into the Mary Drexel Home with a large pelvic
abscess. He had been playing around all week, having
iiever gone to bed at all.
The differential diagnosis is most difficult and im-
portant. I know of no condition in the realm of sur-
gery which is so hard to diagnose as some types of
appendicitis in children. Especially is this true in cases
with symptoms of pneumonia. We have kept patients
under observation after having them in the hospital
with all the facilities for making special examinations
and laboratory tests and in some cases have been una-
ble to make a positive diagnosis for several days. In
those cases that you are not sure of, it is much wiser
to wait and see if symptoms will not come to a focus
so that you are able to make a correct diagnosis. In
regard to drainage, we use rubber dam, cigjarctte
drains, rubber and glass tubes. If you wish to drain
thoroughly you have to use a tube. We like glass
tubes, though it requires more nursing, there is a slight
' danger of its breaking and it does seem, according to
statistics, to favor fecal fistula. Our statistics, how-
ever, do not bear this out. We have had only one
fecal fistula in this series of 500 cases. In our sta-
tistics we have nine case's of intestinal obstruction;
secondary abscess, secondary accumulations of pus are
aj^o quite frequent abdominal complications. Glass
drainage tubes are more apt to maintain their position
than rubber tubes, as often in transporting the patient
back to bed the rubber tubes become dislodged. This
is not so with a glass tube. We take out the glass tube
in 24 hours to 36 hours and place a rubber tube in its
place.
THE OUTLOOK OF CHRONIC
NEPHRITIS*
JAMES M; ANDERS, M.D., LL.D.
It is to be premised that healthy kidney func-
tion is dependent upon both vital and mechanical
processes. The latter are a combination of
cardiovascular and vasomotor influences, while
the former are connected with the functions of
the glomeruli and tubules and their epithelium.
John McCrae* has pointed out that in time of
stress, glomerulus may compensate for failure
of tubule and vice versa, and both failing to-
gether, their work may be temporarily performed
by adjuvant systems, the skin, alimentary tract
and other lesser excretory organs. It is to be
recollected that the nephritides do not as a rule
involve a particular anatomic element but are
fairly diffuse. The structures that remain intact,
however, not only function normally, but may
display compensatory activity. It is further
known that in some cases the sodium chloride
elimination is interfered with, and that of urea
is normal, while in other cases the reverse ob-
tains. These facts have practical significance,
since in chronic diffuse nephritis the necropsy
table often reveals more or less circumscribed
areas showing pathologic changes in striking
contrast with healthier areas.
A lack of harmony often exists between the
clinical and necropsy findings in cases of nephri-
tis and that a high degree of functional insuffi-
ciency may arise with comparatively insignificant
lesions is a well authenticated fact. Kidney
•Read before the Section on Medicine of the Medical So-
ciety of the State of Pennsylvania, Pittsburgh Session, October
5, 19^0.
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EteCEMBER, 1920
CHRONIC NEPHRITIS— ANDERS
143
function cannot, therefore, be translated into
kidney lesions at present writing. Moreover,
important in the production of renal insufficiency
and uremia are the organic nitrogenous com-
pounds that have resulted from protein decom-
position, the so-called residual or nonprotein
nitrogen element, 'but these are usually met with
during the advanced stage of nephritis. It would
prove of immense advantage to us in endeavor-
ing to present the issue, to know the etiology of
chronic nephritis, a subject regarding which our
knowledge is far from complete.
Outcome in Atypical Cases. — It is generally
conceded that our classification of cases of
chronic nephritis is imperfect and it is the com-
mon experience of all active clinicians that many
examples of the disease met in practice do not fit
the classical design. There are cases of appar-
ently genuine nephritis, which are atypical ; they
present a considerable variety of details for con-
sideration in connection with the question of
their outcome, and their individual clinical and
pathological peculiarities govern the prognosis.
It is to be recollected that the rules of renal func-
tion in health are not hard and fast and this is
even more true of the kidney under conditions
of disease owing to its so-called adaptability.
Many of the atypical instances of chronic
nephritis, especially those met with in young and
middle aged persons are as Huebner has sug-
gested, due to previous infections. It is in these
cases that the changes are often of the circum-
scribed variety rather than general. The outloo^
is obviously modified by the extent of the fibro-
sis, hence when distinctly limited, life may be
little, if at all, curtailed thereby.
There is a special group of cases dependent
upon gout in which is observed albuminuria,
often intermittent for a period of several years,
leading later on to true chronic interstitial ne-
phritis. In the earlier stages of this type, a
change of diet and the adoption of proper habits
of living is sometimes all that is necessary to
cause the disappearance of the albumen and tube-
casts, and proves effective in greatly prolonging
life, or even bringing about apparent cure.
The so-called cases of essential hypertension
form still another group, which must be consid-
ered here. As pointed out by Krehl' while its
relationship to arteriosclerosis is unknown, it is
possibly a precursor. Fischer's' studies indicate
that a large proportion of the cases of essential
hypertension, "especially those with a systolic
reading of i8o or over, are really due to anatom-
ical changes in the kidneys, despite the fact that
they do not betray themselves during life by uri-
nary findings." Such cases may be shown to be
not without renal involvement by the quantita-
tive methods of estimation of the nonprotein
nitrogen in the blood, which is an index of the
functional efficiency of the kidneys. Again the
Phenolsiilphonephthalein test of Rowntree and
Geraghty is available for the determination of
the residual nitrogen. These tests have therefore
both diagnostic and prognostic value not only in
this class of cases, but also in all recognized types
of chronic nephritis.
Every practitioner of wide experience has en-
countered cases of undoubted chronic nephritis
belonging to this category, which have endured
without appreciable change, so far as the indica-
tions of kidney involvement were concerned, for
many years. There is still another type of
chronic nephritis which warrants a favorable
prediction. This is of cardiac origin, and due to
infarcts, which lead to localized areas of fibrotic
change. In this form of kidney lesion either in-
termittent or continuous albuminuria and mod-
erate elevation of blood pressure are present and
the duration long, though indefinite.
Cases illustrative of these atypical forms of
nephritis are more commonly encountered and
pursue a more favorable course in private than
in hospital practice. It is a matter of common
observation that the cases met with in institu-
tions have reached on the whole a more ad-
vanced stage of the disease and occur in persons
of lowered vitality.
It should be pointed out here that painstaking
care in diagnosis is essential in all atypical cases
in which the diagnostic features are scanty. It is
especially important to avoid mistaking albumi-
nuria due to infections, to renal congestion, to
pyuria or even hematuria for chronic nephritis.
It is sometimes confessedly difficult to eliminate-
the passive congestion of valvular lesions of the
heart, but this is an important matter from the
viewpoint of prognosis since death rarely, if
ever, results from this cause in properly treated
cases. And whilst it is true, that albumen and
casts due to the cyanotic kidney of cardiac origin
may vanish in response to rest and cardiac stimu-
lants ; the prospects of life are in some cases, at
least, less encouraging than in true nephritis, and
the danger of an early cardiac death greater. In
estimating the prospect of life, a reasonably cor-
rect view is only possible after a thorough study
of the case over a considerable period of time.
When this is done, diagnostic discrepancies often
disappear, leaving the outlook more hopeful than
it seemed when the cases were first observed.
Personal experience dictates that the systemic
tolerance of cases of what might be termed cir-
cumscribed or partial nephritis is often surpris-
ingly great and if the environing factors and
habits of those thus afflicted can be properly
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144
THE PENNSYLVANIA MEDICAL JOURNAL December, 1920
regulated, the condition is compatible with the
preservation of life, for an indefinite period and
with comparative comfort even, in many in-
stances at least. It is not unreasonable to claim,
as will be seen hereafter, and this also applies to
true diffuse nephritis; that early recognition of
the disease and the steadfast practice of careful
hygienic measures which will afford the kidney
rest and hence opportunity for repair will pre-
vent, to a considerable degree, the advance of the
sclerotic changes. In this connection, much im-
portance attaches to a diet that will maintain the
nutritive equilibrium of the patient without pro-
ducing irritation of the kidneys.
CLASSIFICATION OP TYPES
The classification of the more typical forms
that will be adopted here is a modification of that
of Senator, as follows :
1. Chronic parenchymatous nephritis (chronic
diffuse nephritis without induration).
2. Chronic interstitial nephritis (chronic dif-
fuse nephritis with induration), under which the
arteriosclerotic kidney is considered.
3. Mixed type, a combination of i and 2, i. e.,
diffuse nephritis.*
From the standpoint of prognosis of the indi-
vidual case, it is important to recognize the type
since these vary in regard to the rapidity with
which they undermine the general resistance.
I. CHRONIC PARENCHYMATOUS TYPE
Taking up chronic parenchymatous nephritis,
it is to be observed that the functional activity
of the kidney is reduced much more rapidly than
in chronic interstitial nephritis as a rule. Recov-
ery in cases which have lasted for one year is
rare. Disappearance of the symptoms with res-
toration to health occurs in exceptional instances
and is rather more common in children than in
adults. Occasionally, the so-called small white
kidney is a sequel to chronic parenchymatous
nephritis, — a favorable event, since it is followed
in many cases at least by the long course of the
interstitial variety of the disease. Death, in the
type under discussion, is usually caused by inter-
current inflammation of the serosa, by anasarca
with pulmonary edema, or by uremia. These
complicating conditions, however, may occur
without fatal termination and that repeatedly.
This is more particularly true of inflammations
of the serous membranes, and edema of the
lungs. Whilst, therefore, it is not possible to
prognosticate the immediate outcome when these
intercurrent conditions arise, the fact that they
may be survived with persistence of the progres-
sive renal lesions, is to be recollected.
Dropsy, even if severe, is not necessarily of
highly unfavorable import, but overlooked cases
of associated hydrothorax, do sometimes, as I
have seen, exert a decidedly untoward bearing
upon the outcome by overtaxing cardiac strength
not to speak of the exhausting influence of the
irritative cough and of the dyspnoea occasioned
thereby. By timely aspiration of the chesi, how-
ever, its unfavorable effect can be minimized and
life prolonged. From the foregoing facts, it fol-
lows that the prognosis in confirmed chronic
parenchymatous nephritis is exceedingly grave,
although not altogether hopeless. Again, the
course is much prolonged in cases ending in the
small white kidney.
2. CHRONIC INTERSTITIAI, TYPE
In chronic interstitial nephritis, the duration
commonly varies from ten to twenty or more
years, depending on the habits and mode of life.
It is sometimes cut short by the intercurrent de-
velopment of complications, e. g., apoplexy, acute
uremia, and disturbances of the cardiovascular
apparatus. Certain facts speak against the view
that the course of this disease is uninfluenced by
treatment. I have observed cases in which
strongly presumptive evidence of chronic inter-
stitial nephritis existed, that showed marked and
lasting improvement in the blood pressure, dis-
appearance of the albumen, and tube casts from
the urine as the result of treatment including a
rearrangement of the diet, correction of bad hab-
its and the mode of life.
, Of 177 cases with clinical records coming un-
der personal observation 73 were only seen once
during an office consultation. Of the remaining
104 which were under observation for longer or
shorter periods of time, 56, or 53 per cent., were
improved, and 22 fatal. The remaining 26 cases
were unimproved, but these had reached a more
advanced stage than the larger group (56) which
showed improvement.
It will be observed that 82 of the 104 cases
which continued under personal care either im-
proved or remained about stationary. Of these
21, or 25.5 per cent., showed an average dura-
tion of 18 years to date. The members of the
latter group still give indications of a fair pros-
pect of life, while many cases which have been
under observations for a shorter time give every
promise of reaching the same class. For ex-
ample, of the 21 cases whose average duration
has been 18 years to date, not less than 7 have
lasted from 22 to 27 years without any marked
aggravation of the symptoms of the disease.
From the nature of the anatomic changes it is
undoubted that the disease is always ultimately
fatal, but in view of the possibility of diminish-
ing renal insufficiency by suitable measures, its
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December, 1920
CHRONIC NEPHRITIS— DISCUSSION
145
serious consequences may be retarded. The ad-
vent of cardiovascular complications, cardiac di-
latation in particular, presages a not distant fatal
termination. It is quite possible, however, to af-
ford a more or less lengthy immunity from these
dangers by timely advice and careful manage-
ment, more especially by keeping the demands
made upon the heart well within its reserve
power.
It may be, therefore, claimed that while the
outcome is never recovery, the prognosis is
sometimes at least guardedly favorable if the dis-
ease be recognized early so that to hold out a
gloomy prospect of life in all cases is unjustifiable.
The serious consequences of the complaint can
be obviated by prophylactic means cautiously
and skilfully employed, including the removal of
foci of infection, and it is my habit to inform
sufferers in the earlier stages of this fact, so as to
gain their full cooperation, at the same time tell-
ing them of the danger of the sudden advent of
serious complications and accidents in the event
of their failure to observe rigid protective meas-
ures.
Not a few nephritics in whom the renal
changes are not advanced may live the allotted
time of man by rigidly observing proper dietetic
and hygienic measures. Complete amenability to
appropriate regulations, however, is too com-
monly unattainable among these subjects with
ensuing serious developments. The outcome is
influenced by many factors and associated con-
ditions in a disease of so protracted a course, and
■.vhilst, as before stated it is steadily progressive
in general, sometimes apparent remissions in
symptoms at least or standstill occur and the
more dangerous developments are postponed. It
is not improbable that "when our knowledge of'
the thyroid function increases, many cases of
latent nephritis will be cured by treating the
hypothyroidism" (Janney). Finally, although
the outlook is not reassuring, the dangers are
much minimized by judicious treatment provided
that the diagnosis is made sufficiently early. The
mere diagnosis of chronic interstitial nephritis
therefore does not afford justification for a de-
cidedly gloomy prognosis.
The arteriosclerotic type of chronic interstitial
nephritis which is quite common may show seri-
ous involvement of the renal arteries, although
in the majority of cases these lesions are not ad-
vanced, and do not have a potent effect on de-
creasing longevity. In those instances of arterio-
sclerosis in which the pathologic changes are
most pronounced in the renal arteries (the so-
called renal type) the outcome is less favorable.
The progress of this form of the disease cannot
be arrested, but may be retarded given a reason-
ably early diagnosis by correcting aggravating
habits when found to exist, and by removing the
influence of ascertainable causes, including infec-
tive foci. The chief dangers to life in this type
are apoplexy and coronary sclerosis as well as
myocardial degeneration.
Cases due to neglected syphilis may manifest
a shorter course than other types, because of the
greater liability of developing serious complica-
tions elsewhere, e. g., aortic insufficiency, aneu-
rysm. On the whole, the end of life is ap-
proached in a more gradual manner in the arte-
riosclerotic form than in the other types of
chronic diffuse nephritis with induration.
3. MIXED TYPE
In the mixed type the outlook is gloomy as
compared with that of the usual, uncomplicated
contracted kidney. These hybrids present some
of the main characteristic features of both varier
ties, and often-manifest the more serious devel-
opments of chronic nephritis, e. g., marked
dropsy, uremia, retinal hemorrhages at a com-
paratively early period of their course. The
superimposition of the two leading types of ne-
phritis is readily confused with chronic interstitial
nephritis in the stage of cardiac incompetence in
which the immediate outlook is gloomy. Per-
sonal experience with the combined types of ne-
phritis, however, tallies with the opinion that the
outcome is fatal within one or at most two years.
Two aids in attempts to form an opinion as to
the probable outlook in all varieties of chronic
nephritis remain to be briefly mentioned; they
are the functional kidney tests and the ophthal-
moscope. It is an undoubted fact that an op-
thalmoscopic examination often reveals tortuous
and ruptured retinal vessels or optic neuritis, or
all of these lesions in cases in which the urinary
findings gave no evidence of serious kidney in-
volvement. These ocular changes when well
marked portend grave or even fatal consequences
within a short period of time. This means of
arriving at a diagnosis and prognosis is often
neglected, and its importance in these respects
not fully appreciated by the average general
practitioner.
With regard to the functional tests of the kid-
ney, already alluded to, it is to be further ob-
served that in the present state of our knowl-
edge, they are not to be regarded as the sole
criterion of the prospect of life in chronic ne-
phritis. For example, a few instances of
chronic interstitial nephritis in which the
phenolsulphonephthalein test of Rowntree and
Geraghty showed the excretion to be as low as
15 at the end of one hour and 30 at the end of
2 hours, go on subsequently to practical rfcovM-y^ f
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146
THE PENNSYLVANIA MEDICAL JOURNAL
December, 1920
Granting that this and other functional tests
closely parallel the residual nitrogen determina-
tion, as claimed by Beifeld and others, personal
experience has not always been confirmatory of
their reliability.
MacNider* found that in the more common
type of renal lesion, in which the glomerulus is
damaged out of proportion to the tubule the pig-
ment excretion test is of greater value than are
the retention tests, the latter showing the pres-
ence of urea and creatinin only after the injury
of the kidney has reached a severe type.
R. Fitz» closely analyzed 15 cases of chronic
glomerulonephritis and 26 cases of arterioscle-
rotic nephritis, which had been studied during
life by one or more phenolsulphonephthalein
tests and blood nitrogen determinations, but
these did not suggest any definite relationship
between the type of nephritis found at autopsy
and the results of these two tests for kidney
function made during life, nor did they show
any close relationship between the amount of
gross anatomic destruction of the kidney and the
apparent degree of impairment of renal func-
tion.
REFERENCES
I. Osier & McCrae, Modem Medicine, Vol. Ill, p. 766.
3. Principles of Clinical Pathology, Third American Edition,
p. 81.
3. Archives f. klin, Med. CIX, 469.
4. Quoted bjr Herrick, Osier & McCrae, Vol. Ill, p. 848.
5. Archives Internal Medicine, July, 1920, i.
6. Boston Medical & Surgical Journal, August a6, 1920, 347.
DISCUSSION
Dr. M. Howarb Fusseu, Philadelphia: Dr. Anders
has wisely called atteirtion to the too often overlooked
fact that anatomically and clinically nephritis is not art
entity with uniform microscopic and clinical findings.
That severe anatomical lesions often do not, for A
long time at least, seriously disturb the functions of
the kidney and that serious impairment of the func-
tion of the kidney is frequently due to a temporary
lesion which may entirely disappear.
That no two cases are exactly alike, that paren-
chymatous and fibroid changes exist in varying pro-
portions in practically all cases.
Of special importance in the treatment of nephritis,
Dr. Anders calls attention to the fact that many
chronic cases of nephritis have their beginning in an
infection of local or general character and that early
discovery and attention to this lesion, as a cause of
the nephritis, will frequently prevent the sequel of a
chronic renal lesion with its possible dire results. It
seems to me that recognition of this important fact
is the basis of the outcome of all cases of nephritis.
He makes an excellent point in calling attention to
the fiuKtional tests which can be applied by us all and
by the use of which we may judge of the prognosis
and the effect of treatment and guide our therapeutic
measures.
He also points out that the albumin and tube casts
are evidences of disturbed renal function in cardiac
cases, and that this renal disturbance may be lessened
by attention to the cardiac disease early. This early
recognition and treatment of the cardiac disease will
«ften delay the renal involvement indefinitely.
In his three classical divisions Dr. Anders desires,
of course, to make a point that while certain cases are
the seat of dominating fibroid changes, others of
parenchymatous change, all have characteristic symp-
toms and some differences in treatment. All cases
have both fibroid and parenchymatous lesions, and
need somewhat different treatment.
That the cases with dominant parenchymatous
changes have earlier and more severe functional loss.
The most severe functional loss may at least tempor-
arily be recovered from.
Dr. Anders does not mention what seems to tne
true, that some of the loss of function in cases of
chronic nephritis, where the symptoms have become
acute, is made distinctly more dangerous by the
thoughtless use of so-called diuretics. I am certaia
that the use of caffein and other drugs which stimu-
late the renal tissue often will increase the inflamma-
tion in the kidney, and change a -relatively mild case
of chronic nephritis with acute symptoms, into one
which will be fatal.
Stimulating diuretics have no place in a renal dis-
ease case with acute symptoms.
In interstitial nephritis, he points to the fact that
while not curable in the sense that the kidney will be
made normal — ^yet by proper hygiene, rest, air, food,
and exercises, cases with undoubted renal changes may
live comfortably for many, many years.
It was outside of Dr. Anders' theme to state that
the presence of tube casts and albumin in the urine
are not the death warrant of the person whose urine
contains these substances, and that the*prognosis of a
case is frequently badly affected by a physician telling
such a patient that he has Bright's disease.
Bright's disease in the mind of the average patient
spells death. The presence of albumin and tube casts
may be of no importance as to longevity.
In addition to the use of the functional tests as
valuable in both prognosis and treatment. Dr. Anders
calls attention to the most valuable help of the oph-
thalmoscope as showing the general arteriosclerotic
changes in the vessels.
In a word the outcome of nephritis is not always
fatal. Its outcome can be greatly governed by early
treatment. Many cases get well, and all are tremen-
dously influenced by cooperation of the patient
Dr. J. M. Anders, in closing : I simply wish to make
it clear that the diagnosis of chronic nephritis does
not justify an immediate, unfavorable prognosis. This
is especially true of chronic interstitial nephritis, in-
cluding the arterio-sclerotic type and case of atypical
nephritis, which follow the acute infections, more par-
ticularly, and to which Dr. Fussell referred. This re-
mark does not apply to the advanced stages of these
forms of the disease either, but to that long stage, or
period which precedes disturbance of the cardio-
vascular compensatory mechanism. With proper care,
particularly hygienic care, including the regulation of
the mode of life, and habits of the patient, we can
greatly prolong his days. I grant you that a person
carrying a very high blood pressure, whose arteries are
in a state of advanced arteriosclerosis, runs serious
dangers, but it is often a matter of surprise to see an
unexpectedly long duration of life tmder these circum-
stances, where the patient is willing to accept timely
advice and profit by it. I wanted to add a point which
I omitted from the paper, namely that all cases of
chronic nephritis are thereby rendered unduly sus-
ceptible to pneumococcus infections. This has an un-
favorable bearing, which I think we should always bear
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December, 1920
MASTOIDITIS— KRAUSS
147
in mind in considering the outlook of chronic nephritis.
I have no criticism to make of what Dr. Fussell has so
well said .and I quite agree with him in his interpreta-
tion -of the special tests.
MASTOIDITIS IN CHILDREN*
FREDERICK KRAUSS, M.D.
PHILADELPHIA
I feel that I owe an apology for presenting the
subject of "Mastoiditis in Children" to a body
of men who have had much experience in this
line of work. The subject has been one of great
interest to me for a number of years, and if any
practical point is brought out in the paper or in
the discussion which will be of mutual service, j
hope that we will be repaid for your indulgence.
The presence of so many discharging ears in our
clinics is a positive indication that active meas-
ures have been sadly neglected by some one, in
acute mastoiditis.
This disease affects children of all ages, ex-
treme youth presenting no protection. The
youngest baby operated upon by me was less
than three months of age. It seems to be much
more frequent in children than adults, probably
due to the presence of enlarged tonsils and es-
pecially of large adenoids. Though the latter may
not be sufficient to obstruct the nasal breathing
ordinarily, an acute infection of their glandular
tissue causes great swelling extending to the
Rosenmuller's fossa. This blocking of the eusta-
chian tubes in the presence of pus or other infec-
tive organisms, presages the advance of the
swelling and infection into the middle ear. When
the drum membrane is resistant, invasion of the
mastoid cells is practically certain to a greater or
lesser degree.
It is well known that the nose and throat are
distinguished by the constant presence of staphy-
lococci, streptococci and frequently pneumococci
and other organisms, and as long as a balance is '
maintained between the protective and invading
forces, the child is normal.
When the fresh infecting forces such as scar-
let fever, measles, influenza and the like are in-
troduced, the balance is destroyed and acute in-
flammation follows.
The acute infectious fevers of childhood, in-
cluding pneumonia with or without influenzal
infection, are the commonest causes of the ex-
tension. In my experience the pneumococcus is
perhaps the most frequent exciting causes,
though staphylococcus is a close second.
In very young children of depraved health,
the presence of the tubercle bacillus is not an un-
*Reul before the Section on Eye, Ear, Nose and Throat
Diaeaaes, of the Medical Society of the State of Pennsyl-
vania, Pittsburgh Session, October s, 1920.
common complication and makes for a slow
convalescence. The ordinary symptoms of mas-
toiditis are known to everybody. An attack of
otitis media with discharge after a time usually
precedes mastoid symptoms, such as tenderness
and pain behind the ear, especially over the mas-
toid antrum, associated with more or less tem-
perature. If the disease progresses, redness and
swelling appear usually high up in the mastoid
area, on a level with the upper attachment of
the concha. Pus soon forms below the perios-
teum, due to necrosis of the overlying bone, or
in some cases, it travels along the external canal,
by apparently separating the periosteum from
(■he bone of the ear. If the case is neglected, the
destruction of bone becomes very extensive,
with possible formation of cerebellar abscess,
sinus infection and so on. The cerebellar ab-
scess is often located on the side opposite to the
focal lesion.
Acute mastoiditis often begins as essentially
an original infection. We have seen cases in
which the first symptoms consisted of intense
pain and tenderness over the mastoid bone, fol-
lowed shortly by greatly diminished hearing.
The drum was then found pale and bulging with
loss of landmarks. The temperature was often
very high. A free paracentesis within 24 hours
is followed by a copious discharge of serosan-
guinous fluid, necessitating constant changing of
absorbent dressings. In a few days the pain and
discharge subside, followed soon after by heal-
ing of the wound in the drum and good hearing.
If nature is allowed to proceed without inter-
ference, the condition may continue in the course
of the ordinary mastoiditis as stated above. As
a rule, however, the inflammation is first con-
fined to the middle ear, extending from thence
to the mastoid cells.
A mysterious increased temperature continued
or intermittent, with headache in a young child,
should be suspicious of ear trouble. Pressure
over the tragus, or over the antrum, is usually
followed by a cry of pain. Spontaneously or
otherwise the discharge from the middle ear be-
gins with relief of the symptoms.
The discharge continues more or less co-
piously for about one week, when it ought to
show signs of diminishing. It may continue for
several weeks without harm. The symptoms of
mastoid involvement that indicate early eperation
are continued severe pain after the discharge has
been freed, tendernees, beginning over the mas-
toid antrum, and increasing in intensity, swell-
ing and redness behind the ear. In children this
swelling is apt to be considerably higher up than
in adults, and often begins on the level with the
upper attachment of the concha. In these cas^^
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THE PENNSYLVANIA MEDICAL JOURNAL
December, 1920
the external canal is apt to be greatly narrowed
by the bulging gi the posterior and upper wall.
A rapidly increasing leucocyte count, I consider
of vast importance.
This is illustrated in a case of acute mastoiditis
observed practically from its inception. The pa-
tient had recovered from scarlet fever, when
symptoms of mastoiditis appeared. She was im-
mediately sent to the hospital and placed under
my observation. After a free paracentesis and
rest in bed, the inflammatory symptoms and
temperature subsided. The discharge gradually
lessened. The leucocyte count remained sta-
tionary, around 9,000 for six days. The only
disturbing feature was tenderness over the mas-
toid antrum on deep pressure, but no pain. On
the ninth day there was a return of pain and in-
creased tenderness, a profuse discharge and an
increase to 17,000 leucocytes. Upon immediate
operation, the mastoid antrum was found greatly
increased in size due to beginning necrosis. The
loss of bone was much less than it would have
been if this condition had been allowed to con-
tinue, thus a short convalescence was assured,
with perfect healing.
In my cases, therefore, if pain and tenderness
continue, with increasing leucocytosis beyond
ten days at the outside, I feel it my duty to inter-
fere surgically.
I do not consider it fair to the patient to allow
a suppuration to continue with destruction of the
ear drum, ossicles, necrosis of the temporal bone
with the attendant dangers of brain abscess, gen-
eral pyaemia due to sinus infection or menin-
gitis, when a simple operation, attended in skill-
ful hands by practically no mortality, can cui^
the patient rapidly, with practically complete
restoration of hearing. When a patient is suffer-
ing from some complicating illness like pneu-
monia or pernicious anemia, the prognosis is nat-
urally altered, as well as the operative procedure.
Delay in operation can only increase the pa-
tient's danger and reduce the amount of hearing.
As in appendicitis, some patients get well spon-
taneously, but the risk of chronic running ears
and its attendant danger is great.
A confusing type of mastoiditis is found in
children who have very thick and hard cortex
which jeplaces the cancellated bone of mastoid
process. We find this anomaly not uncommon
in otherwise healthy children, who have not had
any previous disturbance of the hearing appa-
ratus. I feel therefore that this induration is
rather a developmental fault, rather than patho-
logical.
Its importance lies in the fact that in these
cases, the inflammatory symptoms do not come
to the surface since it is well nigh impossible to
erode through three-fourths inch or more of
ivory hard bone. The symptoms in such cases
are a varying degree of temperature, sfcvere pain
especially at night, more or less discharge from
the ear with great narrowing of the external
canal, and increasing leucocytosis. Tenderness
can often be elicited by deep and hard pressure
over the mastoid antrum, which can be compared
with equal pressure on the opposite side. In
later stages, tenderness usually develops in and
behind the mastoid tip, and if the case is n^-
lected the necrosis extends inward and down-
ward, making the so-called Bezold's abscess.
In sclerosed temporal bones, the seat of acute
mastoiditis does not show the usual redness,
edema and swelling behind the ear, because there
is no subperisoteal pus in the r^on of the mas-
toid antrum. These signs may be looked for in
more advanced cases behind and below the mas-
toid tip.
In the ordinary case of mastoiditis there is
usually much destruction of the cancellated tissue
before the external perforation takes place. Es-
pecially is this true of the very young infants of
precarious health, in whom there may be very
little inflammatory reaction present, though the
external wall is found to be necrotic. In these
cases the healing is very apt to be prolonged, with
no tendency to filling up the cavity, and tubercle
bacilli are often found.
In the treatment, I feel that the first thing to
obtain is free exit of the inflammatory exhudate
and reduction of the swelling.
A free opening in the drum is essential. The
external canal is kept as free from discharge as
possible by frequent lavage with hot boric acid
solution. Occasionally I substitute a weak bi-
chloride of mercury solution — i to 6,000 or
10,000.
I am careful to state that the quantity of the
solution may be as large as you wish, but force
in its use always must be absent. I have seen bi-
chloride solution forced through the eustachian
tubes in a convalescent patient in sufficient quan-
tity to cause mercurial intoxication in a sensitive
individual.
I have very little faith in the use of ice bags
on the mastoid process. It may ease the pain,
but I feel it will not help cure the disease. In
fact, after the drum is opened, I advocate heat
to relieve the pain. In a general way the patient
should be kept in bed with the skin acting freely.
Potas. citrate in 15 gr. doses with aconite, is
helpful. If the patient does not improve in a
few weeks, or has relapse of pain at intervals, it
is safer to open the mastoid bone to secure
drainage. Especially is this true if there is edema
behind the ear. When you have reason to sus-
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Dbcember, 1920
MASTOIDITIS— DISCUSSION
149
pect pus in this swelling, the sooner it is opened
the better for the patient and the less bone may
have to be removed.
In acute cases of a pneumonia in which acute
mastoiditis developed very rapidly, I have made
a long, incision through the periosteum and in-
troduced a good sized gauze drain, wet with bi-
chloride solution I — 6,000 under the separated
periosteum. Occasionally the patient will get
well without further operation. This can be
done without general anesthesia and only takes
a minute. This is, however, only a makeshift.
The technique for the operation for acute mas-
toiditis is well described in textbooks and I will
not take your time for further description, ex-
cept to state that I have found it possible to re-
move too much bone in young children. The
opening in the mastoid should be free enough to
drain thoroughly and allow rapid granulation,
but needless cutting away of the bone makes a
poorly healing proposition, especially in poorly
nourished individuals. If care is exercised to
preserve the periosteum from injury, and bring
the edges well together after the operation, when
a large opening is required by widespread nec-
rosis, the healing is much expedited.
The mastoid antrum should always be found
as a prime necessity and well drained with no
overhanging edges allowed to remain. Expo-
sure of the sigmoid sinus is very frequent on ac-
count of its location very near the surface in
most children. In some cases, it overlies the an-
trum. This is particularly true in sclerosed cases
where the antrum is often separated from it by
a very thin layer of hard bone. If due care is
exercised, there is slight danger, as the membra-
nous covering of the sinus is very dense.
Healing is very rapid wheh the sinus is freely
exposed without injury. In sclerosed cases with
beginning Bezold's abscess, I have found it ex-
pedient after reaching the mastoid antrum which
is usually very small, to elevate the periosteum
downward and posteriorly, reaching and drain-
ing the subperiosteal space on the inner surface
of the mastoid bone.
In cases of retarded healing due to the pres-
ence of tubercle bacilli, I have done the radical
operation with good results.
In packing the bony wound and the external
auditory canal, I think that I have found much
better results from 1 — 6,000 bichloride wet pack-
ing and dressings, than from chloride and oxy-
gen derivatives.
After operation I employ three-fourth inch
gauze packing wet with 1—6,000 bichloride of
mercury solution, using a narrow wet packing
in the external canal, reaching the drum mem-
brane. The external layers of gauze may be
changed but the packing is allowed to. stay four
or five days before being disturbed. I change
the light packing in the external ear every time
that the external dressings are changed. Three
to six weeks is required before the wound is
completely healed. In some patients, the granu-
lation tissue is free in its growth, and must be
excised. In others, the reaction is so slight that
healing must be stimulated by Silver, or Scarlet
Red salve. Even then the desired granulations
are remarkable occasionally by their absence. I
never use irrigations in the ear or wound after
operation, depending entirely upon drainage with
gauze. After the first week, I am inclined to
w^et boric acid or normal salt solution instead of
bichloride, which sometimes causes a dermatitis.
In conclusion, the main purpose of the paper
is emphasizing the necessity of an early interven-
tion in mastoiditis in children. The production
and retention of a chronic running ear should be
regarded cis a serious offense in preventative
meidicine. A free dischage must come from the
mastoid cells or the eustachian tube, as the mid-
dle ear is very small. If due to diseased tonsils
and adenoids, they should be removed. If the
discharge does not cease, the reason should be
ascertained at once.
When a child has earache, enough to keep it
awake at night, and the drum has lost its land-
marks, a free incision will relieve it and gen-
erally a more serious operation is avoided.
There is no reason why nature should be allowed
to necrose the drum, leaving a permanent per-
foration.
The cut always heals in an inflamed drum, and
perfect healing follows. An early operation for
mastoiditis is ja-actically devoid of danger and a
source of deep satisfaction in ridding the patient
of the danger of running ears, offensive dis-
charges, chronic mastoiditis with cholestrum for-
mation, sinus infection, brain abscess and other
disagreeable infections.
I realize that I have only skimmed the surface
in presenting this paper and much could be
added, but I feel that discussion will make even
a short paper of interest.
1703 Chestnut Street.
DISCUSSION
Dr. John R. Simpson (Pittsburgh) : I do not think
Doctor Krauss need make any apology for bringing
the subject of acute mastoiditis before the section, be-
cause the last word has not been said on the subject.
I think most of us will agree that tonsils and adenoids
are very often the seat of development of acute mas-
toiditis, and that since their removal has become quite
general the number of cases of mastoiditis has been
somewhat reduced.
Our experience has been that the streptococcus and
pneumococcus are most commonly found in connection
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150
THE PENNSYLVANIA MEDICAL JOURNAL
December, 1920
with these cases of acute mastoiditis. I am inclined
to think that where the staphylococcus is found we
are possibly dealing with a chronic suppurative condi-
tion in the middle ear rather than an acute involvement
of the mastoid.
I want to emphasize what Doctor Krauss has said
about location of the swelling in the upper posterior
part of the mastoid. In children the co'rtex is thin
and soft and it is very easy for infection to travel to
the outside and produce a subperiosteal abscess. And
furthermore, the periosteum covering the squamous
portion is more easily pushed up than that covering
the petrous portion, so that the swelling tends up-
wards. I do not think we very often encounter a
thick, hard cortex. That has been the exception in our
experience.
Of course some of these children are very young and
it is difficult to bring out the sigrt of tenderness or to
determine just how much pain is there; but we caa
determine that more by the restlessness and fretful-
ness of the child. We are inclined to rely a good deal
on temperature in a child. The absence of tempera-
ture in an adult does not count for much, but tempera-
ture in a child is an important guide to go by and we
feel that the temperature should be taken every three
hours per rectum and carefully recorded. Close ob-
servation of the temperature chart from day to day
will help us greatly in determining whether or not an
operation is necessary.
When we come to do the operation I agree with
Doctor Krauss that there should not be needless sac-
rifice of bone, although the operation should be done
thoroughly. Especially in the region of the antrum, it
is a mistake to do any curetting because you will have
difficulty in getting that mastoid healed. There will be
a permanent communication between the middle ear
and the antrum. Then in doing a mastoid operation
it is well to remember the location of the seventh
nerve and keep away from the anterior wall.
Dr. N. Arthur Fischer (Pittsburgh) : When we
consider the important structures that surround the
mastoid and middle ear, such as the facial nerve, the
temporosphenoidal lobe, the lateral sinus, I think we
will all agree that this mastoid operation is far more
serious than possibly Dr. Krauss's paper unintention-
ally leads us to believe.
With regard to the time of ten days given as the
maximum for doing a mastoid operation, I should
judge we would be far better off to consider each case
as an individual one and regard all the symptoms in
that particular individual as the deciding factor with
reference to the time of operation rather than to put
down a definite time limit of ten days for every case.
It is not always necessary to wait for swellnig over
the mastoid. We can make our diagnosis of mastoid-
itis in many cases before this particular symptom. But
the mastoid operation should not be performed unless
the man who is doing it is sufficiently competent to
judge of its necessity. There are many anomalies in
this mastoid bone that we must take into considera-
tion, and even in the hands of the very best and most
skilled men, the operation does not always result in
the way we should like to have it. I do not mean,
however, that we should delay doing the mastoid
operation when once we have decided that it should
be done.
Dr. Matthew S. Ersner (Philadelphia) : During
the year of 1914 and 1915 I made extensive bacterio-
logical studies of the organisms found in acute and
chronic suppurative otitis media. We found the strep-
tococci were most prevalent, the pneumococci came
second, and the remainder were staphylococcus, pyo-
genes, pseudo diphtheria, occasional colon and fried-
lander, and by making vaccines and administering
them early we were able to avoid mastoiditis, or at
least some of them.
At that time we tried to find tubercle bacilli, but I
must confess that in only two instances out of about
two himdred cases did we find acid fast organisms, and
in those patients we did complement fixation tests under
the supervision of Dr. John A. Kolmer of Philadel-
phia, at the Polyclinic Hospital, but we were tmable
to get positive complement fixation. Dr. Krauss says
he was able to find the tubercle bacillus very fre-
quently. I wonder whether some acid fast organism
may not have been present there and should have been
investigated further. We especially looked for the tu-
bercle bacillus in so-called perforated ear drums, but
in only two cases did we find them.
As to postauricular oedema being a most prevalent
symptom, I wish to differ with Dr. Krauss. Of all the
mastoids that we (Dr. Coates and myself) did this
year, some 74, we have in only three or four instances
found postauricular oedema.
We are not radical. We will not say that we oper-
ate on the eighth or tenth day; there is no rule that
can be set down for that; there are many other fea-
tures to watch. We employ everything available — we
use the X-ray, we watch the leucocyte count But we
do not say that on the eighth or tenth day we will
operate.
The doctor spoke about cleansing. The modem
thought about cleansing, I think, is to leave the ear
alone. Most of us in Philadelphia simply try to wipe
the ear dry and avoid any solutions, because when we
analyze the basic principles of bacterial multiplica-
tion, we find it requires heat, moisture, darkness and '
nourishment, and if we wash the ear we supply the
moisture — and there is heat and darkness already pres-
ent in the middle ear. In other words, wipe the exter-
nal canal as thoroughly as possible and employ some
drying substance to absorb the secretions and thus im-
pede the multiplication of organisms. Another reason
for not washing the ear is that one is apt to wash in as
many organisms as are cleansed.
Among some of the other, diseases that cause post-
auricular swelling are infection of the skull, which is
accompanied by pain caused by the glands draining the
sktill, which carries infection. Over and over again
we see patients rushed into the dispensary with a note
stating that a mastoid should be performed, when all
that is necessary to do is to examine the skull. The
otitis cases of last year were rather peculiar. We had
a g^reat deal of oedema, especially at the mastoid tip
with enlargement of the glands, and in nine cases of
the group we had (probably 150 ear drums we opened
during the winter) developed retropharyngeal ab-
scesses. In some the swelling extended upwards, and
later on the postauricular oedema disappeared.
Dr. Frederick Krauss (closing) : The diagnosis of
acute mastoiditis, especially in children, is a thing that
cannot be discussed in five or ten minutes, and to speak
of one symptom as telling the whole story is very
shortsighted.
As to the time limit for operation, we do not wait
for ten days, or twenty days. We are guided by the
symptoms that the patient presents. I simply mean
that if after the drum is opened there is a free flowing
discharge and the patient still has pain, then something
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December, 1920
INDUSTRIAL PHYSICIAN— ELLENBERGER
151
else must be wrong. And then, in addition you have
tenderness on pressure, a narrowing of the ear canal,
and an increase in leucocytosis.
Of course the danger of operation is greater if it is
done by someone who has not had considerable expe-
rience, but an experienced man can operate and not
expose his patient to great danger, although he must
be careful when he has the lateral sinus bulging out
and has not reached his antrum — when he has to chisel
along the side it takes great care.
As to the presence of the tubercle bacilli. The cases
I have observed were mostly young infants, some as
young as one month — a number from one month to
three months. They are the ones that are very slow
to heal and show very few inflammatory symptoms.
" They have a bulging behind the ear and you cut down
and find the whole wall gone and a great deal of the
cancellated bone destroyed. In those cases the ten-
dency is that tubercle bfcilli may be present, but be
sure to prove them present by staining.
THE INDUSTRIAL PHYSICIAN*
J. WESLEY ELLENBERGER, M.D.
HARRISBURG
As members of the Medical Profession we
are justly proud of the great increase in medical
knowledge which has been made in the last half
century, and especially in the last few years.
We take great pleasure in contemplating the re-
sultant diminution in the amotmt of sickness, in
the consequent increase in happiness, and the
steady increase in the years added to man's life.
We have not hesitated to scrap theories and
practices which have interfered with medical
progress. As a result the practice of medicine
has changed considerably in the period under
consideration. ,
We have heard much of the passing of the
faithful old family physician, who served his
people well, not only as their doctor, but also as
their friend and counselor. He it was who
helped in sickness or death, or other catastrophe,
who was ccMisulted not only about medical mat-
ters, but also about financial and religious sub-
jects, sociological questions generally, and any
other subject in which his people were greatly
interested. His advice was usually good, so that
his influence was a real uplift to his community.
All honor to those splendid unselfish men who
did so much for their followers; nor is their
species extinct to-day.
We have heard also of the employer of men,
the small manufacturer who knew intimately
each person who worked with him and for him,
and who also was the counselor and friend of
his employees. Very often the family physician
and the employer were the good angels who
'Read before the General Meeting of the Medical Society of
the State of Pennsylvania, Pittsburgh Session, October 5, 1920.
jointly came to the assistance of the workmen in
time of need. As the employer has been suc-
ceeded by an organization, the intimacy between
the owner and the employer has diminished.
Yet the need of sympathetic guidance is as great
to-day as ever.
The great corporations have for a generation
employed surgeons to give first aid to those in-
jured in their service, but such help was not
enough. A few years ago some wide-awake em-
ployers began to do more. They sought to do
for. their employees the same generous "service
which the old-time family doctor, and the old-
time employer, had done for the working
glasses. They organized new hospitals, or they
contributed to those already in existence, for the
purpose of caring for their employees, especially
for those who had been injured in their service.
They did not, however, adequately pay the phy-
sicians who served on the hospital staff. They
reasoned that the prestige, and the opportunity
to utilize the facilities of the hospital for private
patients, was sufficient reward. In addition to
the duty of caring for those who had been in-
jured, the company doctor was expected to care
for the company's interests by preventing law
suits for damages if possible, or by helping to
win suits if such were inaugurated. Physicians
so employed usually received small salaries, but
sometimes were given the privilege of collecting
their bills for services to the employees' families
through the office, or they had some other per-
quisite which made the position attractive to
them. In recent years, corporations have been
showing an increasingly greater interest in the
welfare of their employees and have employed
more and more persons to look after this phase
of work.
In 1916 the evolution had reached such a stage
ojE. development , that there was bom in Detroit
an organization of these workers, under the
name of the Industrial Physicians of America.
There were gathered at this session many phy-
sicians and others who were enthusiastic pio-
neers in the new development. They told of
their experiences and demonstrated that there
was an excellent opportunity for a new specialty,
whose devotees might accomplish really worth
while results. These physicians, they declared,
should do more than merely treat the sick.
They should combine the functions of the old-
time family physician and the old-time employ-
ers, so far as these related to welfare work, but
they should not stop there.
The A. M. A. at its 1916 sessions gave a sym-
posium on Industrial Medicine, which proved to
be illuminating and inspiring. Since thenindi^ i
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152
THE PENNSYLVANIA MEDICAL JOURNAL
EteCEMBER, 1920
trial medicine has loomed quite conspicuously
upon our view, and the industrial physician has
become a factor of real importance. Therefore
a consideration of his duties may not be inop-
portune at this time.
His duties might be divided into those that
pertain to medical service, and those that pertain
to welfare work.
Under the first heading should come an ex-
amination of every prospective employee. Such
a course would aflFord an opportunity to give to
a man the job for which he was most competent,
and would eliminate the injustice of placing a
man at work at something for which he was not
physically fitted, and where he would be sure to
fail. It does not, however, mean that men with
physical imperfections should be rejected. On
the contrary, men who are below par, even those
with but one arm, or leg, or eye, have been as-
signed to duties for which they were fully com-
petent and have proved to be valuable em-
ployees. It has been stated that such employees
are more reliable and less migratory than are
those physically sound; possibly because the
former appreciate a job more than the latter.
Inspection of machinery is made upon instal-
lation, and periodicjilly thereafter, and is found
to be profitable. A man is of more value than
any machine and should have at least as much
attention as the machine. If, upon such ex-
amination, defects are found, the employee may
be referred to the family physician, or to a spe-
cialist, or to any other who may offer the best
prospect for a speedy restoration to health.
And many defects will be discovered, often suf-
ficiently early to afford opportunity for cure,
thus reducing morbidity and mortality with their,
distress and loss.
The industrial physician should, of course,
look after those injured in the service of the
company which employs him. He should see to
it that they receive the very best care possible.
He should also be the counselor of the em- .
ployees who become ill, including such as prefer
a physician of their own choosing, but who also
may desire the counsel of the company's repre-
sentative. Experience teaches that a competent,
conscientious, industrial physician, acting as a
consultant, has additional opportunity to fur-
ther diminish morbidity and mortality among
the employees. When employees are absent
from work because of illness, the industrial
physician should be notified of the fact. He
should then ascertain the conditions, through the
family physician or by his own observation, and
have an opportunity to help in establishing a
cure or in preventing a recurrence if feasible.
Employees who h^ve been ill should be reex-
amined before they return to work.
The phyisician should likewise inspect the
plant. He can do much to improve the sanita-
tion, and the safety of the conditions under
which the employees work. These conditions
include the light, heat, ventilation, humidity,
avoidance of dust and noxious odors and gases,
in the plant, and the installation of safety de-
vices. By conversation with the employees, and
by lectures, he may improve the habits of the
men so far as these affect their health. He may
go further ; he may become their friend and ad-
viser, and help his people in physical and mental
education, in financial matters, and in morals.
Is not such a vista an insfyring one?
The physical education should embrace such
subjects as exercise, diet, cleanliness of body
and surroundings, food, clothes and sleep. He
may tactfully help some to acquire a better edu-
cation, developing their mental ability and in-
creasing their value to themselves, their em-
ployer, and the community.
His opportunities are exceptionally great in
the field of finance. Some one long ago de-
clared that it is not what one earns that counts,
so much as what one saves. There is truth in
this. Yet it is astonishing to note how few men
save anything, or having saved something, suc-
ceed in retaining it until their time of need.
Statisticians state that ninety-seven per cent, of
those who have lived until their sixty-fifth year
have accumulated nothing, but are dependent
upon their daily earnings, or upon others, for
their support. Our fathers were wiser in this
respect than are we. The writer is convinced
that this generation lacks thrift, and that this
lack is responsible, at least in part, for the un-
rest that is so prevalent throughout the world.
Therefore he earnestly recommends to his pa-
tients, and to his medical friends as well, the
great importance of saving something from their
earnings, and of acquiring a title to a home at
the first opportunity. As soon as a man be-
comes theowner of his own home, he becomes a
more stable citizen, one who will pay his honest
debts (including his doctor bills), who will be-
come interested in civic matters, and who will
frown upon anarchy and all of its kindred.
In one of the companies which the speaker
represents, it is the custom to encourage the men
to invest in a good building and loan association,
and to purchase homes through this same
agency. Sometimes this company guarantees
the payments for a time, or until the equity of
the purchaser becomes sufficient to make the en-
dorsement unnecessary. The company keeps its
plant in as nearly dustless a condition as possi-
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December, 1920
TONSILS— GODDARD
153
ble; insisting upon, cleanliness everywhere.
The rooms are well lighted, and well ventilated.
There are rest rooms, and a good auditorium,
lectures are provided by the management, and
other entertainments are arranged by the em-
ployees. In addition to the compensaticm insur-
ance required by the state, this company pays
for group insurance to protect the dependents
of the workers in case of death. The men pay
for additional insurance through the company,
to cover losses due to sickness. The employees
are superior to the average, earn and receive
more than the average, and are loyal to their
employer.
Another company in which the writer is in-
terested, provides a twenty-five-cent lunch at
noontime for such employees as wish it, that is
popular and good. The meal consists of roast
beef (or its equivalent), several vegetables (as
potatoes, peas or com), a salad, bread and but-
ter, milk or coffee and pie. This has been in
operation nine months. About one hundred are
served daily and the expense has been less than
$400.00 thus far.
Large employers of labor have found that one
lesult of efforts such as are described in this
paper has been a marked diminution in the labor
turn-over. This one result has produced a sav-
ing which has more than paid the entire expense
of the supervision. These employers have, how-
ever, secured good men and paid them well.
Cheap service here is like cheap service else-
where, one cannot buy sflk for the price of cot-
ton.
The properly trained industrial physician has
the opportunity to improve the health of his peo- -
pie, to increase their prosperity, and to add to
their happiness and well being. His efforts will
also contribute materially to the success of the
plant employing him. In return he may receive
the consciousness that he has done his part in
the world. He should also receive as a recogni-
tion of this performance, a sufficient monetary
reward.
TONSILS CONSIDERED FROM THE
VIEWPOINT OF THE SPECIALIST
AND GENERAL PRAC-
TITIONER*
HERBERT M. GODDARD, M.D.
PHn,.\DELPHIA
Those of us who specialize in nose and throat
work appreciate the necessity of more intimate
knowledge regarding tonsillar conditions and
realize the advisability and advantage of a free
'Read before Lackavranna County Medical Society, Scranton,
Pa.. May 4, 1920.
discussion at such times as this, since we can all
profit at these times and thus be in a better posi-
tion to advise those who consult us.
In order to present the subject in a clear, con-
cise and methodical manner, let us consider its
various steps, taking up first the clinical anatomy
of the tonsils. As we all know the faucial tonsil
is situated in the sinus tonsillaris between the
faucial pillars, and has its origin in an invagina-
tion of the hypoblast at this point. Later the de-
pression thus formed is subdivided into several
compartments which become the permanent
crypts of the tonsils. Lymphoid tissue is depos-
ited around the crypts, and thus the tonsillar
mass is built up. The inner part or exposed sur-
face, including the cryptic depressions, is cov-
ered with mucous membrane, while the outer or
hidden surface is covered by a fibrous capsule.
It will be observed that the tonsil is an encap-
sulated organ, and that it is characterized by
from eight to twenty crypts or tubular depres-
sions. Many practitioners have confused the
tonsil with the follicular tissue immediately sur-
rounding it. So long as they were able to re-
move follicular tissue through the wound in the
tinus tonsillaris, they thought they were remov-
ing tonsillar tissue. In this they were mistaken,
as the lymphoid tissue immediately surrounding
the tonsil is not encapsulated,, nor is it character-
ized by cryptic depressions, and is therefore not
tonsil tissue.
The tonsil does not always completely fill the
sinus tonsillaris, the unoccupied space above it
being known as the supra-tonsillar fossa, into
which several crypts usually open. It is impor-
tant to remember that the outer aspect of the ton-
sil is loosely attached to the superior constrictor
muscle of the pharynx, thus subjecting it to com-
pression with every act of deglutition. The
plataglossus and platapharyngeus muscles of the
pillars also compresses the tonsil and there are
some observers who claim that the compression
of the muscles forces food and bacteria into the
crypts, rather than out of them. The crypts are
usually tubular and almost invariably extend the
entire depth of the tonsil to the capsule on its
outer surface. Some, however, are compound,
e. g., they divide below the surface into two or
more tubules. They are usually comparatively
straight, though they may be tortuous in their
course. I have examined n^my hundreds of ton-
sils which have been removed with their capsule
intact, and have never found crypts that did not
extend through the follicular tissue to the cap-
sule. Clinically, the crypts seem to be the source
of the greatest amount of local and constitutional
disturbances, as they often become filled with
food, tissue debris, and bacteria. This is espe- ,
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THE PENNSYLVANIA MEDICAL JOURNAL December, 1920
dally true of those capped over by an overlying
membrane as the Plica Supratonsillaris, and the
anterio-inferior portion of the tonsil which is
covered by the Plica Tonsillaris. It is in these
cases, particularly, that the contents of the crypts
are retained.
Reasoning from a mechanical point of view,
one would reach the conclusion that the reten-
tion of the infected secretions must necessarily
give rise to infectious inflammatory processes,
and it may be stated as a general law in physi-
ological pathology, that mechanical obstruction
to the drainage of any secreting cavity tends to
result in local morbid processes and in toxic in-
fectious manifestations in remote parts of the
body.
The free surfjice of the tonsil, including the
crypts, is covered with stratified pavement epi-
thelium, the deeper layers of which are columnar
in type. Some years ago, Wright showed that
there is a vast difference in absorptive power
of the tonsil for dust and for bacteria. He in-
troduced carmine powder and bacteria into the
crypts of the tonsils and excised them in fifteen
minutes. The microscope showed the carmine
particles in great abundance, beneath the epithe-
lium and within the intercellular spaces, whereas,
no bacteria were found beneath the surface. We
know, however, from abundant clinical experi-
ence, that there are conditions under which the
bacteria are absorbed through the cryptic epithe-
lium in sufficient numbers to excite marked local
and constitutional disturbances. As long as the
epithelium of the crypts is in a state of tonicity
or health, an equilibrium between immunity and
infection is maintained. When the cellular foh-
icity is impaired, the equilibrium between im-
munity and infection is lost and infection occurs.
When the crypts are closed by the Plica Supra-
tonsillaris and the Plica Tonsillaris, or by con-
cretions in the mouths of the crypts, a very ac-
tive warfare between the retained microorgan-
isms and the epithelial cell is begun. The cells
throw out a poisonous ferment, whereas the bac-
teria throw off a toxin for the purpose of im-
pairing the tonicity of the epithelium, if the siege
is continued sufficiently long, the cells give way,
and the infectious host penetrates the epithelial
barrier and enters the deeper tissues of the ton-
sils.
The relation of the tonsil to the lymphatic ves-.
sels, as you gentlemen know, is somewhat dif-
ferent from that which exists between the Ijrm-
phatic glands and vessels. The difference in the
relationship consists in the fact that the lymphat-
ic vessels have their origin in the tonsils, where-
as they pass through the lymphatic glands. The
question of chief clinical importance is the course
and termination of the tonsillar lymphatic ves-
sels which drain into the deep cervical chain un-
derneath the sternocleidomastoid muscle, from
then to the thoracic glands and finally into the
thoracic duct. By this route infection is carried
to- all parts of the body.
The tonsil, under certain conditions, being pe-
culiarly susceptible to infection, becomes, there-
fore, the atrium of infection for a great variety
of diseases, extraneous to itself. Literature is
rich with clinical reports of diseases illustrating
this fact. The facility with which the invasion
of pathogenic microorganisms is accomplished
through the tonsils depends upon the following
factors :
1. The virulency of the invading microorgan-
isms.
2. The pathogenicity of the microorganisms.
3. The general health of the patient.
4. The existence or the absence of the stru-
mous diathesis.
5. The condition of the epithelium of the mu-
cous membrane covering the tonsillar crypts,
and the condition of the tonsillar tissue.
Bacteriology of the Crypts. The organisnu
most commonly found are the pneumococcus,
streptococcus and the staphylococcus; in fact,
these microbes are almost constantly present in
the crypts of the tonsils and the most virulent
of these is the streptococcus-hemolyticus. The
recognition of the hemphytic streptococcus as
a distinct species with a special affinity for cer-
tain tissues is of recent date. In fact the expe-
rience of the late war has brought out and ex-
posed the virulency of this microorganism. It is
not always easy to differentiate the hemolytic
from other forms of streptococci, and it is
claimed that other varieties of streptococci may
change into the hemolytic type. That this or-
ganism seems* to have a selective action on cer-
tain structures in the body ; for example, the en-
docardium and other serous membranes, has
been proved by post-mortem examinations.
The Function of the Tonsil. This very inter-
esting question is still being investigated and up
to the present time apparently no definite conclu-
sions have been reached. There are some, how-
ever, who theorize and attribute certain functions
to this organ, but I am inclined to agree with
Wright, who, commenting upon the function of
the tonsils, asserts that we are unable thus far
to describe the function or physiology of this
organ as these terms are ordinarily used, but
rather to speak of the tonsil in its relations to
the process of immunity and infection.
When Should Tonsils be Removed. The ques-
tion of when tonsils should be removed offers an
opportunity of a lengthy ami interesting disais-
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December, 1920
TONSILS— GODDARD
155
sion and while there is no doubt in my mind that
volumes could be written on thie subject, it seems
to me the answer could be simplified by saying
one's clinical experience is the guide. In brief,
whenever I find hypertrophied tonsils, the pos-
terior portion of which acts as an irritant to the
pharyngeal wall, thus setting up irritation, I al-
ways remove them. Again whenever there is a
history of frequent attacts of tonsilitis, removal
is always indicated. As a matter of fact, there
are, as we all know, innumerable indications for
removal, and yet rather than burden you with
repeating them all, I will say my guide is first,
the history obtained, the general appearance of
the tonsil, but most important of all, the picture
seen by making pressure with a tongue depressor
upon the tonsils, and noting if free pus or
foul smelling caseous material, exudes from
the numerous crypts. Because of the uniformly
satisfactory results I have obtained, it is my in-
flexible rule when such a picture presents itself,
10 advise removal regardless of history and ap-
pearance, and right here, let me ask you gentle-
men, when the final decision is to be rendered, is
it not one's own personal clinical experience that
should be the deciding factor rather than knowl-
edge gleaned from the promiscuous literature?
Your answer, I am sure, is "clinical experience."
As to when tonsils should be operated I would
say, just as soon as it is decided that they are
the offending members, providing, of course,
that there is no acute inflammatory condition
present to contraindicate their removal.
Method of Removal. This is better answered,
perhaps, by the individual, since it all resolves it-
self down to the fact that one uses the method by
which he gets the best results, and this is only
arrived at by repeated trials and changes. Not
long ago my very dear friend, Dr. E. B. Gleason,
whom we all know stands foremost in his spe-
cialty, honored me with his presence during an
operation. Sometime later he said,* "Do you
know, Goddard, I have been trying to figure out
just what method you do employ, and have con-
cluded you have selected your various steps from
different techniques." This, indeed, seems to
answer the question, and while my present tech-
nique is perhaps as original as any, yet I venture
to say, like all others doing this work, it is the
result of selecting a step here and a step there,
and in the final analysis I am using the method
best suited to my needs, the one giving the most
satisfactory residts in the quickest possible time,
name it what you will.
In children, general anesthesia, e. g., ether is
always used, but from fifteen years upwards, I
always advise local, because it is absolutely pain-
less and eliminates the often unpleasant results
of a general anesthetic and likewise the danger
attending a general anesthetic, regardless of the
skill with which it is given.
Technique. This is the same, whether local or
general anesthesia is used. The patient being
properly prepared, the tonsil is grasped with a
tenaculum forceps and is gently pulled outward
and forward, then with a Goddard tonsil knife
a cut is made at the junction of the plica triangu-
laris and tonsil tissue about the upper third ; an-
other cut is made at the junction of the posterior
pillar and the tonsil tissue corresponding to the
first incision. The tonsil is now released and
with a tenaculum passed through the wire loop
of an Ever's snare, it is again grasped and trac-
tion is made towards the median Une, inversion
of the tonsil follows and the loop of the snare
is placed around its base and with one quick
manipulation of the snare the tonsil is removed,
with its capsule intact, without injury to the an-
terior or posterior pillar and with the minimum
amount of trauma or bleeding.
Upon removal of the tonsils, any bleeding vessel
is at once grasped and crushed with a hemostat, on
the same principle that the general surgeon uses
a hemostat. At no time are gauze sponges placed
ill the fossa to control hemorrhage, since to my
way of thinking it not only fails, but is respon-
sible for increased trauma to the parts and often
retards healing. I am sure no one ever sees a
general surgeon try to stop a definite bleeding
point by holding to said point a gauze sponge.
Where Should Tonsils be Removed? It is
generally supposed that tonsils in children,
which, of course, invariably includes adenoids,
should be done at the hospital, but gentlemen, it
is my opinion that more satisfactory results fol-
low by operating at home, providing there is
electricity and the operator goes properly
equipped. This has been my custom for some
years past, because I believe it eliminates to a de-
gree the nervousness in children since it does
not require placing them in strange surround-
ings, and because with properly trained assist-
ants, there is no reason to worry in the event of
hemorrhc^e, since a specially trained nurse is
quite capable of dealing with this emergency until
the operator can be summoned.
Under local anesthesia I much prefer operat-
ing in my office and allowing patients to go home
when all danger of hemorrhage is past, which
usually means thirty to forty minutes. If pa-
tients are from out of town, I then arrange for
them spending the night in a hospital.
Complications. — While there are reports of
numerous complications, hemorrhage up to the
present time seems to be the only one of impor-
tance. As we know, the tonsil is an extremely
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THE PENNSYLVANIA MEDICAL JOURNAL December. 1920
vascular organ, receiving its blood supply from
numerous sources. The tonsillar artery, a branch
of the facial, is the chief vessel to the tonsil,
though the ascending palatine, another branch
of the lingual, sometimes takes its place. The
tonsillar artery passes upwards on the outer sur-
face of the superior constrictor muscle, through
which it passes and gives off branches to the ton-
sil and soft palate. The palatine, another branch
of the lingual, also sends branches through the
superior constrictor to the tonsil. The ascending
pharyngeal also passes upward outside of the su-
perior constrictor, and when the ascending pala-
tine artery is small, it gives off a tonsillar branch
which is correspondingly larger. The dorsallis
linguae, a branch of the lingual artery, ascends
to the base of the tongue and sends branches to
the tonsil and pillars .of the fauces. The descend-
ing or posterior palatine artery, a branch of the
inferior maxillary, supplies the tonsil and soft
palate from above, forming anastomosis with the
ascending palatine. The .small meningeal artery
sends more branches to the tonsils, though they
are of minor importance. Because of this pro-
fuse blood supply, the danger from hemorrhage
is perhaps the greatest objection to the operation.
Is this a real or an imaginary obstacle? It is
both in adults. It is real in that severe hemor-
rhage does occasionally occur in operations on
the tonsils. It is imaginary as to the repeated
frequency of its occurrence and the degree of
danger attending it. Clinically, I have observed
that the most frequent sight of arterial hemor-
rhage is at about the middle portion of the sinus
tonsillaris, where the tonsillary branch of the
facial pierces the superior constrictor musck of
the pharynx. Other points of hemorrhage are
usually limited to the inferior portions of the
sinus tonsillaris, where the tonsillar venus plexus
is located, and to the anterior and posterior pil-
lars.
A knowledge of the possible sources of hemor-
rhage will enable the operator to largely elimi-
nate its occurrence. Furthermore, there are cer-
tain matters in the technique of local anesthesia,
and in the after treatment which, if properly ap-
plied, will greatly reduce the frequency and se-
verity of hemorrhage and there need be no great
anxiety.
After Treatment. In children little or none is
given. In adults the fossae are kept clean by
antiseptic spray and local applications until
healed.
SELECTIONS
"We live in deeds, not years; in thoughts, not in
breath ;
In feelings, not in figures on the dial.
We should count time by heart throbs when they beat.
For God, for man, for duty."
TREATMENT OF PUNCTURE WOUNDS
Frank Bbnton Block, M.D., F.A.C.S.
PHItADELPHIA
The orthodox method of treating puncture wounds
by means of wide incision is undoubtedly eflkient but
whether such treatment is necessary or advisable in all
cases is open to question. The industrial surgeon who
widely incises every puncture wound that he sees wiU
be following the usual custom and cannot be adversely
criticized by his professional brethren but he will be
very harshly criticized by the average industrial work-
er and will not have many such cases report promptly
to him for treatment. Can any less radical but as
efficient method of treatment be substituted for inci-
sion in these cases? I think the method that I have
been employing for nearly two years has answered the
purpose very well and as yet 1 have seen no bad re-
sults and have not been obliged, to incise any puncture
wound.
The method consists essentially of cleansing the sur-
rounding skin with gasoline followed by tincture of
iodine and the iodine is allowed to flow into the wound
as far as it will go. A small probe is inserted into the
wound to determine the direction and extent of the
puncture. The probe is removed and an intramuscular
needle which has had the point removed is passed into
the wound to the deepest point and the wound is then
thoroughly flushed with tincture of iodine by attach-
ing a Luer syringe containing the iodine to the needle.
To be sure, this causes some pain but not nearly so
much as that caused by deep incision. After the needle
is removed, a small rubber dam drain is inserted to
the bottom of the puncture and a dry dressing applied.
Every day for a week the wound is flushed with tinc-
ture of iodine through the intramuscular needle and a
drain reinserted. After a week, if the wound is not
painful, the drain is left out and the wound is allowed
to heal.
Any instrument maker can readily prepare such a
needle by merely grinding down the point of an ordi-
nary intramuscular needle until the end is smooth so
that the needle can be painlessly introduced into any
puncture. The needle should be kept scrupulously
clean and a wire stylet allowed to remain in the lumen
when not in use, as iodine tends to obstruct the needle
if allowed to crystallize in the lumen.
MEDICAL PENNSYLVANIANS, PULL
TOGETHER!
■ There's fifty-seven varieties of Pennsylvanians, none
of them "pickles" but all "hot stuff." Oh yes, they
are I The only real trouble is that this polyglot, varie-
gated, assorted and more or less assimilated citizenry
have failed to realize that, whatever may become of
the Hon. Woodrow Wilson's international League of
Nations, Pennsylvania could get up one of her own
for intra-state purposes, with nearly every nation and
language represented, and that sh^ ought to do it.
Yes, she ought to do it; ought to do it in order to
make- good Americans of every Pennsylvanian — not
Quakers, or Pennsylvania Germans, or Italians, or
Hungarians ; but out-and-out Americans all, now and
forever.
Probably the Keystone that we pride ourselves as
representing — justly so, — was in Colonial days an Eng-
lish stone. Be that as it may, whether English, ^otch,
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December, 1920
SELECTIONS
157
Irish, Quaker, Indian, or what not, we need a new
Keystone — one with every kind of stone represented
in a rich mixture with grit and sand and the cement
of good Americanism (and prohibition water) to make
it stick together for innumerable ages, as reinforced
concrete does.
We Pennsylvanians are here — ^all kinds of us — be-
cause we're here; and what the need we care
now ? We're here, are we not ? Then suppose we let
it go at that, and not bother so much about who used
to be here, or who will be here after while, but who
are here now and what are we going to do about it?
All Pennsylvanians are divided into three parts, val-
ley people, mountain people and Philadelphians.
There are also a few Democrats. We have too much
valley; from little Path Valley to the immense Sus-
quehanna Valley, most of us are valleyites, more or
less provincial and isolated from the other valleyites
just over the mountain. Cumberland Valley people
are very different from Lebanon Valley people and
they take pride in accentuating the difference ; Lehigh
Valley people consider their neighbors in the Panther '
Valley as foreigners. Why we even name our rail-
roads and traction lines after valleys, as follows : Al-
legheny Valley, Beaver Valley, Cumberland Valley,
Delaware Valley, Hickory Valley, Indian Creek Val-
ley, Kishacoquillas Valley, Lehigh Valley, Ligonier
Valley, Newport and Sherman's Valley, Pittsburgh and
Ohio Valley, Rural Valley, Tionesta Valley, Tuscarora
Valley, Altoona and Logan Valley, Lackawanna and
Wyoming Valley, Lykens Valley, and a whole lot more
valleys; and in every one of these valleys there are
different breeds of Pennsylvanians. Honestly, brother,
how many of these valleys have you ever heard of or
ever visited? Seriously, it's a pity our geography
makes it so hard for us to be neighborly and get ac-
quainted except as we meet each other when we go to
the city that all valleys lead to. We need to break
down our mountain barriers by building more good
mountain roads and digging more tunnels, connecting
valley with valley all over the state, and bringing our
separated people more intimately in touch with each
other.
Mountain people are much the same all over the
Union, and Pennsylvania mountain people are no ex-
ception; but all mountain people are different from .
valley people.
And what of Philadelphia people? We all know
them so well as to make discussion superfluous; but
most Philadelphians do not know the rest of us, and
in consequence Philadelphia is not influenced by state-
wide opinion as are the large cities in states less sepa-
rated by mountain ranges, and she is inclined to estab-
lish her own standard.
Philadelphians know New York, Washington and
Atlantic City much more intimately than they do
Scranton, Williamsport or Erie ; and this is not to be
-wondered at. Nevertheless it is somewhat unfor-
tunate that our metropolitan district in Pennsylvania
is so little in touch with large areas of the state, and
it accounts for a certain coldness that is more appar-
ent than real and due to a lack of acquaintanceship
■with each other.
Some people think Harrisburg a rather strange
place ; but it, as the state capitol, is really more repre-
sentative of blended Pennsylvanianism than is any
•other city in the state, and it represents about what
Pennsylvania would be all over were our people more
mingled together and peculiar valley prejudices obliter-
ated.
Pennsylvania Doctors.
The profession averages up, in Pennsylvania, con-
siderably better than does the medical personnel in
some other states; in fact, owing to the fact that
Pennsylvania medical educational standards, and the
schools giving instruction in medicine, are and have
been in advance of many other states, has tended to
fill Pennsylvania with adequately trained physicians.
As educated men, trained in real medical centers, they
are not, as a class, provincial or narrow ; and they are
not marked by neighborhood or valley peculiarities or
mannerisms. ^Medicine in Pennsylvania, therefore, is
in a very healthy condition. Quackery is rather at a
minimum here and the proportion of ignorant physi-
cians, while still high enough, is low as compared with
some other states. Taking all of these things into con-
sideration, there is very little reason why Pennsylvania
physicians should not pull together ; yet they do not to
rthe degree that they should. The writer believes any
lack in this regard to be due, first, to inertia ; second,
to insufl[icient organization, and third, to certain local
interests being emphasized unduly.
There are several kinds of inertia and Pennsyl-
vanians suffer from all of them ; but the principal
kind from which we suffer is that caused by being
good. Boyd, in "The Recreations of a Country Par-
son," said : "Any great reformer will find less prac-
tical discouragement in the opposition of bad people
than in the inertia of good people." We know that we
are the Very Chosen and are incurably good, and that
makes us inert against the Philistines; but perhaps a
little revival of medical religion might convict us of a
few sins and lead to repentance as regards our inertia
and sins of omission.
Electric inertia is the resistance caused by self-
induction to sudden outside variations of current in a
circuit, and we suffer rather acutely from that kind of
inertia. Self-complacency is a medical vice in Penn-
sylvania that almost makes for self-sufficiency. If
our own writers and researchers say so, what's the use
of looking further, and especially looking farther?
Yes, we have the "magnetic lag" all right, due to our
own intellectual coercive force that makes us slow to
pespond to outside currents of thought or let go of our
own. This Pennsylvania habit of thought seems much
like uterine inertia; for just as we are giving birth to
big medical ideas inertia supervenes and the forceps
delivery is done by some researcher from a less fav-
ored state. Ask Johns Hopkins about this. She grabs
our most promising young professors who do not hap-
pen to belong to old Philadelphia families, and she gets
the credit for work almost ready to publish here. The
writer belongs to an old Philadelphia family himself,
and so he knows. Thus far, he has not heard a peep
from Johns Hopkins but lives in hope.
Hi there, Pennsylvanians, gear' in high and step on
the gas 1
Some one has said "whenever three Americans get
together they organize," and we may add that they are
always President, Treasurer and Secretary, for other-
wise they would not organize at all. If three thousand
Ameritans get together they start a whole lot of or-
ganizations so as to parcel out a lot of oflices. That's
what's the matter with medical organization in Penn-
sylvania. Not content with one strong state medical
society, our men who hanker for a large consultation
practice join so many outside societies that they are
merely nominal members of our own society.
Channing had the better idea, for he said: "The
mind, the spirit, is the end of this living organization
of flesh and bones, of nerves and muscles." Assuredly
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158
THE PENNSYLVANIA MEDICAL JOURNAL
December, 1920
we men who are treating flesh and bones and nerves,
in our professional organizations should make the
mind and spirit paramount to material considerations.
The Medical Society of the State of Pennsylvania is
not a board of trade or a mutual admiration society;
it is a pull-together society, or ought to be, not spe-
cifically for Philadelphia, or Pittsburgh, or Harrisburg,
but for the whole commonwealth — for you and for me
and for all the rest of us. Yes, we have insufficient
organization. Too much whiskers and not enough cal-
low youth, too much me-too and not enough you-also,
too much Chestnut street and not enough sixty-ninth
street, and too much my-section and not enough your-
section. The most live medical society meeting the
writer has attended in a long time, for which the mem-
bers generally were better prepared, was in Scran-
ton ; it put to shame the average Philadelphia or Pitts-
burgh meeting and was proportionately more largely
attended. Medical Pennsylvania at large is much
more alive than either Philadelphia or Pittsburgh
imagine to be the case, with all deference to these
cities, be it said.
Hi there, you Pennsylvania medical team, pull to-
gether !
And local interests unduly emphasized, what of that ?
Hale, speaking of certain historical tendencies, said :
"It was a local question, regarding the fisheries of the
Potomac and Chesapeake, which led to the meeting
which issued the call for the convention that made the
Federal Constitution of to-day." Local interests may
be, and often are, of tremendous import ; so, then, we
must not decry the local problem, or the local medical
society. Great things have usually started in some
obscure region and it is not wise to ask, "Can any
^ood thing come out of Nazareth?"
But after the convention has been called together,
the common weal is the creed of the commonwealth,
and the common weal is — must be — the creed of the
Medical Society of the State of Pennsylvania.
After all, medically considered in Pennsylvania, it is
not sectionalism but schoolism that is deplorably tend-
ing to divide medical Pennsylvania into East and West.
Medical dynasties are- easy of achievement and the
wearers of the purple seldom die and never reidgn, for
the purple is hereditary. However, this is a democracy
and dynasty is spelled die nasty. We cannot afford to
admit dynastic rule into the state medical society.
Speaking of schoolism, we have a bad attack of it
in Pennsylvania, both East and West, and what wc
really need is one great State University in Pennsyl-
vania; but it will be a long time in the making, the
writer is compelled to admit.
The Harvard Yard, with all its classical associations,
became too cramped and not sufficiently modem for
the great medical group of Harvard University, one
of the finest medical teaching plants in the world ; but
the railroad yard was not too plebean for the begin-
ning of the West Penn Medical School, now the splen-
did medical school of the University of Pittsburgh.
There's two kinds of smoke out there, and one of them
is the smoke that school is making, or is trying to
make. Yes, it's a bit raw yet, and it utterly lacks tra-
dition, scholasticism and moss. Its professors are not
yet used to mortarboards and black nightgowns for
day wear; and some of them can swear — Oh, how
they can swear! — when no nurse is around. But the
school is in luck; it has no local competitor to say
mean things about it, and therefore it can do as it
pleases, and it does it in a thoroughly human way, dis-
tinctively Pittsburghian, therefore aggressive, particu-
larly against the East, much to the horror of the an-
cient and honorable University of Pennsylvania. Now
that's their funeral, not any boncern of the state med-
ical society, that loves both East and West and does
not care at all for funerals.
Philadelphia claims to be Ike medical center of
America ; and the state society says : All right, let it
make good on its claim; we won't kick any. Any
wheel needs a hub and a lot of spokes to mount the
felloes on, and our principal interest is in the Fellows,
for they are all Good Fellows together, no difference
which spoke they are tied to. The Felloes go 'round
faster than the hub anyway.
But it's funny to hear some Pittsburgh comment on
Philadelphia and its claim of being the medical center.
Some live Pittsburgh doctors playfully call attention
to the fact that one of the Philadelphia medical schools
rejoices in the name of "Jeff," while a certain other
one would throw a fit if called "Mutt." And it would I
Yea, verily I A big six-footer doctor out there wiped
the sweat and grime off his face and remarked the
fact that the University of Pennsylvania campus, with
its superabundance of unnecessary but allegedly orna-
mental iron fences, like Biddle and Cadwallader family
plots, its ivy and myrtle, looks like a cemeteo'! and
many of its professors are so stiff and formal that
they dress like undertakers. Awfully mean slam that,
but it illustrates the difference between what the East
and West in Pennsylvania revere at home and are
made fun of for three hundred miles away. Such is
the great Commonwealth of Pennsylvania — big enough
and broad enough for both points of view ! And such
is the Medical Society of the State of Pennsylvania!
Now, Brothers— East and West, — ^all nonsense
aside, let's pull together ! We are tired of leg-pulling,
and Mr. Volstead won't let us pull corks in a toast to
each other ; so, "As the tides are lifted beneath the un-
seen pull of the moon, so human aspirations must be
exalted," and the Medical Society of the State of
Pennsylvania, as the moon, wants to pull YOU up-
ward and onward and have all medical Pennsylvanians
pull together. Let's go to it!
Particeps Criminis.
UNIMPINGED NERVE
The initiated Bill to Establish a Board of Chiro-
practic Examiners contains a bevy of niggers in the
woodpile. It grants a special chiropractic examining
board, though such a board has no legitimate reason
for existing. It grants licenses automatically to chiro-
practors who have been practicing illegally for a year
in any one county of the state. It grants to chiro-
practors "all the rights and privileges and immunities
by law extended to physicians and surgeons in this
state," except the right to practice obstetrics, perform
surgical operations and prescribe medicine to be taken
internally. This permits the chiropractor, without
preparatory training, to administer anesthetics, to treat
venereal diseases, to fit eye-glasses, to treat poison
cases and insanity, to give drugs hypodermically, -and
in a hundred ways to endanger the life of his patient
He is then permitted to sign the death certificate,
stating the cause of death, which his training does
not permit him even to conjecture.
Such a preposterous bill can pass only by reason of
apathy on the part of the medical profession. — Denver
Medical Bulletin.
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PITTSBURGH ACADEMY OF
MEDICINE
Abstracts op Papers Read Bepore the
Academy
HEAT STROKE
DR. S. H. JOHNSON
During the past ten years I have observed and
treated five hundred and eleven cases of Heat
Stroke, seventy of which were examples of Heat
Prostration, so few of which were due to the di-
rect rays of the sun that I prefer the avoidance
of tl^e term Sun Stroke, 441 have been of the
■much more common disturbance classed as Heat
Exhaustion.
Heat Stroke is a morbid state, an acute aci-
<losis due to a suddenly disturbed metabolism,
the result of excessive temperatures upon the
tissues and organs of the body, particularly
when combined with physical exertion.
These conditions are primarily caused by ab-
normally high temperature which is favored by
numerous factors as, high temperature of the
surrounding air, excessive moisture, stillness of
the air, direct action of the sun rays, amount of
clothing investing the body and its texture,
personal hygiene, confined quarters, poor venti-
lation, bodily fatigue, improper diet, and auto-
intoxication.
The body loses heat in three ways; by con-
duction, by radiation, and by evaporation.
Under normal circumstances radiation is the
most active but as the surrounding temperature
rises, radiation becomes necessarily less impor-
tant and evaporation (perspiration) becomes
more active until at temperatures which equal or
exceed that of the body evaporation alone is of
value.
The normal heat losses through various chan-
nels are as follows: urine and feces 1.8%, ex-
pired air 3.5%, vaporation of water from lungs
27.2^, evaporation from skin 14.2%, by radia-
tion and conduction 73%. So long as evapora-
tion is active high temperature alone will not
change the temperature of the body, it is when
evaporation is insufficient that heat produces
serious results.
H the forgoing facts are true, then prophy-
laxis would consist in preventing the accumu-
lation of an abnormal amount of heat in the
l)ody by the wearing of proper clothing, better
hygiene, proper diet, abstinence from alcohol,
plenty of water, avoidance of fatigue, worry,
and anxiety, and the last but most important —
attention to the excretory organs, thereby avoid-
ing auto-intoxication which to my mind is the
most important factor in the production of Heat
Stroke, as all the cases I have observed were
suffering from auto-intoxication.
Symptoms: Heat Exhaustion is a condition
of extreme prostration manifested by subnormal
temperature, a small rapid weak pulse and a cool
pale clammy skin. The vision is dimmed while
the patient complains of noises in the ears, diz-
ziness, headache, and nausea. He may give a
history of having had constipation or diarrhea.
Collapse or even delirium may occur.
In case of Heat Prostration the patient may
have premonitary symptoms of headache, dizzi-
ness, nausea, vomiting and dryness of the skin
fit he may fall unconscious without having had
any of the symptoms. When seen he may be
semi or unconscious, the temperature is always
elevated, may reach 110 degrees, pulse rapid
and full, breathing labored and deep, face
flushed, the skin dry, muscles usually relax
though convulsions are not uncommon, the pu-
pils are first dilated but later contracted. In
fatal cases coma deepens, pulse becomes rapid
and feeble, breathing hurried and shallow.
The prognosis of Heat Exhaustion under
proper treatment is good. The prognosis of
Heat Prostration is not so favorable ; unfavora-
ble indications are: increasing temperature,
cardiac failure, convulsions, absence of reflexes
followed by complete muscular relaxation.
Favorable indications are: decline of tempera-^
ture, stronger pulse, increased depth of respira-
tion, restored reflexes and return to conscious-
ness.
Sequelae: Neuritis, meningitis, muscular
atrophy, wrist drop, foot drop, difficulty of
speech, long continued acceleration of pulse and
respiration, vertigo, enfeebled niemory.deaf ness,
cardiac lesions, impaired digestion and nutrition
and anemia.
Treatment: Heat Exhaustion: Remove pa-
tient to a cool well ventilated room, remove
clothing or loosen it so as not to interfere with
respiration and circulation, recumbent position,
. lower head, apply heat to body and ice cap to
head, if respiratiwi is impaired atropine sulph
Gr. i/ioo, if heart is weak stimulate with digi-
talis or strychnine. As circulation improves, the
body becomes warm and the patient regains
consciousness, give stimulating enemata to move
bowels, investigate the condition of the bladder,
if secretion is scanty give water freely, give hot
liquid nourishment as soon as possible, during
convalescence give tonics of iron, quinine, and
strychnine.
Treatment : Heat Prostration : Remove the
patient to a cool well ventilated room and re-
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THE PENNSYLVANIA MEDICAL JOURNAL December, 1920
move the clothing, apply ice cap to the head,
give ice rubs, ice baths, cold packs, cold enemata
to reduce the temperature. If the temperature
begins to fall rapidly, remove the patient from
the bath as otherwise the temperature will con-
tinue to fall until it becomes subnormal and the
patient may pass into a condition of collapse.
( Length of bath 20 to 40 minutes. Repeat in
2 hours if temperature rises.) In some of these
cases it is obvious that congestion of the internal
viscera is embarrassing heart action, therefore
venesection may be performed and a pint of
blood removed, this loss of fluid from the circu-
lation may subsequently be restored by the in-
jection of normal salt solution if deemed advisa-
ble. The principal object in the treatment is id
reduce the heat content of the body and bring
about elimination of its toxic elements.
Hydrotherapeutic methods are of more value
than drugs, as to stimulate an already burdened
organ can do but little good and much harm.
ETIOLOGY AND PROPHYLAXIS OF
PNEUMONIA
DR. A. VERNON HICKS
Lobar pneumonia is a systematic infection
usually associated with febrile disturbances and
with a croupous inflammation of greater or less
extent in one or both lungs due to the pneumo-
coccus of Frankel and other associated organ-
isms.
Fatigue has a most important place in the pre-
disposing causes as has prolonged chilling or ex-
posure to cold. We have all seen cases follow a
hard day's work in cold damp weather.
Seasonal variations are marked, three-fourths
of the cases developing in the last two and the
first three months of the year.
During the winter of 1917-18 an extensive
outbreak of measles in various army camps and
cantonments was followed by a secondary in-
fection giving rise to broncho-pneumonia. Once
started, the infecting agent seemed to gain in
virulence and became the cause of many cases
of broncho-pneumonia independently of measles.
Those from rural and southern communities
suffered more severely due probably to a les-
sened acquired resistance to organisms that
abound in more densely populated areas.
According to Vaughan and Palmer nearly
four million men passed through the army
camps of the United States from September,
191 7, to January, 1919. Of this number, 30,859
died of disease before reaching the port of em-
barkation. To November, 1918, 16,000 died of
di.sease in France, making a total of 47,000,
while 40,000 gave up their lives in combat. Of a
total death list of 87,000, 54% were from dis-
ease. During the winter period from October,
1917, to March, 1918, pneumonia was the cause
of 62% of all deaths, and during the autumn'
season, September to December, 1918, pneu-
monia and influenza were resp<Misible for 93.7'^.
Pneumonia is a communicable and mildly con-
tagious disease, and being so, patients ill of it
should be isolated to guard against droplet and
dust infection. Expectorated material should
be collected in suitable cups and burned, and all
discharges of the body subjected to disinfection.
Bedding and night clothing should be handled
without shaking and sterilized, and rooms occu-
pied by a "pneumonia patient should be disin-
fected. Contact by unnecessary persons with
the patient should be avoided and nurses or
other attendants should be especially careful.
Since dust contains all the germs found in the
pneumonia, it must be an important cause and
to prevent its dissemination is a prophylactic
measure of great value. Floors and streets
should be sprinkled before sweeping, and an ap-
l>lication of oil to streets to prevent dust has
been found of value in cities that have tried its
use. Those known to have a bronchial weak-
ness should sleep in the open or in rooms with
widely opened windows but with sufficient bed
coverings to keep up the body warmth. Increas-
ing the general resistance of the body by good
hygiene, regulating the diet and manner of work
done will prevent many so-called colds and sub-
sequent pneumonia. From a standpoint of Pub-
lic Health all homes, churches, theatres, schools,
and public buildings as well as institutions for
the sick, the best of ventilation should obtain
and the maximum amount of sunlight permitted
entrance to keep down the incidence of new
cases.
Those with colds should sneeze or cough into
a handkerchief held to the nose and mouth thus
preventing droplet infection, as experiment has
shown that a Petri dish held four feet distant
will collect colonies of germs from such a per-
son.
The promiscuous use of the streets and pave-
ments in lieu of sputum cups must be held as
the chief source of infection, the sputum drying
and being carried hither and yon in the dust
laden air. The most satisfactory means of pre-
venting respiratory affections in those abroad
ship for the A. E. F. was the continual wearing
of gauze mask except at nieal time.
Since it seems true that we have serums and
vaccines for everything from alopecia to herpes
zoster so we find we have one for pneumonia.
The first work was done by Wright in South
Africa in an attempt to combat the high mortal-
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ABSTRACTS— PITTSBURGH ACADEMY
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ity among the native mine workers. The re-
sults were encouraging as the incidence of the
disease fell from 40 per 1,000 in 1911 to 7.4 per
1.000 in 1913 and the death the same period.
While the death rate from other diseases showed
a decline. it was not so marked as in pneumonia.
The first work in America was done for Cole
by Cecil and Austin at the Rockefeller Institute
and was given to the Seventy-Seventh Division
at Camp Upton. The vaccine contained the three
fixed types of the pneumococcus. Three or four
innoculations were given at intervals of five to
seven days, the total dosage being six to nine
billion of types one and two, and four to six bil-
lion of type three. This demonstrated that large
bodies of people could be vaccinated without
difficulty, without serious local or general reac-
tions. The results were apparently good. Dur-
ing the following ten weeks no cases of types
one, two or three occurred in those vaccinated,
while in the 20,000 uninocculated troops 26 cases
of pneumonia of the same types developed.
It was also found that the type four pneumo-
coccus and streptococcus produced fewer cases
although the vaccine did not contain these or-
ganisms. At the close of the period of observa-
tion it showed 17 cases of pneumonia in the vac-
cinated and 173 among the unvaccinated with
an annual death rate for the two groups of 0.83
per thousand for the vaccinated and 12:8 for
those not vaccinated. Other work was done by
Cecil and Vaughan at Camp Wheeler with rcT
suits that were encouraging but not as good as
at Camp Upton, possibly on account of the epi-
demic of influenza raging at that time. It would
seem that prophylaxis to a considerable degree
is possible but sufficient work has not been done
to brand it as a success entirely.
BANTI'S DISEASE.
CHARLES B. MAITS
The name Banti's Disease has been given to a
syndrome and pathologic complex, which was
first described by him in 1895. This condition,
comparatively rare, has provoked much discus-
sion, and in the years since Banti published his
first work, patholc^sts, clinicians and surgeons
have disagreed on practically all points without
however, adding much of real value to our
knowledge of the etiologj', symptomology, path-
ology or treatment.
Banti's disease is a primary splenomegaly
without known etiology which presents, (i)
Anemia. (2) Cirrhosis of the liver of Laennec
type, which is always secondary to the spleno-
megaly. (3) Ascites. (4) Progressive hypo-
sthenia which is often accompanied by hemor-
rhages from the nose, esophagus, stomach or
bowels.
Banti divides the disease clinically into three
stages: First Stage, a period of three to five
and up to twelve years, during which there oc-
curs an anemia and splenomegaly. Second
Stage, a shorter period characterized by an en-
larged liver ; and third, the stage of ascites with
small liver. This is the terminal stage, the
symptoms of which are those of an ordinary
atrophic cirrhosis, with death following from
hemorrhage or autointoxication from the cir-
rhosis.
Pathologically, Banti describes the condition
as follows: First, in the spleen there occurs a
fibrosis of the reticulum, accompanied by nar-
rowing of the splenic veins and a thickening of
the capsule. Second, fibrosis of many malpigh-
ian follicles. Banti lays stress on the prolifera-
tion of the lymphatic tissue of the pulp and the
follicles, and used the term "fibroadenia" to in-
dicate that in spite of connective tissue changes
the lymphatic stroma retains its adenomatous
appearance. Third, cirrhosis of the liver of the
Laennec type. Fourth, often, though not in-
variably there is found an endophlebitis of both
the splenic and portal veins. In the ascitic stage
endophlebitis of the mesenteric veins has been
leported frequently. Fifth, leukopenia is usu-
ally noted, but Banti says it is not constant.
Sixth, freedom from general glandular enlarge-
ment.
The main blood changes are: the number of
erythrocytes is diminished, the color index is
lowered, olegochromenia is always present, mye-
locytes are never present.
In connection with Banti's belief that this pri-
mary splenomegaly may be due to an infectious
agent, the report of Yates is interesting. He re-
ported in 1914, pure cultures of diptheroid or-
ganisms, identical with or closely related to
Bacillus Hodgkin's were obtained by him. His
conclusion is that Banti's disease might be
Hodgkin's disease of the spleen. This work of
Yates and the results published by Gibbons who
found Gram positive streptotrichal organisms in
the spleen in six cases of Banti's disease are not
borne out yet by other observers.
As to the symptomatology — constipation in the
early stage is frequently reported, but there may
be no symptoms at this time aside from the en-
largement of the spleen. Later as the anemia
develops, symptoms characteristic thereof occur.
The patient suffers little or no pain during the
early stage but as the second or transition .stage
develops the patient often complains of various
gastro-intestinal symptoms, pain in the abdomen
in varying degrees of severity, attacks of diar-
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THE PENNSYLVANIA MEDICAL JOURNAL
Decemuek, 1920
rhea, often nausea, seldom vomiting, and pro-
gressive weakness. As the third stage comes on
the ascites appears and very often edema of the
legs; cachexia is marked, and the patient may
die following an esophageal or an intestinal
hemorrhage.
If not treated, or treated only medicinally
Banti's Disease is almost always fatal. When
the disease is recognized in the early stage and
splenectomy performed, complete recovery is the
rule, with the rapid disappearance of all symp-
toms. The blood picture usually approaches
normal — though possibly taking three to five
years in the process.
But the prognosis is bad after the hepatic cir-
rhosis has developed, and the mortality is very
high when splenectomy is done at this stage;
Banti estimates it at 50% — others as high as
70%. In severe cases, according to Graham,
blood transfusion, if done shortly before the
operation, seems to increase the ability of the
patient to withstand the shock of the operation.
Pain in the long bones is frequently noted, post-
operatively and also, for the first two weeks fol-
lowing the operation there is always danger of
hemorrhage. Transfusion is the best treatment
for the hemorrhage. Medicinal treatment is pal-
liative at best. Iron and Fowler's solution may
be given for the anemia. Salvarsan and x-ray
may give temporary relief but no more.
In the case to be presented, the diagnosis of
Banti's disease was made and splenectomy per-
formed before we received the case. When we
saw the patient the blood picture was not strictly
that seen in Banti's, however, it may not have
been so at the time of operation. Also, this case
presented a very complex problem in diagnosis.
Tuberculosis and lues had to be considered, and
the mental state was very interesting.
Frederick B. Ulley, M.D., Secretary.
THE PHILADELPHIA LARYNGOLOG-
ICAL SOCIETY, OCTOBER, 1920
CUNICAL NIGHT
Presentation of cases:
Dr. Henry A. Laessle: — "Angiofibroma of
Lateral Wall of Nosel" This case is extremely
interesting. It has the appearance of a polyp
when looking at it casually and when touching it
with a probe, it bleeds readily. However, it is
an angiofibroma and has been confirmed by
pathological report. The history of the case is
as follows: In 1918, the growth was first no-
ticed. He had difficulty in breathing and con-
sulted a physician who diagnosed it as a growth
in the nose, and since then he has been going
from one physician to another. The growth is
now of two years' duration. The swelling has
been increasing on the left side of the face and
the patient is quite anemic, due to losS of blood.
These cases are rare. Since removal of some of
the growth by f ulguration the breathing has im-
proved.
Dr. Herman B. Cohen had two or three slides
under the microscope of fibroangioma of the
septum. History of the patient — This man, col-
ored, 55 years of age, complained of obstructed
breathing, November, 1919. Attacks of epis-
taxis and increasing nasal obstruction. There
was a complete nasal stenosis of the right side
which looked like a polyp, lobulated, etc. After
cocainization and treatment, I was able to get
around it with a snare and found it attached to
Kisselbach area. I then removed it with an
ordinary snare and cauterized it. Relief was in-
stantaneous. Report from laboratory was fibro-
angioma.
Dr. Robert F. Ridpath— "Post-Orbital Dis-
turbance Causing Marked Exophthalmos." I
made this examination expecting to find that the
exophthalmost was due to the nasal condition.
X-ray was negative. The history is as follows :
Patient is five years of age. When nine months
old the mother noticed a small swelling at inner
cantus of the right eye and this swelling seemed
to increase when the child contracted cold, dur-
ing the first two years of its life. The swelling
seemed to subside after the cold was better.
However, since last March, after a severe cold
which lasted longer than usual, the present con-
dition persisted and is becoming worse. I have
not had an examination of the eye made as I
only saw the child the second time to-day. The
first time was three days ago. There was no
pain except the last two days. When the child
goes to bed there has been a sharp lancellating
pain lasting only a few minutes. The sight is
only slightly impaired, he can count, read the
alphabet. Since I saw the patient last, the eye
has become more protruded. I had hoped to
have the x-ray plates here to-night. It is nega-
tive, however, as far as the condition originating
from the nose goes, according to Dr. Pfahler's
report. It might be a mucocele originating from
the nose and breaking through the ethmoid cells
in the orbital cavity. I am hoping for your diag-
nosis and your remarks, after the case has been
shown. The scar over the superorbital region
was made at the Wills Eye Hospital in March,
1920.
Dr. Benjamin D. Shuster — "Throat Compli-
cations of Hodgkin's Disease or Sarcoma." For
differential diagnosis. This man is 40 years old
and since 6 months ago, following an acute mas-
toiditis, which subsided in a few davs, he no-
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December, 1920
ABSTRACTS— PITTSBURGH ACADEMY
163
ticed some swelling on the right side of his neck.
It gradually increased in size and application of
ichthol ointment and other substances, usually
used in glandular enlargement, failed to effect
any change. At about three months it became
painful and he noticed interference in swallow-
ing. He went to various physicians and dispen-
saries for treatment. On two occasions an en-
largement behind the posterior pillar on the
.same side was incised as a peritonsillar abscess,
but without obtaining any pus. At this time
glandular enlargement was noted by the patient,
on the opposite side. He became weaker and
weaker and lost about 15 pounds of weight within
four months and was unable to follow his occu-
pation. At present there is considerable swell-
ing behind his left posterior pillar (the first side
affected) causing dysphagia. There is also some
swelling behind the tonsil on the opposite side.
Two distinct and very large glands are present
in the left axilla. A chain of enlarged glands is
also palpable on each side of the neck from the
large mass to the supra-clavicular space. He
has had two radium treatments; following the
first he thought he had relief but unaffected by
the second. When I first saw him I thought of
Hodgkin's disease because of the consecutive en-
largement of the glands on both sides of his
neck and in the axilla. Sarcoma usually does
not give glandular enlargement in the neck un-
less the tonsil is primarily affected. In this case
his neck seemed to have been affected first and
the pharynx encroached upon later. Dr. Coates
thought it a sarcomatosis from its appearance.
We only saw him pnce and no detailed blood
study was made, although the patient thought
that in some hospital a blood test was made
which they called negative, probably a Wasser-
man. The case being an interesting one, and
this meeting being quite close, Dr. Coates sug-
gested that I bring it up here in spite of our not
having fully worked it out. At the same time
we would like some of you gentlemen to express
an opinion as to diagnosis.
Dr. H. A. Schatz — "Post-Auricular, Subperi-
osteal Abscess, Simulating Mastoid Disease,
Complicating Contagious Diseases." The fol-
lowing facts were observed by the writer during
a short term of service as Oto-laryngologist to
the Philadelphia Hospital for Contagious Dis-
eases, during the busiest months of the current
year:
That the number of cases of superiosteal post-
auricular abscess without mastoid involvement
in Scarlet Fever was far greater than in non-
contagious practice, particularly in" cases of
Scarlet Fever complicated by measles. A re-
view of 900 cases proves it nearly 1%. That the
swelling, in the earlier stage at least, was usual-
ly over the upper part of the mastoid (supra-
auricular) although it often spread downward
later, covering the body of the mastoid process.
That a certain percentage of these cases tended
to point with spontaneous rupture through the
cartilage in the roof of the external meatus.
That simple incision over the mastoid with
drainage cured three of the seven cases observed
in from two to four weeks. Two other cases
went home one and four weeks respectively,
after incision, with sinuses still discharging.
That the mastoid was found normal in two cases
operated upon, and that in one case failure to
clear out all the mastoid at the primary opera-
tmn necessitated a secondary one about two
months later when the mastoid was found nec-
rotic and the lateral sinus exposed over a con-
siderable are.
Luc brings out several important points in a
table of differential diagnosis between abscess
with mastoid and abscess without mastoid in-
volvement, (i) He states that in the former
condition the otorrhoea is abundant and persist-
ent whereas in the latter it is slight and transi-
tory, having generally stopped when the swelling
appeared. In our cases the otorrhoea was usual-
ly quite marked. (2) Luc observes that in mas-
toid disease the swelling is retro-auricular,
whereas in abscess without mastoid it is rather
supra-auricular covering the greatest part of the
temporal region and pointing inferiorly toward
the upper wall of the meatus ; the soft parts in
this region being raised by infiltration.
Here again our observation differed in that
^he swelling spread rapidly downwatd over the
greatei- portion of the mastoid process, simulat-
ing closely the appearance of mastoiditis.
(3) The mastoid region is tender under pres-
sure in mastoiditis, but generally little or not at
all tender in abscess.
(4) There is deep spontaneous pain with
throbbing and sleeplessness in the former, little
or no spontaneous pain and no sleeplessness in
the latter condition.
(5) More or less high fever with altered
focies in the former, little or no fever, focies
normal in the latter.
As regards treatment, Luc advises deep inci-
sion through the cartilage in the roof of the ex-
ternal meatus with drainage. In our cases it
seemed more commonly indicated to incise over
the mastoid, except those few cases that rup-
tured spontaneously into the external meatus.
(IjMC — Transactions of First International
Congress of Otology.)
Dr. Herman B. Cohen — "Epitheloma of
Tongue" and "Two Cases of Fistual following
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THE PENNSYLVANIA MEDICAL JOURNAL December, 1920
Teeth Extraction witK Chronic Maxillary Sinu-
sitis."
1. Epitheleoma of Tongue. — The cause is not
certain. The patient was 6i years of age, ro-
bust, and in perfect health, until three months
ago, when he noticed some pain in swallowing.
Denies venereal infection. Wasserman is nega-
tive. He has worked for ten years in a steel
mill. Has smoked a pipe all his life, clay pipe
for thirty years. Twenty-five years ago had
a left lower molar tooth extracted. He is mar-
ried and has three children. There is no cancer
history in family. He is otherwise well. He
now presents an ulcerated and indurated area in
anterior two-thirds of tongue. Has occasional
dull pain in left ear and left parotid. A few '
glands on either side are palpable. He should
undergo block dissection previous to x-ray treat-
ment.
2. Two cases of fistula following teeth ex-
traction with chronic maxillary sinusitis. The
question is how to close these fistula. They are
both on the left side, following teeth extraction.
Both had chronic maxillary sinusitis. First one,
Mrs. A. M. has had several teeth pulled after
which pus discharged through the alveolus, but
the discharge is practically nil at present. Has
been cauterized and curetted but fistula is still
open. The second case, J. P., age 48, similar
history of old chronic maxillary sinusitis. He
has had second premolar tooth extracted from
which date discharge followed. He has had a
left hyperplastic ethmoiditis. I hope you will
suggest the closure of these fistulas.
Dr. N. P. Stauffer— "Bone Transplant (tibia)
tor Nasal Deformity." This young man came
to me three or four months ago saying that he
did not like his nose and wanted a bone trans-
plantation made. He apparently had no nasal
process at all from the x-ray. He has a perfora-
tion which he had before. He has never had a
submucous resection done and the Wassermann
was negative. The tibia was cut out, a slit was
made across the eyebrow, and the bone slipped
in. Bone put in nose was i J^ inches long. 1 do
not like rib resection as patient is sick much
longer. The tibia is much safer.
DISCUSSION
Dr. Herman Cohen's case — "Two Cases of Fistula
Following Teeth Extraction with Chronic Maxillary
Sinusitis."
Dr. Frederick Strauss: Has a submucous been
■done?
Dr. M. S. Ersner: In fistula of the antra I have al-
ways made it a point to determine definitely whether
there is any disease present in the antra. Antra free
of pus does not mean that there is no disease for a
pyogenic membrane may be present and act as a
«hronic irritant and thits prevent the closure of the
fistula. Therefore, the most important thing is to clean
the antra thoroughly as x-ray in these conditions are
of no avail. In my experience with fistula, I had under
my observation three such cases. In one a Cooper
operation was performed. The other two hstula re-
sulted from teeth extraction. These fistula continued
for months and they did not dear up until a thorough
antrum operation .was performed and all of the pyo-
genic membrane removed. The operation employed in
two of these cases was the Skillern preturbinal and the
other the Danker.
Dr. Herman Cohen, in closing: In answer to Dr.
Strauss' question, there was a submucous resection per-
formed on Mrs. A. M. in April. She has practically no
discharge at all from the antrum. However, she has a
fistula. Do all sinuses close after antrum operation?
I think some remain open. I would like to ask Dr.
Skillern. In the other case, nothing has been done to
the antrum. He has, however, had a fistula for 15 to
20 years. What is the method of closing these fistulas?
I would like to ask if the diagnosis of epitheleoma of
the tongue is correct. There is little literature of T. B.
of the tongue. What should be done if it is?
Dr. R. H. Skiuern : The pathological condition de-
pends very largely on what we are going to do with
these fistulas. If we have a pathological condition,
there is nothing that will close it up until we get rid of
that discharge. The question is just exactly what to
do to stop that discharge. It depends very largely on
the nature of the case. Cleaning out the polyps in
some cases, the fistula will clear up. If food gets up
and irritates it, it is just as well to let it alone. Clos-
ing a fistula is simply a matter of getting enough tissue
from where there is no tension, taking part of the
alveolus. The treatment depends entirely on the patho-
logical condition found.
Dr. R. F. Ridpath's case — "Post-Orbital Disturbance
Causing Marked Exophthalmos."
Dr. G. W. Mackenzie : Dr. Ridpath should get back
of the eyeball and try to find out what is there. It
might possibly be a mucocele of the frontal sinus or
may be a tumor formation. Go after it radically and
see what is behind the orbit, that is pushing the eyeball
.forward.
Dr. Ridpath : I have only seen one case similar to
this. The patient was at St. Agnes Hospital, adult
about 30 years of age. She had had, as in this case, an
operation before she came to me. I diagnosed the case
as a mucocele of the frontal sinus and did a radical
Killian and the case recovered. The eye gradually
went back into its socket, there was no change of vi-
sion or exophthalmos. The frontal does not start to
develop until later in life which eliminates in my mind,
mucocele of the frontal in this case. There is a possi-
bility of mucocele originating in the ethmoids. I agree
with Dr. Mackenzie that something radical must be
done immediately, if we are going to save the eye at all.
Dr. Schatz's case — "Post-auricular, subperiosteal Ab-
scess, Simulating Mastoid Disease, Complicating Con-
tagious Diseases."
Dr. Frank Emberv: In my experience with mas-
toids I have seen only one case that was not mastoid
infection.
Dr. N. p. Stauffer: I recall one of my cases which
I lost. I was called in consultation with another man
who said the patient has a subperiosteal abscess. I
said to operate immediately. A third doctor was called
discharged. Subsequently he did get well without it.
and he said patient need not be operated on. I was
He had a mastoiditis but it discharged externally with-
out any further operative measure. I would not advo-
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ABSTRACTS FROM STATE JOURNALS
165
cate such surgery. The great difficulty is in not taking
the familiar mastoid which is bulging, as a great many
patients are better off operated on and would get well
without a great deal of complications.
Dr. M. S. Ersn'Es: I would like to ask Dr. Schatz
whether any bacteriological study was made. Last
year we had a great many otitis media cases with post-
auricular glandular involvement and the x-rays taken
were negative as to mastoid involvement. Among-
these cases nine developed retro-pharyngeal abscesses.
During that period the temperature continued and the
post-auricular edema did not subside until the pus was
evacuated through the oro-pharyiix. Speaking about
post-auricular abscesses complicating contagious dis-
eases reminds me of a patient which I had .following
chicken pox. The family physician thought this condi-
tion to be a post-auricular abscess and he made a wild
incision with the hope of evacuating the pus but as
time went on the child became worse and the typical _
toxic temperature ranging between 97 and 104. I was
unable to place the child in any hospital as there was
no room to accommodate her at the Municipal or at
the Philadelphia General Hospitals and was therefore
compelled to do the mastoid operation on the kitchen
table in patient's home. It was surprising to note the
extensive involvement. The lesson to be drawn in this
case is to be very cautious not to operate unnecessarily
and at the same tiirie not to overlook true mastoiditis
when present.
Dr. G. W. Mackenzie: My own boy developed
retro-auricular swelling which looked like the text-
book pictures of mastoid abscess. Of course, I had
the history of this case to work on. He had had a boil
on the posterior wall of the canal. The boil became
infected again and subsequently pus. About the same
time, I had a case similar to this a child two years of
age. I suspected mastoid. The child had had earache
a few days before and father had put omega oil and
peppep into canal, which relieved the pain but caused
swelling, and which upon incising, I evacuated two
tcaspoonfuls of pus. The only thing I cannot grasp is
how a patient can have a middle ear discharge with a
subperiosteal abscess and the mastoid escape. You can
get a double condition where patient may have a mid- •
die ear condition with complicated boils in exttmal
canal and boils causing circumscribed auricular swell-
ing. We can get a middle ear discharge with no mas-
toid involvement but external canal condition causing
retro-auricular lymphoid swelling. I saw a case where
a man had discharge from ear which was watched for
a few days and eventually had small area of localized
cellulitis in posterior canal wall which cleared up in a
few days. The condition returned later and when the
mastoid was operated upon, he had extensive mastoid
involvement
We do not frequently see leucocyte count differences.
Only one of these cases had been diagnosed as a fu-
runcle at its lirst inspection. Make deep incision in
roof of external meatus. It is not good surgery to
wait in these cases, it can do harm. As to bacteriology,
I cannot answer, one man claiming to have found
pneumococci and Glut found streptococci. It is a
glandular origin. These abscesses originate in upper
part and higher up.
Dr. Mackenzie on Dr. Stauffer's case: Is this a pre-
liminary operation to another one?
Dr. Stauffer : I thought it would be enough.
Dr. Strauss on Dr. Shuster's case : I believe it is a
sarcoma. Matthew S. Ersner, M.D., Recorder.
ABSTRACTS FROM STATE MEDICAL
JOURNALS
FRANK F. D. RECKORD^ M.D..
Assistant Editor
THE DIAGNOSIS AND TREATMENT OF THE
HEMORRHAGIC DISEASES
By Ralph C. LAMABEe," M.D.,
Boston
From the study of a large number of diabetics over
a period of ten years, the following conclusions are
drawn :
1. That by all the modem methods of low calory
diet, the diabetic patients do better than by former
methods.
2. That without careful blood estimations, diabetics
cannot be satisfactorily treated and good results ob-
tained.
3. That the complications of diabetes will develop
even though the urine contains no sugar if the blood
figures remain high.
4. That the prevention of obesity will reduce* the
number of diabetics tremendously.
5. That the study of other functions such as kidney
function, and the removal of all possible foci of infec-
tion, are essential to having the diabetic patient do
well.
6. That routine twenty-four-hour urines must be
more frequently done, or routinely done, to be able
to recognize diabetes as well as other kidney condi-
tions early, and allow earlier treatment.
7. That the disease diabetes illustrates the impor-
tance of laboratories where simple routine analyses
can be done at a reasonable figure. — From The Bos-
on Medical and Surgical Journal for August, 1920.
REMARKS ON THE THERAPEUTICS OF
ESSENTIAL EPILEPSY
By L. Pierce Ci,ark, M.D.,
New York Oty
We may conclude that the present modern trend in
a specific training of the epileptic individual begins in
a careful analysis of the instinctive fault in each case.
By conscious analysis of his daily conflicts and those
that specifically seem to precede his seizure episodes,
as well as those conflicts and strivings that appear in
the automatism, one gains «. definite point of attack
to increase the patient's insight. Teaching an epileptic
his essential faults and the means for overcoming
them is the continued plan that promises much for the
future. This principle incorporated into the present
mental and physical regimen, already carried out so
admirably in many special sanatoria and colonies for
epileptics, gives us more precise methods of attacking
our great problenx, the healthful alteration of the basic
fault of the epileptic constitution. Unfortunately the
method throws an enormous task upon all having to
do with epileptic individuals; but can we afford to
neglect our new visions and opportunities? — From
The Boston Medical and Surgical Journal for Septem-
ber, 1920.
ENCEPHALITIS LETHARGICA
By Charles A. McDonald, M.D.,
Providence, R. I.
Encephalitis Lethargica is a toxic, infectious disease
characterized by lethargy, cranial nerve involvement,
and a febrile state. In medical literature sporadic
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166
THE PENNSYLVANIA MEDICAL JOURNAL
December, 1920
cases of this disease have been referred to as far back
as the time of Hippocrates, and since the middle of
the Eighteenth Century cases have been reported in
detail of somnolence, ophthalmoplegia and fever. For
our recent awareness we are indebteded to Von
Econimo. In Vienna, in the winter of iqi6 and 1917
he observed several cases of somnolence and cranial
nerve involvement and reported them and called the
disease encephalitis lethargica. In March, 1918, Netter
in France, encountered a series of cases with this
triad and identified these cases as like those described
by Von Econimo and published a paper in which he
called the malady epidemic encephalitis lethargica. A
short time afterwards, epidemics of this disease oc-
curred in England, Africa, America and Australia.
In this country the first occurrence was probably in
and around Boston, later in New York and Con-
necticut.
In this country the mortality has been much lower
than in Europe and the Isles.
The pathology may be considered — first, an infiltra-
tion of the walls of the smaller vessels with lympho-
cytes and a few plasma cells. Second, occasional foci
of infiltration with round cells. Third, slight changes
in the nerve cells. Fourth, foci of perivascular hemor-
rhage.
Concerning the etiology there is surprisingly little
knowledge. Some have suggested that it may be due
to influenza. There has been some experimental work
in Europe; observers have found an organism with
which they have been able to reproduce encephalitis
in monkeys. The work has not been substantiated in
America. That one organism was the cause of these
three diseases was naturally thought of when this epi-
demic of encephalitis came following that of polio-
myelitis:— The encephalitis, the cerebral type of the
disease ; poliomyelitis, the spinal type. The important
matter is largely where the lesion is located. It has
been rather generally accepted that there might be a
cerebral type of infantile paralysis. There are many
cases of the cerebral types. This lends a certain
weight to the supposition that this is an extension of
the same process located predominantly in the brain
rather than in the spinal cord. On the other hand
there are certain definite differences in the two con-
ditions. Poliomyelitis occurs in children predomi-
nantly, yet not exclusively, and encephalitis occurs
predominantly in adults. The pathological anatomy
is similar, yet not identical. In one the nerve cells are
more involved; in the other, the perivascular spaces
and the nerve cells not to any great extent. Observers
who have had the greatest opportunities for study do
not identify the two conditions. Encephalitis has no
relation whatever to the sleeping sickness of Africa.
The relationship of influenza, infantile paralysis, and
encephalitis is of very great interest, but not definitely
proven. — From the Rhode Island Medical Journal for
October, 1920.
THE MIGRATORY CONSUMPTIVE AS A
FINANCIAL BURDEN TO THE
SOUTHWEST
By Aixen Hamilton Williams, M.D.
The essentials of recovery from tuberculosis must
always be rest, fresh air, good food and a contented
mind. Without these, climate is vain. And the prog-
ress toward cure is slow ; at the best it is a long
drawn out and painful problem. But this the average
consumptive fails to realize. He moves West to get
well ; he becomes migratory. Getting well proves to
be a much longer affair than he expected. And, after
a time, unless his bank account be large, he finds him-
self without friends or resources, an alien in a .strange
land ; he becomes indigent. He is unable to get proper
food or living conditions, or any medical care. He is
haunted by financial worries. Under these circum-
stances he must grow worse, and ultimately he be-
comes a burden on the community until he dies. This
is the history of thousands of cases. Frequently in
his ignorance he has trusted solely to the climate, has
had no medical advice, has exercised as he pleased,
and thus has thrown away all chances of recovery even
before his funds b«?gan to give out. — From Southwest-
ern Medicine for September, 1020.
CHRONIC APPENDICITIS, THE SCAPEGOAT
OF ABDOMINAL SURGERY
By Hugh Cabot, M.D., F.A.C.S.,
Ann Arbor, Michigan
The patient with vague abdominal pain and reflex
intestinal disturbance which might be produced by
chronic appendicitis is entitled to have the evidence
carefully sifted. He is entitled to be assured not only
that his symptoms might be produced by appendicitis
but that no evidence can be obtained to show that
they can in fact be produced by anything else. When
we advise patients that their appendix should be re-
moved, they are entitled to the assurance that we
-have studied the other possible causes of their difficulty
and excluded them as far as possible. They are en-
titled to a decent respect for the privacy and integ^rity
of their abdomen and to be shielded against the sort
of exploration which is, in fact, nothing more than
idle curiosity. If long incisions are to be made, they
must be justified by the results and failure to show
justification must be regarded as a definite error in
judgment. If we expect and demand the confidence
of our patients, we must do more to justify it.«— From
The Journal of the .Michigan State Medical Society,
October, 1920.
ETIOLOGY OF AND PROPHYLACTIC
■ ■ H<OCULATION IN INFLUENZA
Bv E. C. RosBNow, M.D.,
Rochester, Minnesota
The Mayo Foundation
As a result of our study of the sputum and exudates
after death, we can say that in influenza there is pres-
ent a green-producing streptococcus which appears to
bear specific relationship. The monovalent serum de-
veloped in the horse has the power of agglutinating
practically all of the strains. Single agglutinable cul-
tures absorb the specific agglutinins from this serum
for practically all of the strains. By means of a vac-
cine containing type pneumococci a high percentage of
the freshly isolated strains, having this peculiar rela-
tionship together with pneumococci of Group IV.
hemolytic streptococci, and staphylococci, it appears
possible to rob influenza of some of its terrors.
The formula of the vaccine, aside from type pneu-
mococci, should be made to correspond roughly with
the bacterial flora at hand in different parts of the
country, although a study of the results obtained last
year indicates that special adjustment is, in general,
not necessary. The strains should be incorporated as
soon after isolation as practicable. Bacteriologic lab-
oratories in various communities, the biologic manu-
facturers, and state and municipal boards of health
should supply properly prepared vaccines for prophy-
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December, 1920
ABSTRACTS FROM STATE JOURNALS
167
lactic in'oculation. The oil vaccine, it seems to me,
should be preferred, since the dose can be made larger
with less constitutional reaction owing to the slow
absorption. Moreover, the method for the preparation
of lipovaccines, which Osterberg and I have developed,
is quite simple. During our study of prophylactic
inoculation with a saline vaccine, it became clear that
the immunity conferred diminishes perceptibly after a
period of six weeks to two months, and hence indi-
cates that revaccination at the end of this time is de-
sirable, which can be done more readily with oil vac-
cine, since only one dose at a time is necessary. — From
The Journal of the Iowa State Medical Society, Oc-
tober IS, 1920.
VERTIGO: ITS ETIOLOGY. DIAGNOSIS AND
CLINICAL MANIFESTATIONS
By Horace T. Aynesworth, M.D., F.A.C.S.,
Waco, Texas
The causes of vertigo may be classified as follows :
(i) Lesions primarily involving the ear or eighth
nerve, as the various types of labyrinthitis; embolus,
thrombus or hemorrhage into the labyrinth, as in
Meniere's syndrome; irritation of the labyrinth sec-
ondary to middle ear inflammations or noninflamma-
tory affections; sudden destruction or impairment of
the labyrinth by trauma or by effusion or hemorrhage,
as in diabetes, nephritis or arteriosclerosis; neuritis
of the eighth nerve secondary to chronic focal infec-
tions, as of teeth, tonsils, etc., and primary degenera-
tive changes in the labyrinth not traceable to any
specific cause.
(2) Lesions involving the ear mechanism as a result
of toxaemias, as from constipation, gastro-intestinal
disturbances, genito-urinary diseases, alcohol, quinine,
ptomain poisoning, tobacco, nephritis, syphilis, the in-
fectious fevers, etc.
(3) Ocular disturbances, such as refractive errors,
especially oblique, astigmatism, paresis or paralysis of
the eye muscles, etc. These latter* conditions affect
the vestibular apparatus through the eye muscle nuclei
or through association fibers from the cuneus to the
vertigo center. In doubtful cases the ocular balance
should always be carefully determined as well as the
refractive condition.
(4) Lesions in the brain along the pathways from
the ear. This includes all forms of intracranial trou-
ble, such as congestion, ichaemia, tumors, hemor-
rhage, effusion, -embolus, infarct, abscess, gumma,
tubercle, multiple sclerosis, hydrops, meningitis polio-
encephalitis, etc.
(5) Involvement of the ear mechanism by circula-
tory disturbances, cardiorenal and cardiovascular con-
ditions.
(6) Involvement of the vestibular apparatus from
reflex irritation, neurasthenia and the like.
Vertigo associated with middle ear affections, pri-
mary degenerative changes in the labyrinth, ocular
disturbances and toxaemias, are most often seen.
To determine the cause of vertigo one may have to
examine the entire vestibular apparatus, and should
do so in all obscure cases where it is possible and
practicable. In addition, a complete general examina-
tion may be required, including all possible laboratory
aid. The eyes must be examined, including the pupils,
fundi, fields, muscles, etc. In testing the vestibular
apparatus, we are concerned with those symptoms or
phenomena that are spontaneously present or may be
evoked by appropriate tests. The spontaneous phe-
nomena include nystagmus in any direction, vertigo.
past pointing and falling, and also the Romberg sign,
pelvic girdle reactions, deafness, tinnitus, etc. The in-
duced nystagmus, vertigo, past pointing and falling
are now carefully studied after appropriate rotation
in the Barany chair or some modification of it, and
after douching theear with water at 68° F., or colder.
The galvanic current is advocated by some, especially
MacKenzie, of Philadelphia, but does not seem to be
much in favor. The exact response to each and every
test is carefully noted — whether present, absent, in-
creased or diminished. When all the responses are
normal a functional neurosis, an ocular disturbance,
an evanescent toxaemia or mild focal infection, is sug-
gested, and our efforts to find and remove the cause
must be along these lines. When the responses are
abnormal or absent an organic lesion is suggested,
and from the nature of the responses and from the
associated symptoms its location often may be deter-
mined with considerable accuracy. Thus, in the case of
peripheral lesions, we generally have no doubt as to
their location, and can, in the case of central lesions,
with reasonable precision in many instances, state
that the medulla, the pons, the cerebellum, the pedun-
cles, third ventricle, or other portions of the brain are
involved. — From Texas State Journal of Medicine for
October, 1920.
RENAL INFECTIONS
By W. G. Sexton, A.B., M.D.',
Marshfield, Wisconsin
To a(;complish any results in the care of infection
of the kidney, the first essential feature is an accurate
diagnosis. This can only be arrived at by the use of
the cystoscope with ureteral catheterization, and iil
many instances this must be supplemented by pyelo-
grams or roentgenograms to exclude stones. In most
instances one should also use the wax bulb on a cathe-
ter as described by Hunner to determine the presence
or absence of a ureteral stricture.
Having determined the type of organisms and the
site of the infection, one must then proceed with as
conservative and safe treatment as possible. Med-
ically there are practically only three lines of proce-
dure: I. The use of urotropin. This must be given
at least every four hours and must be combined with
some acids or acid salts, such as boric acid or sodium
benzoate in order to render the urine highly acid, re-
membering that jurotropin breaks down into formolin
in the kidney only in acid urine. 2. The second line
Of treatment is that of giving alkalies, such as potas-
, sium acetate, bicarbonate or citrate or a combination
of the three. Large doses must be given and at regu-
lar intervals night and day. Change of posture must
also be tried.
Vaccine therapy has not given much success in any
of the large clinics of this country. We have had
two cases this past year that have been relieved of
their symptoms following the use of autogenous vac-
cines. The general consensus of opinion is that the
relief is only temporary. The best results are obtained
by pelvic lavage through a ureteral catheter. In our
hands silver nitrate i/iooo has been used almost ex-
clusively and has given satisfactory results. Many of
our cases have not responded to treatment until we
resorted to dilatation of the ureter by the use of large
catheters or the wax bulb. When one has a pyone-
phrosis or a case of acute suppurative nephritis, ne-
phrectomy is indicated.
As it is well recognized by many investigators, such
as Hunner, Lewis and Cabot, that ureteritis and pye-
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THE PENNSYLVANIA MEDICAL JOURNAL
EteCEMBER, 1920
litis are blood borne infections, one must not feel
tliat he has accomplished a core until he has found the
source of the infection and removed it. This is fre-
quently in the tonsils, nose, with its accessory sinuses,
or the teeth.
In conclusion we believe that infections of the kid-
ney and stricture*, of the ureter areinuch more com-
mon than we have 'heretofore believed. We feel that
most cases that • have been operated for chronic ap-
pendicitis and have had pain a'fter the operation were
kidney or ureter cases and we wish to add a word of
caution, against operating any case of chronic appen-
dicitis until lesions of the urinary tract have been
scientifically excluded. — From The IVisconsin Medical
Journal for October, 1920. •
PYLORIC STENOSIS IN INFANTS
Bv Eugene H. Smith, M.D.,
Ogden, Utah
Every case of persistent vomiting occurring in a
young infant should be carefully investigated with
the possibility of stenosis of the pylorus in mind.
In milder cases the possibility of spasmodic obstruc-
tion should be considered, and the relation of the
vomiting to any existing nervous diathesis should be
investigated. As in adults, gastro-intestinal symptoms
may have an origin outside the abdominal cavity. In
this conneotion the unstable equilibrium of the in-
fant's nervous organization should not be lost sight
of.
Improper food is not the only cause of vomiting.
Sometimes the receptacle is deranged physiologically,
mechanically or both.
■ Changes in an infant's food, especially if from
mother's milk, should only be made for sufficient cause,
with a rational idea of what is to be accomplished,
and with an adequate appreciation of the responsibility
undertaken.
No child should be allowed to die of stafvation on
account of pyloric stenosis. An operative death, even,
indicates that an attempt was made to relieve the con-
dition.— From Northwest Medicine for October, 1920.
TRACHOMA IN THE NEAR EAST
"Every physician should himself suffer from the
diseases which he is treating. That's the only way he
can come to an adequate appreciation of what he is
trying to cure." So says Dr. Blanche Norton, Near
East Relief worker just returned from Constantinople ,
where she was singled out by the Greek, government
to be the first and only woman on whom they had
ever conferred the decoration of the King George I,
first class. This distinction came as the result of Dr.
Norton's wonderful work in caring for the trachoma
victims among the Greek refugees; and as may be
guessed by her statement above, she not only cared
for trachoma patients, but she contracted the disease
herself and speaks with double authority on its causes
and cure
"Not that I can say a great deal about its causes,"
she said on her arrival in New York. "Besides the
fact that it is extremely contagious, very little is
known about its origin and contraction. The Orien-
tals have suffered from it and other eye diseases for
so long that they take very little interest in the mat-
ter. When the patient becomes almost blind they fol-
low out a very misguided conception of isolation, and
let it go at that.
"For instance, when I arrived at Kerrasunde, a lit-
tle town on the Black Sea, I found that nearly a hun-
dred little children were 'isolated' in a cold dark cellar,
with no occupation, with almost no care and very in-
adequate food and clothing. Many of them were
blind ; all of them were sick and weak. Yet most of
these children might have been cured had they re-
ceived the proper treatment in time.
"The same mode of treatment, with the exception
of the shortage of food and clothing, is what has al-
ways been given the victims of this disease. It is no
'wonder, then, that fully a fourth of the population of
the Near East are afflicted, and that sore eyes are so
common a sight on the streets of an Oriental town,
that they cease to attract notice. In Constantinople
we made a very careful survey of all the orphanages
there — institutions which had been very efficiently run
and where the refugee children of the Armenian and
Greek massacres received the {greatest care. We
found here that exactly twenty-five per cent of them
were suffering from trachoma. That the percentage
among the outside population, particularly the refu-
gees who throng the streets of the Eastern capitol, is
much greater would be safe to say.
"It will be up to American scientific medical re-
search to discover the origin and cure of this terrible
disease," said Dr. Norton. "While the Greek physi-
cians are heartily in sympathy with us and aided us
in every way and proved most capable, the impetus
must come from American physicians. That it is a
field in which they may well be interested, I am sure,
for it is not only in the Levant that trachoma is mak-
ing such headway, but in our own country as well. In
New York and many of our large cities the foreign
quarters are filled with the disease and it is becoming
more and more prevalent in our Southland.
"It is a most distressing and disastrous disease to
have, I can say that for it. While one suffers less
with it than with many its effects are very painful.
Extreme nervousness and debility are among the first
symptoms. The icontinued strain caused by dimmed
vision is more than annoying. Finally its tendency in
the large majority of cases to bring. blindness marks
it as superlatively dangerous."
Dr. Norton expects to devote herself for the next
few years to research work in connection with this
disease and its cure. Her own experiences should
prove invaluable if there is any foundation in her
initial statement that the physician should first suffer
from the disease he is treating.
THE FRUITS OF QUACKERY
One of the best hotels in a great city, towering high
on a beautiful boulevard, almost within the business
district and yet overlooking the lake! In a beautiful
suite high up, away from the noisy bustle of the city,
sits a kindly looking gray-haired man. A touch of the
wall buttons brings servants scurrying to do his bid-
ding, for he is free with tips and with his smile. At
his word a seven-passenger Peugeot, of the latest
model, guided by a uniformed chauffeur, rolls up to
the entrance. He wishes, perhaps, to attend the thea-
ter or to take an airing in the park or to see a friend.
Not too often the latter, for he has few friends! The
transient guests inquire of the clerk as to his identity.
Perhaps he is a member of some foreign royal family;
perhaps a magnate resting on the well-earned laurels
of some gigantic deal in copper or in cotton ! But no !
It appears he made his fortune by selling sugar and
salt. A pinch of salt and a pinch of sugar in a barrel
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December, 1920
propaganda' for reform
169
of hydrant water guaranteed to cure any disease if the
sufferer will only put one drop in each eye night and
morning — approximate cost, 6 cents a gallon — selling
price, $S an ounce ! Through the Middle West, in lit-
tle country graveyards, are the bodies of some who
read the advertisements and believed. And the "pro-
fessor" orders out his car and says to the chauffeur
with a lordly wave of his hand : "To the park, James."
The mills of the gods grind slowly » * * obviously.
— Jour. A. M. A., Oct. 2, 1920.
PROPAGANDA FOR REFORM
Moke Misbbanded VENEREAt Nostrums. — The fol-
lowing preparations have been the subject of prosecu-
tion by the Federal authorities charged with the en-
forcement of the Food and Drugs Act, on the ground
that the therapeutic claim; made for them were false
and fraudulent: Injection Malydor (The Williams
Mfg. Co., Cleveland, Ohio), essentially a dilute watery
solution of boric acid, ohenol, a zinc salt, glycerin,
acetanilid and unidentifiea plant material. G Zit (The
Stearns Hollinshead Co., Inc., Portland, Oregon),
bougies consisting essentially of cacao butter and a
silver compound. G Zit Antiseptics (The Stearns Hol-
linshead Co., Portland, Oregon), composed essen-
tially of oils of copaiba and cubebs, and a compound
of sulphur. Hinkle Capsules (Hinkle Capsule Co.,
Mayfield, Ky.), consisting essentially of powdered
cubebs, copaiba and cannibis indica. Tisit-Pearls (S;
Pfeiffer Mfg. Co., East St. Louis, 111.), consisting es-
sentially a mixture of oil of sandalwood, balsam of
copaiba, oil of cinnamon and a fixed oil. Tisit (S.
Pfeiffer Mfg. Co., East St. Louis, 111.), a watery solu-
tion of zinc sulphate thymol, alum and glycerin. Black-
Caps (Safety Remedy Co., Canton, Ohio), consisting
essentially of copaiba, subebs and saw palmetto.
Hexagon (Montebello Laboratories, Kansas City), an
injection consisting essentially of a watery solution of
zinc sulphocarbolate, boroglyceride and bismuth sub-
nitrate and capsules containing hexamethylenamin.
Hyatt's A. B. Balsam (C. N. Crittendon Co., New
York City), consisting essentially of potassium iodid,
alum, Epsom salt, plant extractives and untdentiBed
alkaloids, sugar, glycerin and alcohol. DuQuoin's
Compound Santal Pearls (Wm. R. Warner and Co.,
Inc., New York City), consisting essentially of a mix-
ture of santal oiland copaiba {Jour. A. M. A., Oct. 2,
1920, page 954).
More Misbranoeo Venereal Nostrums. — The fol-
lowing preparations have been the subject of prosecu-
tion by the Federal authorities under the Food and
Drugs Act, chiefly because the therapeutic claims made
for them were false and fraudulent. Injection Zip
(The Baker-Levy Chemical Co.), consisting essentially
of acetates and sulphates of zinc and lead, opium,
berberin, plant extractives, alcohol and water. Three
Days' Cure ("3 Days" Cure Co.), consisting essentially
of zinc sulphate, boric acid and water. Redsules (H.
Planten and Son), consisting essentially of oil of san-
tal, copaiba and methyl salicylate. Blakes Capsules
(Henry K. Wampole and Co.), consisting essentially
of a tablet of salol suspended in a mixture of volatile
oils, oleorsins and plant extractives, including copaiba
and cubebs. Compound Extract of Cubebs with Co-
paiba (The Tarrant Co.), consisting essentially of
cubebs, copaiba and magnesium oxid. Santal Midy
Capsules (E. Fougera and Co.), containing essentially
oil of santal {Jour. A. M. A., Oct. 9, 1920, page 1016).
Succus Cineraria Maritima. — The medical profes-
sion is at present receiving through the mail circulars
extolling this nostrum for its alleged virtue in "ab-
sorbing" various forms of cataract. In February, 1917,
the Bureau of Chemistry of the U. S. Department of
Agriculture issued a Notice of Judgment which
showed that the government authorities had prose-
cuted the firm which markets the preparation — The,
Walker Pharmacal Company — because claims were
made on the trade package to the effect that this nos-
trum was a remedy for cataract and other opacities
of the eye. The authorities charged that these claims
were false and fraudulent. To this charge the com-
pany pleaded guilty, but these claims are still being
made through other avenues to the medical profes-
sion (Jour. A. M. A., Oct. 9, 1920, page 1007).
Bran-O-Lax Tablets. — The public is urged to pur-,
chase these "Laxative Wheat-Bran Tablets for consti-
pation and indigestion instead of those severe and
harmful drugs." The essential claims, either inferred
or expressed, are to the effect that Bran-O-Lax Tab-
lets are wheat bran in condensed form and that they
are free from "harmful drugs." It is also claimed
that "Bran-O-Lax contains one heaping tablespoonful
of plain nutritious wheat bran condensed into tablet
form." The A. M. A. Chemical Laboratory reports
that Bran-O-Lax Tablets contain wheat bran, reducing
sugar (prpbably glucose) in large amounts, a gummy
substance, probably acacia, and about one grain of
phenolphthalein per tablet. Whereas a heaping table-
spoonful of wheat bran was found to weigh about 166
grains, the total weight of a Bran-O-Lax Tablet was
only about ssyi grains (Jour. A. M. A., Oct. 16, 1920,
page 1083).
Toxicity of Arsphenamine. — Roth has determined
that if an alkalized solution of arsphenamine or a solu-
tion of neoarsphenamine is shaken in the presence of
air for one minute, 'the toxicity is increased. He
points out that arsphenamine preparations which are
soluble with difficulty ar^ likely to be shaken to aid in
the solution of the drug with the risk that chemical
reaction may occur (Jour. A. M. A., Oct. 16, 1920,
page 1072).
Fake Orange. Beverages. — The orange and other
citrus fruits possesses value other than that which can
be measured by flavor or fuel value. They are relied
on as antiscorbutic by a large number of persons in
the preparation of food mixtures which for some rea-
son are deficient in this protective element. Oranges
merit additional favor because they are relatively rich
in the water-soluble vitamin B, sometimes designated
antineuritic vitamin, which promotes well-being in as
yet an undetermined way. In view of these facts,
the chemists of the U. S. Public Health Service have
done well in their timely warning against the "fake"
orange beverages that have come to their attention.
They report that in most cases the fraudulent products
consisted of carbonated water, flavored with a little
oil from the peel of the orange and artificially colored
lo imitate orange juice (Jour. A. M. A., Oct. 16, 1920,
page 1073).
Capsules Folia-Digitalis-Upsher Smith and
Tincture op Digitalis Upsher Smith. — The Council
on Pharmacy and Chemistry reports that these prepa-
rations, advertised and sold by Upsher Smith, St. Paul,
Minn., were considered and found to have the status
of official articles. For this reason they were not ad-
mitted for inclusion in New and Nonofficial Reme-
dies (Jour. A. M. A., Oct. 30, 1920, page 1205).
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170
THE PENNSYLVANIA MEDICAL JOURNAL December, 1920
THE PENNSYLVANIA
Medical Journal
Publuhed monthlr under the supervision of the Publication
Committee of the Trustees of the Medical Society of the Sute
of Pennsrlvania.
Editor
FREDERICK U VAN SICKLE, H.D Harrisburg
Aulitant Editor
FRANK F. D. RECKORD Harrlaburg
AftooUte Editors
Joseph McFailand, M.D Philadelphia
Georci £. Pfahui, M.D Philadelphia
Lawsbhck LiTCHPiiLD, M.D., Pittsburgh
GloRCi C. Johnston, M.D., Pittsburgh
J. Stkwart Roduah, M.D., Philadelphia
OHH B. McAlistek, M.D Harrisburg
Beknasd J. Myers, Esq Lancaster
Publication Committee
Ika G. Broiuakir, M.D., Chairman, Reading
Thkodorr B. ArriL, M.D Lancaster
Frank C. Hammond, M.D Philadelphia
All communications relative to exchanges, books for review,
manuscripts, news, advertising and subscription are to be ad-
dressed to Frederick L. Van Sickle, M.D., Editor, aia N.
Third St., Harrisburg, Pa.
The Society does not hold itself responsible for opinions ex-
pressed in original papers, discussions, communications or ad-
vertisements.
Subscription Price— $3>oo per year, in advance.
December, 1920
EDITORIALS
THE NURSB SHORTAGE
I believe all physicians realize that there is a
Mitrse Shortage, either because there is not a
.sufficient number of nurses, or because so many
people of moderate financial means cannot af-
ford the expense of employing needed nurses.
This is a problem for solution along with some
of our purely medical problems.
The seriousness of our national problem of
illness is generally recognized. The humanity
of it, as well as the annual cost in money is enor-
mous, and experts tell us that half of this sick-
ness could be prevented by utilizing knowledge
and methods already available. This will not be
possible unless the need for nurses be met in
some way.
The war and the influenza epidemic further
brought to our notice the fact that the demand
for nurses far exceeded the supply.
Now we understand that legislation pending
or actually passed will call for 50.000 Public
Health nurses in the near future. This is in ad-
dition to the nurses required for private prac-
tice, for training schools, for hospitals, and for
associational work. More constructive meas-
ures to conserve public health are being
launched each year, which cannot be carried out
successfully without a sufficient number of
nurses.
Safe, sensible attendance on the sick is nec-
essary for the sick as well as for the success of
the physician attending those sick. At the pres-
ent time ninety per cent, of all illness is attended
in the homes. Hospitals care for the remaining
ten per cent., which insures care for the poor.
The other larger class of middle income people
cannot afford to employ regular trained nurses
at the rate of fees charged to-day. I do not for
one minute mean to insinuate that nurses fees
are too high. If ever a laborer was worthy of
bis hire, the nurse is of her's. But such fees
place her care among the luxuries which the
hriddle class sick cannot enjoy for any extended
period, and not infrequently a day and a night
nurse is required in a critical period in the case.
I mean by middle income people those not so
poor as to necessitate the use of the hospital, yet
whom the expenditure of thirty-five dollars per
week for one or seventy dollars for two nurses
would be a serious burden ; those people out of
reach of the hospital and where hospital accom-
modations are not adequate. For we know most
of our hospitals are crowded and nurses not suf-
ficient in our hospitals. Then too, all of our
people are not educated to hospital advantages
and many are not to be persuaded to go to the
hospital who should have such care.
Insufficient nursing and medical care of peo-
ple of moderate means is one of the arguments
for the demand for Health Insurance. Social
reformers are proposing various schemes for
relieving the conditions and hardships sickness
imposes upon the fairly well-to-do.
The medical and nursing professions must
.meet these complaints themselves. They must
not allow them to be adjusted by unsympathetic
or nonunderstanding interests. The first step
to be taken in this adjustment would seem to be
to rec(^nize the need for more nurses, and to
devise some plans whereby they may be ob-
tained. The intimate relation and dependence
of the medical profession upon the nurse should
not make it offensive for our interest in this
problem. Public Health nursing must be car-
ried on with increasing vigor. Visiting Asso-
ciations are clamoring for more nurses. We
need more school nurses unless this generation
of children is to suffer impairment for many
correctable diseases. We need more nurses for
antituberculosis work. We need more indus-
trial nurses. Their aid has so reduced accidents
and sickness that their work is regarded as an
economic factor in big business itself. We need
more nurses for Infant Welfare. Without them
the Federal Children's Bureau cannot do the
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December, 1920
EDITORIALS
171
task it has set itself of saving loo.cxx) children
yearly. In every branch of the work of life
saving we need more nurses. Where are we to
get them? During the w^ar, the Committee of
the Council of National Defense, by its vigorous
action, increased the registration of pupil nurses
in training by twenty-five per cent.
The training for the Public Health Nurse re-
quires that she be a graduate of an accredited
hospital training school and besides have taken
a post-graduate course in Public Health nursing,
with a' knowledge of health administration and
social science. Such a long period of training
necessary as it may be, shuts out the possibility
of relief from this source. The fully equipped
r^stered nurse requires three years hospital
training in most states before she is regarded as
skilled enough to care for the suffering. Not
much hope of reducing the nurse shortage by
this means, especially as business is offering
young women such flattering financial returns,
with so much less time of needed training.
Could not a shorter training period be offered to
young women, women with a taste for, and a nat-
ural apitude for nursing? Such young women,
while not receiving the degree of Registered
Nurse, could surely render invaluable aid in hos-
pitals and in homes, releasing many Registered
Nurses for more urgent cases, more skilled
duties and families able to afford the skill. The
family's finance would not be so strained, and
the sick member would receive much more skill-
ful and intelligent care than if some totally un-
trained member of the family assumed the bur-
den. • *
During the influenza epidemic capable women
took First Aid courses. Red Cross Emergency
training and helped pull influenza stricken
America through its crisis in an amazing man-
ner..
Could there not be more of such nurses?
There were committees which gave himdreds of
young, country and small-town girls, a three
months' course in home nursing, when the war
threatened suffering because of the nurse short-
age. Could not such committees extend their
work so that people in isolated or rural districts
beyond the reach of Registered Nurses, could be
assured sympathetic and understanding atten-
tion, even if it were not up to the high grade
efficiency of the regular nurse. Even a short
course of training would install in the pupils
minds elementary health facts, simple instruc-
tions in bed making, bathing, invalid food prep-
aration, administration of medicine carefully
and accurately measured, and the keeping of
charts for the doctor, who would thus be im-
measurably helped in his work.
Could not our training schools, especially of
our smaller hospitals adopt a shorter course of
training, and under proper state supervision
grant a degree of Junior Registered Nurse?
Thus protecting the Registered Nurse, while
furnishing a more adequate supply of sick room
attendants. The Junior Nurse could care for
the sick but not engage in Public Health work,
nor act as instructor or supervisor in hospitals
or similar institutions.
Nursing offers a magnificient career for the
highest type of woman and we medical men can
do much to bring to the notice of the women of
America the need for help in relieving the nurs-
ing .shortage. J. B. McA.
CANCER
It has been estimated that approximately loo,-
ooo people will die of cancer in the United
States in 1920 and that more than twice as many
died of this disease in the United States during
the two years we were actually engaged in the
war than there were American soldiers killed.
Are we physicians making use of all of the
known facts in giving advice to our patients and
in treating cancer? Are we as optimistic our-
selves in the final outcome as the facts warrant ?
We should cure 70% to 75% of these cases but
fall 'far short of this percentage as an average.
How then, can we do our full duty and what are
our shortcomings now ? The responsibility for
the cure of cancer is a divided one. The family
physician must make the diagnosis and the sur-
geon aided by those skilled in the use of special
forms of therapy such as the x-ray, radium,
etc., must eradicate the disease. This- responsi-
bility is divided equally, for a correct diagnosis
is essential to cure and furthermore, we are not
justified in waiting until the diagnosis of already
existing carcinoma is a practical certainty. Re-
liable statistics show that the percentage of cures
is not over 30% if the case is not submitted to
operation until the diagnosis of carcinoma can
be easily made. We must, then, fully appreciate
and always bear in mind that certain conditions,
benign in themselves, are prone to become the
forerunner of cancer. Such condition is ulcer
of the lip, so-called abnormal involution or
chronic cystic mastitis of the breast, chronic
ulcer of the stomach, gall-stone and hypertrophy
of the prostate, fall into this category. The re-
sponsibility of either forestalling the develop-
ment of cancer or of eradicating it in the mi-
croscopic stage should be definitely placed in the
hands of the surgeon at a time when spch a^rer,^!^
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172
THE PENNSYLVANIA MEDICAL JOURNAL
December, 1920
suit is almost a certainty. The writer can show
72% of three-year cures and 50% of five-year
cures, in a series of carcinoma of the breast, but
many of this series were operated on for Chron-
ic Cystic Mastitis which proved to be early car-
cinoma when submitted to the microscope.
The Mayo's report 35% of three-year cures in
carcinoma of the stomach but only because it is
through habit to remove ulcers. The early car-
cinoma was found in the margin of the ulcer.
The writer believes that if we wait until the
diagnosis of carcinoma of the stomach can be
made that we will not cure any of these cases by
surgery.
There is another question that causes the phy-
sician some concern in giving advice to patients
namely, what is his duty in referring patients di-
rectly to the specialist skilled in the use of ra-
dium and the x-ray. The writer is firmly of the
opinion that the surgeon and the specialist can
no longer work independently and that every
sufferer from malignant disease should have the
benefit of every known means of cure. The best
results will be obtained by a combination of the
two not in a casual sense but by a permanent
combination that will give such a patient the best
to be had at a price commensurate with his
means. The writer has seen the marvelous re-
lief that has followed the use of radium in in-
operable cancer and feels it his duty, to see to it
that his patients have the benefit of preoperative
and postoperative radium and x-ray treatment.
He is equally convinced however, that surgery
is still the best single means of treating this dis-
ease in its early stages and feels that every suf-
ferer from the disease should have the benefit of
a surgical opinion as to the operability of his
particular case. Real progress lies in combining
the best that is known in diagnosis and treat-
ment, both surgical and special and the public
has the right to demand this of us, especially in
view of the fact that cancer is still on the in-
crease and is one of the chief causes of death.
J. S. R.
FITTING SHOES BY THE X-R.\YS A D.A.XGER
Recently some enterprising shoe dealers have
conceived the idea of fitting shoes by means of
the x-rays, and this pseudo-scientific application
of the x-ray is intended to appeal especially to
those who have had difficulties in getting prop-
erly fitted shoes. It is, of course, primarily a
means of advertisement. The patient first sees
a demonstration of the salesman's foot inside his
shoe by means of a small x-ray outfit and the
use of a small fluoroscope, and then the sales-
man is supposed to determine whether the shoe
which is being sold to the patron properly fits
the foot. Grave dangers are involved in this
procedure primarily affecting the salesman be-
cause he is the most frequently exposed, but it
is also possible to cause danu^e to the patron if
a prolonged examination is made. These dam-
ages may not occur for a considerable time after
the application. Especially is this true with re-
gard to the salesman who makes repeated exam-
inations of his own foot, even though each ex-
posure is short. To see any object with the x-
ray fluoroscopically the observer should ■ remain
in a dark room for approximately 15 minutes
before attempting to see anything in order that
jthe retina may become properly sensitized. It
is easily understood that neither the salesman
nor the patron is likely to spend this amount of
time preparatory for this observation, but in-
stead an increased amount of radiation is used
to make up for the lack of sensitiveness of the
retina, and sauch a severe exposure may quickly
do considerable harm.
A young physician who purchased a small
portable x-ray outfit attempted to set a fracture,
and the fluoroscopic examination was only made
on this one occasion. This resulted in a severe
bum of the patient's leg and the physician lost
all the skin from his hands. On another occa-
sion, one of the leading surgeons of this state
attempted to remove a foreign body from a pa-
tient's arm under fluoroscopic examination, and
as a result of this single exposure the patient's
arm was severely burned and permanently dam-
aged, and the surgeon damaged his hands per-
manently, and for about a year was unable to
carry bn his surgical work.
If such accidents can occur in the experience
of intelligent and trained physicians, what can
one expect from an untrained enthusia.stic lay-
man who is trying to sell shoes, and whose busi-
ness should be to sell shoes?
There is a false impression that a small porta-
ble outfit can be used without caution or protec-
tion. It may take a longer exposure, but with a
longer exposure as much damage can be done
with a small outfit as with a large one, and the
damage can be very great, as cited in the above
cases. Therefore, those who make use of even
small x-ray outfits should familiarize themselves
with the danger involved, and should learn at
least the underlying principles of x-ray physics
and of x-ray protection.
Aside from the danger, the application is prac-
tically valueless. When an ill-fitting shoe pro-
duces gross deformity it can, of course, be recog-
nized by x-ray examination, but an x-ray
examination is not necessary to recognize gross
deformity caused by ill-fitting shoes. Any corn-
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December, 1920
EDITORIALS
173
petent shoe-fitter, any orthopedic surgeon, any
physician, or even the patron, recognizes this
condition by the discomfort which it causes, and
by comparing the shape of a normal foot with
the shape of the shoe to be purchased. It
should, therefore, be unnecessary to wait until
a series of damage suits occur, or a collection of
cases can be reported in the Medical Journals,
before this danger is recognized. It is the duty
of every physician who learns of this procedure
to caution the proprietor and salesmen as well
as any patients who consult him directly.
G. E. P.
The above editorial is very timely, as the fol-
lowing reprint will show the changes taking
place in the particular industry of shoemaking
and shoe-fitting :
"Are women's ankles becoming thicker?
Question is raised by New York retailers or-
dering shoelaces seven feet long."
"Brockton, Mass., Nov. 2. — A shoestring fac-
tory is turning out shoe and boot laces of ninety
inches, or seven and a half feet long, for the
New York retail trade, largely for women's ten
and eleven-inch boots.
"The men working upon this product are con-
stantly asking, Are women's ankles growing
larger ?
"A new appliance for stylish shoe stores is an
x-ray machine which enables the clerk or the
customer to look at the foot being fitted. It is
possible thus to tell if the shoe crowds the foot
into unnatural position, jamming the bones or
distorting them so that discomfort must result."
— Editor.
CALIFORNIA AND THE ANTIVIVISECTION
CRUSADE
The recent election brought forth an interest-
ing result, especially of importance in relation to
legislative affairs in the State of Pennsylvania.
Some states confine legislative problems en-
tirely to the assembly of the state, while others
submit questions of importance through refer-
endum to the voters of the state. This is true
of California. During some time in the past,
various important problems have been presented
to the voters of that state, and only within a
recent time have they acted most emphatically
upon the question of compulsory health insur-
ance, and put their stamp of disapproval upon
that type of legislation.
At the election of November, there was sub-
mitted to the people of California the subject of
vivisection, and for the first time in the course
of state legislation,.has this effort to prohibit ex-
periments on living animals been made by the
proponents of that particularly obstructive form
of legislation, by submitting it to the ^voters of
the state.
For many years, legislators have been im-
pugned to pass antivivisection bills, such occur-
ring in the National Congress, in the states of
Massachusetts, Pennsylvania, New York, and
many others. Up to the present time, however,
no law has been enacted, limiting scientific ex-
plorers in the endeavor to discover new facts in
medical science and pave the way to better treat-
ment of disease and prevention of disease
through the channel of experimentation upon
living animals.
It would take volumes to tell the story of dis-
cussions before the committees who have been
obliged to hear the appeals of members of the
misguided associations which have championed
the scheme to prevent such experimentation.
Cruelty to animals appeals to public sentiment in
the prevention of anything that causes pain or
suffering to the animal. It is upon this basis
that the Society for the Prevention of Vivisec-
tion has appealed to the emotions of those whom
they desire to influence in their efforts to pass
an antivivisection bill. Their assumption rests
upon the supposed idea that animals used in
laboratories are caused to suffer severely during
experimentation. Widespread exaggerated
statements have been made, and this propaganda
was particularly active during the last campaign
in California.
An editorial jn the American Medical Asso-
ciation Journal, of November 13, 1920, says in
part:
"It is well to remember that the propaganda
of the antivivisectioni.sts rests on two assump-
tions— wanton cruelty in the treatment of labo-
ratory animals, and utter uselessness of the
results of animal experimentation. Both lines
of attack were worked elaborately by the anti-
vivisectionists in California. Large amounts. of
money were contributed by eastern adherents to
promote their cause, and newspaper space, post-
ers and leaflets were used to the utmost. With
limited means, the medical men and the univer-
sity authorities put forth their opposing claims.
It is greatly to the credit of the intelligence of
the California voters that they saw through the
falsehoods and misrepresentations of the anti-
vivisectionists and registered their disapproval
of the measure to abolish animal experimenta-
tion."
We are particularly satisfied in Pennsylvania
in knowing that but few lay people believe the
colleges and laboratories of our state are run
upon anything but the most humane plans.
Scientific research does not need to be cruel to
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THE PENNSYLVANIA MEDICAL JOURNAL
December. 1920
animals in order to carry on the experiments for
the benefit and protection of the human family.
We may, however, be obliged to face the ever-
recurring demand by the antivivisection societies
at the coming session of the legislature, and we
hope that such a state-wide decision as that
which occurred in California should have made
sufficient impression upon these people as to
cause them to cease this activity.
'SOCRATES REDUX"
HOLIDAY GREETINGS!
They have a pretty custom in the South, a
survival of the old slave days, that on Christ-
mas day the negroes meet their white friends
with the greeting "Chrismus Gif " and the
greeting is invariably returned with a gift —
great or small — but always a gift of some sort.
So, on the threshold of this month of joy
and good will, the Editor is taking the oppor-
tunity to meet all his good friends of the pro-
fession with the greeting "Christmas Gift!"
feeling sure that now he will be rewarded with
the gifts for which he has been besieging the
good Santa Claus for many a day.
You ask, "What are these gifts?" Our best
answer to that is contained in this letter we have
just mailed to the good Saint :
"Dear Santa Claus: — I want news items — at least
one apiece — from every county society in the state; I
want county society reports from every society in the
state ; I want a contribution from each of the medical
colleges in the state at least four times a year; I
want a lot more advertising for the Journal ; I want
the members to read the advertisements in the Jowr-
NAL, and to patronize our advertisers, telling them, 'I
saw your advertisement in our Journal'; I want
worth while contributions from the men and women
of the profession, from the greatest to the least; I
wapt the members to take an interest in the construc-
tive legislative program of the Society and to realize
the value of the Society's work to them; I want the
interest and cooperation of every medical man and
woman in the state; I want the Journal to be of
service to them, and I want the Society to be of the
greatest possible service to the doctors and through
them to society.
And, Santa, if you can't carry so many presents in
your pack, please just send them by mail.
I hope you and all our readers will have a merry
Christmas, a happy New Year, and you a pleasant
trip from the North Pole.
Here's hoping I Yours,
The Editor.
P. S.— You will find me at 212 North Third Street,
narrisburg. Pa.
PECULIARITIES OF MEDICAL
JOURNALISM
"You know," said old Socrates, on a recent
visit to our editorial offices, "Medical Journal-
ism is a peculiar thing, unlike anything else in
journalism. It has no critical judgment at all.
Dr. John Doe writes a paper on some subject
about which he knows no more than any other
member of the great and learned profession,
reads it at the meeting of some society, and it is
sure to be published and may even be read."
We were entirely too busy to be bothered, so
said nothing, but he is not to be put .off without
a hearing, and it is one of his most pronoimced
peculiarities that he seems not to care particu-
larly whether he is listened to or not, he just
talks, and trusts to luck that what he says will
be heard by somebody and get out.
"I often wohder whether the editor of a med-
ical journal ever reads the manuscripts he re-
ceives. If he does, how does so much piffle ever
get by ? A doctor once told me that the medical
journals would publish anything that he would
write. Why? Because there are so many jour-
nals that there is not enough copy to go around.
I have even been told that some editors are put
to the extreme expedient of being compelled to
write to their friends and solicit contributions.
Of course when the good-natured friend re-
sponds with a manuscript that has no business
to go anywhere else than in the scrap-basket,
what can the poor fellow do except publish it?
He knows that it is quite unlikely that anybody
will read it, so what difference does it make any-
how? Most medical journals are not to read,
thfey are to put in piles on the office table to im-
press the patients. If a doctor wants to get an
idea of the immense difference between medical
and other journalism, let him write a story or a
travel sketch and send it to any current, popular
magazine, and then see how long he will have to
wait .until it comes back tojiim with one of those
little printed forms in which the editor thanks
him for the privilege of reading it, but also tells
him that it is not suited to the particular require-
ments of that magazine. He may be offended
or indignant, and think that he will make that
editor feel like thirty cents by at once sending it
off to some other magazine, but by the time that
he has made a dozen trials always with like re-
sults, he will wake up to the fact that he is no
longer dealing with the undiscriminating doctor
editor but with the real article who really reads
the stories sent to him, and who really knows
what his readers want and intends to see that
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DecEMBEK, 1920
CURRENT MEDICAL TOPICS
175
they get it. Why should not medical editors be
just as critical? Would it not be better to pub-
lish nothing than to publish that which is worth
nothing?
"As I look over medical journals I see them
overloaded with long tedious papers in which
there is not a single statement that has not been
better made before. One would often suppose
that the writer was under the impression that he
had actually discovered what was really known
before he was bom."
He rose to go, but fired one more shot.
"And why, in the name of the gods, cannot
one of your medical writers say the little that
he has to tell without taking pages and pages of
space to say it in ? It seems to me to be a kina
of slow torture that we have learned from the
Germans. Evolution is all right in its place but
why should a man who has observed that this or
that is true, begin the publication of the fact by
telling us what Aristotle thought about it, and
then come down through all the intermediate
ages to the present time, taking up some pages
of space — paper is precious now, — and waste
hours of the reader's time to tell him in the end
what might have been told in a half page which
would in the long run have been read by many
more readers than will ever have the courage to
read his long article, presuming that anybody
would read it anyhow ?"
CURRENT MEDICAL TOPICS
demonstrated that bread made from wheat flour
of current composition is inadequate as the only
source of protein in the diet. The government
workers have foimd, however, that bread made
with a mixture of 25 parts of peanut flour and
75 parts of wheat flour furnished adequate pro-
teins for normal growth of experimental ani-
mals. The proteins of the peanut bread were
utilized for gain almost twice as well as those
contained in wheat bread. This does not mean
that the familiar "staff of life" should be aban-.
doned or regularly diluted with peanut flour ; it
does, however, put a stamp of real nutritive merit
on a food product that many a physician still
thinks of solely in terms of a trouble maker for
digestion. — Jour. A. M. A., Aug. 28, 1920.
DIETARY JUSTICE TO THE PEANUT
The statistics of the peanut crop in the Unite^
States attest the growing popularity of the prod-
uct. For many years peanuts were eaten essen-
tially as "extra" foods, like candy and other
sweetmeats. Latterly, they have begun to claim
a more substantial place in the diet. Under the
appealing designation of peanut "butter," the
ground peanuts are finding widespread use as a
palatable, wholesome food. Peanut oil is now
expressed in large quantities from shelled pea-
nuts, and has received commendation. From the
resulting press cake, peanut flour has been pre-
pared by grinding. Peanuts are unusual in con-
taining a considerable proportion of protein
along with both fat and carbohydrate. Water-
soluble vitamin is also not lacking. Experts in
the Office of Home Economics at the U. S. De-
partment of Agriculture' have shown that the
nutrients of peanuts are easily digested by man.
Johns and Finks* of the same department have
given an added worth to the food by demonstrat-
ing convincingly the high physiologic value of
the peanut protein. Various investigators have
1. Holmes, A. D.: Bull. 717, U. S. Dept. Agric, 1918.
2. Johns, C. O., and Finks, A. J.: Studies in Nutrition. IV,
The Nutritive Value of Peanut Flour as a Supplement to Wheat
Flour, J. Biol. Chem. 42: 569 (July) 1930.
MORE TRUTH ABOUT SACCHARIN
The proponents of the use of saccharin as a
substitute for sugar have doubtless detected in a
recent publication' an unusual opportunity to
promote their efforts in the defense of the chem-
ical. The assertion was there made that the in-
gestion of saccharin, as shown by animal experi-
ments, produces a large increase in the content
of catalase in the blood. Since the function of
facilitating oxidations in the body has repeatedly
been attributed by the same investigator to this
enzyme, it is a ready inference that saccharin has
a beneficial action on the body. This has been
particularly emphasized for the diabetic. It has
been pointed out repeatedly, however, that the
alleged function of catalase in the body remains
both improbable and unproved. Despite the
enormous doses of saccharin used, Stehle* of the
University of Pennsylvania was unable to dupli-
cate the effects claimed ; and now Becht* of the
Northwestern University Medical School has
likewise contributed the results of elaborate se-
ries of investigations which serve to remove the
illusion about saccharin that may have crept
abroad. Saccharin is neither a food nor a potent
drug. Its usefulness in dietotherapy is limited
to the function of taste ; to increase its use aside
from this restricted scope would be a misfortune
as, indeed, it often is a fraud. — Jour. A. M. A.,
Noy, 13, 1920.
I. Burge, W. E.: Science 47:549, I9J8-
3. Stehle, R. L. : Some Data Concerning the Alleged Rela-
tion of Catalase to Animal Oxidations, J. Biol. Chem. 39: 403
(Sept.) 1919.
3. Becht, F. C: The Influence of Saccharin on the Catalases
of the Blood, J. Pharmacol. & Exper. Therap. 16: 15s (Oct.)
1920.
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The Medical Society of the State of Pennsylvania
OFFICERS' DEPARTMENT
WALTER F. DONALDSON, M.D.
Secretary
8014 Jenkins Arcade Bldg., Pittsburgh, Pa.
CHANGES IN MEMBERSHIP OF COUNTY
SOCIETIES
The following changes have been reported to No-
vember 22:
Allegheny: New Members— ^ressXty M. Lloyd,
6322 Station St., Grover C. Todd, 5851 Northumber-
land St., Pittsburgh; John S. Carson, Jackson St.,
Bellevue; H. R. Weddell, 219 Sixth Ave., McKeSs-
port. Reinstated New Members — Benjamin Kuntz,
Vickroy St., Wilmer D. Abrams, Allegheny General
Hospital, Herbert H. Sullivan, 1004 Homewood Ave.,
Harvey Trotsky, 1615 Fifth Ave., Pittsburgh; Charles
K. Murray, 501 Rosswood Bldg., Wilkinsburg. Trans-
fer—SxAncy G. White, of Warsaw, Indiana, to Kos-
kuisko County Medical Society, Indiana. Removal—
Carl J. Scheflfer from Pittsburgh to Knox Dale (Jeff.
Co.) ; James M. Barr from Pittsburgh to Valencia
(Butler Co.).
Beaver: New Member (Reinstated)— John M.
Jackson, Beaver Falls.
Bradford : New Memtcr— Arthur J. Bird. New Al-
bany. Removal — Howard C. Down from Wysox to
Tow^nda.
Butler: Tronj/^r— Clarence H. Ketterer, 3603
Fifth Ave., Pittsburgh, to Allegheny County Society.
Center: Removal— i^mts R. Bartlett from Pleas-
ant Gap to Bellefonte.
Clearpield: Transfer—lsAic Stalberg, of Board-
man, from Clinton County. Removal— WiWam G.
Falcomer from Woodland to Olanta, R. D.
Dauphin: New Members—]. W. Horn, Jr., Hum-
melstown; Josiah F. Reed, Harrisbiirg; E. B. Sayo,
Penna. State Hospital, Harrisburg. Reinstated New
il/fwifrfr— Maurice O. Putt, Oberlin.
Elk: New Member— EAyiiT A A. Mansuy, Drift-
wood (Cameron Co.). i?ca<A— William R. Palmer
(Univ. of Buffalo '87), of Johnsonburg, recently, aged
59-
Lawrence: New Member— P. Earl Eakin, New
Castle.
Lebanon: £>ca<A— Warren F. Klein (Jeff. Med.
Coll. '87), of Lebanon, September 27th, aged 59.
McKean: Removal — Lawrence W. Dolan from
Kane to 1130 E. Sixth St., Erie (Erie Co.).
Mercer: New Members — Nelson J. Bailey, James-
town; Joseph A. Doyle, Greenville; Dan Phythyon,
Hamory Bldg., Sharon.
Montgomery: New Members — Walter L. Anders,
Robert R. Janjigian, State Hospital, Norristown;
Ronald C. Moore, Schwenksville. Deaths — Samuel B.
Horning (Jeff. Med. Coll. '84) in Norristown, Octo-
ber 21, from cardiovascular disease, aged 57; George
S. Gerhard (Univ. of Penn. '70) at Bryn Mawr, Oc-
tober 26, aged 71. Transfer — John G. Wilsdn, of
Norristown, from Susquehanna County Society.
Northampton: New Member — Clarence E. Deck,
South Bethlehem. Removal — Rolla H. Hoey from
Easton to 1913 Tenth St., McKeesport (Allegheny
Co.).
Northumberland: Death — William W. Moody
(Penna. Med. Coll. '61), of Sunbury, October 15, aged
86.
Philadelphia : D^afAx— Ferdinand T. Stires (Univ.
of Penna. '08), of Philadelphia, September 28, aged
38; Percy H. Ealer (Hahnemann Med. Coll. '90), of
Philadelphia, October 17, aged 42; William H. Lip-
pert, of Philadelphia, recently. Removals — P. Norbert
Bergeron from Philadelphia to R. F. D. 2, Pelham, N.
H. ; Charles S. Pancoast from Philadelphia to Ferry-
man, Md. ; Charles P. Noble from Radnor (Del. Co.)
to 1832 Spruce St., Philadelphia.
Warren: New Member — G. E. Dutter, Ludlow.
Reinstated New Member — B. F. Brewster, Tidioute.
Z?fa<A— George Siggins (Jeff. Med. Coll. '05), of
Tidioute, recently, aged 39.
Washington : New Members — Robert A.
104 W. Wheeling St., Washing^ton; John S.
Bentleyville.
York : New Member — Arthur A. Bobb, Spring
Grove.
Knox,
Hook,
PAYMENT OF PER CAPITA ASSESSMENT
The following payment of per capita assessment has
been received since October 23d. Fgures in first col-
umn indicate county society numbers ; second column,
state society numbers :
For 1920—
Nov. I Northampton
133
7099
$5.00
10 Beaver
59
7100
5.00
Warren
50
7101
5.00
15 Dauphin
147
7102
5.00
For 1921—
Nov. 10 York
I
I
5.00
IS -Mlegheny
1-9
2-10
4500
Bradford
I-IO
11-20
50.00
Dauphin
1-3
21-23
1500
Lawrence
2
24
5.00
Elk
I
25
5.00
16 Montgomery
1-3
26-28
15.00
Mercer
1-3
29-31
15.00
19 Washington
1-2
32-33
10.00
LIMITATIONS VS. LAMENTATIONS
Limitations of human endeavor are elastic
and may be productive of results approaching
the divine ; while lamentations are fixed at a
low point in the .scale of service, and are barren
of results. Shall we of the organized medical
profession merely lament that our cherished
ideals for the protection of the health of the
public are again to be attacked by the apostles
of ignorance and greed; or shall we continue
to the utmost limit our efforts in the defense of
progressive medicine?
Every physician should kindle or rekindle his
altar flame of service to his fellowmen. He
should unite with the medical society of his
choice. He should contribute financially to the
Digitized by VjOOQIC
December, 1920
OFFICERS' DEPARTMENT
177
funds of the Medical Legislative Conference;
and he should constantly defend existing med-
ical practice, acts. He should be an educational
means toward a higher appreciation by the laity
of the necessity for laboratory research, and the
use of animal experimentation in the preven-
tion or cure of disease. .He should be a potent
influence on the lawmaking representative from
his own district, bearing in mind always that
legislators are swayed most by opinions and re-
quests that come direct from their own con-
stituents. New legislation affecting physicians
and their patients is becoming more and more a
personal and urgent problem, and less and less
an abstract and unimportant problem.
MEDICAL DEFENSE
History repeats itself, and since the Pitts-
burgh meeting another Pennsylvania physician
is the recipient of a nonsuit victory in a court
action for alleged malpractice. Skilled attor-
neys retained and generously remunerated by
the Medical Society of the State of Pennsyl-
vania gave their best service to this wise phy-
sician, because among other qualifications for
good standing in the above mentioned society,
he included early payment of county society
dues; and because when notified of suit, he
promptly and properly applied to his society
officers for defense.
NINETEEN TWENTY-ONE DUES
Since the first week in November the secre-
tary of each component county medical society
has been equipped to give official triplicate re-
ceipts for 1 92 1 dues. To date (November 22)
thirty-three receipts with the accompanying
$5.00 State per capita tax have been received at
this office. In most instances the receipts were
issued to new members joining November ist,
and taking advantage of the last opportunity at
the bargain rate of fourteen months' member*
ship for the price of twelve. We trust that the
flow of remittances through the county society
secretaries will be rapid and uninterrupted, and
that March 31, 1921, will find 7,102 old mem-
bers and 300 new members with their 1921 dues
paid and no question possible against their qual-
ification for all the State Society benefits, in-
cluding medical defense.
Appoint yourself a committee of one to see
that your own dues are paid on or before the
day they are due (January i, 1921). Surprise
your county society secretary. Make light his
financial duties that he may lavish additional
time and energy on other phases of his service
to your society ; and by the same token — early
remittance — ^you may be a member of the first
component society to enroll 100 per cent, of
members paid.
FREDERICK L. VAN SICKLE. M.D.
Executive Secretary.
Harrisburg, Pa.
WHAT IS THE VALUE OF THE TITLE M.D.?
During the past few years, a changed condi-
tion has ensued in many things, especially as in-
fluenced by the World War, among the changes
which have taken place being the introduction
of titles, or rather the increased number of
titles that have been placed before and after
men's names.
W^e stop to observe that the title M.D., which
is one of the oldest titles conferred, has appar-
ently been influenced as to its value by numer-
ous other titles and degrees which men assume,
or have had conferred upon them.
What then is the value of this title, and
should we, as a medical fraternity, endeavor to
conserve its value? We ask this question be-
cause legislators are very prone to confer, by
legislative enactment, the very thing which the
title M.D. stands for in the practice of medicine.
When we look back in the history of medi-
cine, we find men sacrificing their lives in the
eflfort to obtain the necessary knowledge, in-
formation and experience in order to practice-
the healng art and in order to have conferred
upon them for meritorious endeavor the title of
doctor of medicine.
We believe that the medical profession of to-
day should look with more reverence upon this
title, as past history has given it a real meaning
and a real value. This valuie can very readily
be made worthless to a great degree if we are
so careless of its value as not to preserve the
landmarks from which it originated, by which
it is perpetuated, and carefully guard the door
through which might come a changed relation-
ship between the doctor of medicine and those
who pretend that which they have not, but are
given privileges granted under the law.
We think that the value of the title is too little v
considered by every one of us, and that, having
had it conferred upon us, we consider it only as
a means to an end.
We would gladly welcome the time when the
members of our profession shall appreciate the
privileges which the present decade have given
when compared to the hardships endured by
our predecessors in the field of medicine. - j
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178
THE PENNSYLVANIA MEDICAL JOURNAL December, 1920
CONSERVATION OF ENERGY
In casting about for a text, we have had pre-
sented, a suggestion by one of our members that
seems to appeal to us as really worth while.
This suggestion is the desire to warn doctors as
to the wear and tear in pursuit of the general
practice of medicine. The suggestion for con-
sideration by the average practitioner is self-
conservation.
We have knowledge of many of our con-
ferees, in times past, to have gone to their re-
ward much too soon for themselves and the
benefit of those of the community whom they
served. Many of these men were rash, im-
petuous individuals, who brooked not the warn-
ing of their advising friends but used up their
energy, burning the candle at both ends, and
dying at an early age. This could have been
otherwise, had these men conserved their phy-
sical energy by applying system in their daily
work.
We are now approaching the eeason of the
year when the greatest hardships ensue, espe-
cially in the general practice and in rural life.
Our friend has also forwarded us a card,
which reads as follows :
"please remember next time
"Doctors, like their patients, need
time for meals, for rest, for play, for
sleep. Doctors also need time for
making house calls.
"Dr. 's hours, to see office pa-
tients, are from to and from
to . He will appreciate it if
patients will call early enough so that
he can leave at the hour last named.
"Please try to avoid Sunday and
holiday office calls as much as possible.
Consult your doctor on business days
at office hours."
The suggestions contained in this card are
extremely good. They offer to the patrons of
the physician a suggestion which should be im-
pressed upon the minds of those who seek the
services of the over-tired, over-worked, and
frequently underpaid doctor. Much of this loss
of sleep, irregularity of meals and duplication
of territory covered could be prevented were
the people to be more considerate of the doc-
tor's hours, become familiar with his office and
visiting hours, and send calls earlier when they
can.
Conservation of physical energy is absolutely
necessary if the human machine may keep up
with the demands of the present everyday prac-
titioner's life. Systematizing work is not al-
ways so easy as some would lead us to believe,
and yet when we see other business brought into
a system, when we see the various lines of in-
dustry whipped into the proper shape for con-
servation of energy, both physical and mental,
we know that there is something lacking in the
system under which the practice of medicine is
operated.
We are very frequently the slaves to a pro-
fession, when we should be masters of the sit-
uation, not only conserving our own energy,
but teaching the public, system where previously
we have usually taught them lack of system.
HEALTH EDUCATION FOR CHILDREN
The attention of the average child grows list;
less if he is compelled to sit very long and listen
to a talk about the advantages of oatmeal and
spinach, of incraesed weight, of tooth-brushing,
baths or any other steps in personal hygiene. It
has therefore been a difficult pedagogic problem
to develop methods for child health education.
However, through a body — the Child Health
Organization — headed by an executive commit-
tee containing such distinguished names as Holt,
Pisek, Sachs, Winslow, Heiser, Mrs. Frederick
Peterson and Hon. Fnuiklin K. Lane, these
problems are being studied and remarkably ef-
fective methods of propaganda developed.
Among the chief features are Cho-Cho, a health
clown — named in honor of the organization ; the
picture man — a. health cartoonist, and the health
fairy. The services of these specialists are avail-
able for teaching the child the essential rules of
the health game. Cho-Cho, because he is a clown,
has the undivided attention of every child. He
teaches the simple facts of health and hygiene
while for forty minutes in an atmosphere of
jollity and happiness he demonstrates the right
way to eat, bathe, sleep and brush the teeth. The
picture man is a cartoonist who, by rapid <lraw-
ings in colored chalks, illustrates the simple rules
of health. The health fairy, in a gown of chiffon
with silver wings, tells the smaller children the
elementary rules which the organization believes
every child should know. The organization also
issues a series of booklets of special interest to
children, such as "Cho-Cho and the Health
Fairy," "The Child's Health Alphabet," cards
and pictures which must by their artistic char-
acter fascinate and interest every child. There
are many physicians unfamiliar with this work
who will, no doubt, welcome an opportunity to
•avail themselves of this service.* — Jour. A. M.
A., Sept. 4, 1920.
Child Health Organization, i;6 Pitth Avenue. Me^ ¥<
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OFFICIAL TRANSACTIONS
The Medical Society of the State of Pennsylvania
Organized 1848
Incorporated, December 20, 1890
MINUTES OF THE SECTION ON SURGERY
Tuesday, October s, 1920
The chairman, T. Turner Thomas, Philadelphia,
called the meeting to order at 2 p. m., giving the title
of his address as "The Relationship of Anatomy to
Surgery" and stating that he would not read it, but
the members could find it in the Journal of the Med-
ical Society of the State of Pennsylvania.
Dr. Robert M. Entwisle, Pittsburgh, read a paper
entitled "Rectal Drainage for Pelvic Abscess."
Dr. Arthur E. Crow, Uniontown, read a paper en-
titled "Abdominal Drainage."
Dr. Richard J. Behan, Pittsburgh, read a paper en-
titled "The Diagnosis of Chronic Appendicitis; Its
Relation to an Enlarged Cecum."
Dr. Emory G. Alexander and Walter B. McKinney,
Philadelphia, presented a paper entitled "Appendicitis
in Children, with a Report of Five Hundred Cases,"
which was read by Dr. Alexander.
These four papers were jointly discussed by Drs.
Silas D. Molyneux, Bloosburg; Charles A. Fife, Phila-
delphia; W. L. Estes, South Bethlehem; F. Hurst
Maier, Philadelphia; J. DeV. Singley, Pittsburgh;
Drs. Crow and Alexander closing.
Dr. Levi J. Hammond, Philadelphia, read a paper
entitled "Concerning Acute Traumatic Surgery of the
Abdomen." Discussed by Drs. John O. Wyncote;
Samuel D. Shull, Chambersburg ; W. L. Estes, South
Bethlehem; Hugh E. McGuire, Pittsburgh: John P.
Griffith. Pittsburgh; George W. Reese, Shamokin;
Richard J. Behan, Pittsburgh ; Dr. Hammond closing.
Dr. William L. Estes. Jr., South Bethlehem, read a
paper entitled "Early Diagnosis of Perforated Gastric
and Duodenal Ulcer."
Dr. Harold L. Foss, Danville, read a paper entitled
"Technic of Gastro-Enterostomy."
These two papers were discussed jointly by Drs.
Charles H. Frazier, Philadelphia; Robert T. Miller,
Pittsburgh; Donald Guthrie, Sayre; J. Stewart Rod-
man, Philadelphia ; W. Wayne Babcock, Philadelphia ;
Moses Behrend, Philadelphia; William E. Lower,
Cleveland, O. ; Emory G. Alexander, Philadelphia;
Dr. Estes, Jr., and Dr. Foss closing.
Adjourned.
Wednesday, October 6, 1920
The chairman. Dr. T. Turner Thomas, Philadelphia,
called the meeting to order at 2 p. m.
The following officers for the Section were elected :
Chairman, Dr. Ellwood R. Kirby, Philadelphia; sec-
retary. Dr. William L. Estes, Jr., South Bethlehem.
Dr. H. Ryerson Decker, Pittsbxirgh, read a paper
entitled "Postoperative Complications and Sequelae of
the Respiratory Tract."
Dr. Lever F. Stewart, Clearfield, read a paper en-
titled "The Problems of Modern Chest Surgery as met
by Physiological Drainage." These two papers were
discussed jointly by Drs. Frederick B. Utley, Pitts-
burgh; J. Ralston Wells, Philadelphia; Drs. Decker
and Stewart.
Dr. Walter E. Sistrimk, Minn., read a paper en-
titled "Carcinoma of the Breast, with a Study at the
Results Obtained in 218 Cases." Discussed by Drs.
Moses Behrend, Philadelphia ; Donald Guthrie, Sayre ;
Dr. Sistrunk closing.
Dr. John B. Roberts, Philadelphia, read a paper en-
titled "Treatment of Complicated Cleft Palate."
Dr. Robert H. Ivy, Philadelphia, read a paper en-
titled "War Surgery of the Face and Jaws as Applied
to Injuries in Civil Life."
The above two papers were discussed jointly by Drs.
A. Ralston Matheny, Pittsburgh ; M.. Behrend, Phila-
delphia ; Dr. Roberts closing.
Dr. Daniel A. Webb, Scranton, read a paper entitled
"Compound Fracture of Femur." Discussed by Drs.
William L. Estes, South Bethlehem; John H. Gal-
braith, Altoona; John B. Lowman, Johnstown; J.
DeV. Singley, Pittsburgh ; Dr. Webb closing.
Dr. Marvin W. Reed, Bellefonte, read a paper en-
titled "Bone Necrosis with Special Reference to Tu-
bercular Lesion." Discussed by Drs. Alexander Arm-
strong, White Haven ; Dr. Reed closing.
Adjourned.
Thotisday, October 7, 1920
The chairman. Dr. T. Turner Thomas, called the
meeting to order at 9 : 20 su m.
Dr. Damon B. PfeifTer, Philadelphia, read a paper
entitled "The Diagnosis and Treatment of Carcinoma
of the Rectum." Discussed by Dr. J. Elmer Porter,
Pottstown ; Dr. Pfeiffer closing.
Dr. Evan W. Meredith, Pittsburgh, read a paper en-
titled "Spontaneous Rupture of the Gallbladder."
Dr. Moses Behrend, Philadelphia, read a paper en-
titled "Repair and Anastomosis of the Bile Passages
for the Relief of Chronic Jaundice." Discussed joint-
Iv by Drs. John J. Gilbride, Philadelphia; A. R.
Matheny, Pittsburgh ; Dr. Behrend closing.
In the absence of the author of a paper on "A Brief
of One Thousand Hysterectomies" by Dr. Harry J.
Donaldson, Willi^msport, was read by title.
Dr. F. Hurst Maier, Philadelphia, read a paper on
"The Value of Subtotal Hysterectomy in the Treat-
ment of Fibromyomata of the Uterus.'' Discussed by
Drs. Herbert B. Gibby, Wilkes-Barre ; Edward A.
Weiss, Pittsburgh ; E. A. Schumann, Philadelphia.
Dr. Edward A. Schumann, Philadelphia, read a paper
entitled "The Practical Aspects of Antenatal Hy-
giene."
Dr. Edmund B. Piper, Philadelphia, read a paper
entitled "Some Practical Aspects of the Case of .a
Parturient Woman and Her Child."
Dr. William H. Glynn, Pittsburgh, read a paper on
"Factors in Fetal Mortality."
The discussion on the preceding three papers was
opened by Drs. H. C. Winslow, Meadville ; Paul Titus,
Pittsburgh ; Drs. Piper and Glynn closing.
Dr. Sidney A. Chalfant, Pittsburgh, read a paper on
"Ovarian Pregnancy. Report of a Case with a Six
Months' Dead Fetus." This paper was not discussed.
Adjoumfd.
Note. — The minutes of the Section on Surgery were
unavoidably omitted in the November Journal. —
RESOLUTIONS ADOPTED BY THE HOUSE OF
DELEGATES IN ANNUAL SESSION IN
PITTSBURGH, OCTOBER, 1920
Tuberculosis Hospital
Whereas, There exists a lack of provision for the
care and treatment of advanced cases of tuberculosis
in Pennsylvania, and
Whereas, These sufferers are a distinct menace to
the other members of their own families and the pub-
lic ; therefore, be it
Digitized by
Cjoogle
180
THE PENNSYLVANIA MEDICAL JOURNAL
December, 1920
Resolved, That this association endorses the plain .of
erecting a hospital for each county or group of coun-
ties for the care of indigent persons suffering from
advanced tuberculosis.
Restoration of Pennsylvania's Timber Production
Whereas, Abundance of pure water is an absolute
necessity for public health, and
Whereas, Our timberless, unproductive, abandoned
highlands of the state are a nursery of floods which
transport germs of disease through the breadth of the
commonwealth ; and by such floods disturb .the even
flow of water Which is so necessary for a production
of water power ; and
Whereas, There are in Pennsylvania to-day five mil-
lion acres of such timberless areas which are a menace
to individual health and to public prosperity, which
land once produced a crop of timber of immense value
to the state, and which, under state control, can be
restored to a productive condition ; theref pre, be it
Resolved, The Medical Society of the State of Penn-
sylvania cordially approves of the wish of His Excel-
lency, the Honorable William C. Sproul, Governor of
the Commonwealth, that these acres be taken under
control of the Pennsylvania Forest Commission by
purchase, that further impoverishment of the soil be
stayed ; that the water power of the state be increased
to supplement the growing demand for coal which, as
the supply becomes more limited, {he price becomes
higher, and the needs of our population grow greater.
Resolved, In order that this beneficient purpose be
made possible, the Medical Society of the State of
Pennsylvania earnestly urge upon the incoming legis-
lature that sufficient fimds be appropriated for the pur-
chase, by the state, of the said land, and their protec-
tion against destructive forest Ares. Under State
Forest control, streams heading in our mountain
ranges and highest ridges would insure an abundant
supply of pure water to a large portion of our popula-
tion.
sauce for the goose is soup for the gander," or words
to that effect— yo«r. A. M. A., Nov. 6, 1920.
AN OPPORTUNITY FOR RETURN TO A
HISTORICAL SOURCE
"In the thirteenth century," says Garrison,, "the Col-
lege de Saint Come was organized at Paris, constitut-
ing a guild the members of which were divided into
the clerical barber-surgeons or surgeons of the long
robe, and in 131 1, 1352 and 1364, royal decrees were
robe, and in 131 1, 1352 and 1634, royal decrees were
issued forbidding the latter to practice surgery with-
out being duly examined by the former. In 1372,
Charles V decreed that the barbers should be allowed
to treat wounds and not be interfered wfth by their
long-robed confreres."
Now it is announced that in 1921 the barbers of
Chicago will charge one dollar for a haircut and from
thirty-five to fifty cents for a shave. This should
make their net incomes average well beyond the in-
come of the average physician. Why should not phy-
sicians and surgeons take up this delicate art? If the
barbers were surgeons, let the surgeons be barbers.
They might call the process "keratinectomy" or "hairo-
stomy" or "pilectomy," the latter term possibly con-
fusing the followers of "orificial surgery." As the
proverb sayeth: "Turn about is fair play"; "What's
AMERICAN MEDICAL DIRECTORY
In the advertising pages this week is an announce-
ment concerning the American Medical Directory.
We emphasize the announcement here because of its
importance. The securing and compiling of the infor-
mation have been attended with extreme difficulties;
not only has the number of removals and changes on
the part of physicians been unusually large within the
last two years, but also the labor situation has not been
all that could be desired. All of this makes not only
for delay, but also for increased expense in produc-
tion. One of the big expenses yet to be met is that of
paper — and here is the real reason for the announce-
ment and for this editorial comment. In the past we
have been liberal in printing a large number of books
that might be called for later on; it is proposed this
year to print only a sufficient number to supply those
who order in advance and, on a carefully conservative
estimate, the probable demand until the next biennial
issue. Therefore all who desire the 1920 Directory
should subscribe before November i. Thus they can
be sure not only of securing a copy but also of the pre-
publication discount. — Jour. A. M. A., Oct. 9, 1920,
INCREASE IN ANNUAL DUES
The report of a special meeting of the House of
Delegates of the American Medical Association called
to act on a proposition submitted by the Board of
Trustees increased the annual fellowship dues. The
House of Delegates modified the by-laws, increasing
these dues from $5.00 to $6.00, the new arrangement
to be effective for 1921. As explained in the minutes
of the meeting of the House of Delegates, this in-
crease is made necessary by the greatly increased cost
of material and labor in the printing trade. Consid-
ering merely the amount of material contained in The
Journal each week, even at the new rate. The Journal
is lower in price by far than any other scientific peri-
odical, medical or otherwise, in the world. The in-
crease is 20 per cent. — very small as compared with
the increase in the subscription prices of other peri-
odicals, especially those published by scientific organi-
zations. The British Medical Association recently has
increased its annual dues, which means subscription to
the British Medical Journal, from $10.50 to $15.75.
It may be well to recall that the income from The
Journal supports the Association's activities in the in-
terest of the medical profession and the public: for
instance, the work of the Council on Pharmacy and
Chemistry, of the Chemical Laboratory, of the Council
on Medical Education and Hospitals, of the Council
on health and Public Instruction, and of the Bio-
graphical and Propaganda departments. Thus, when a
physician pays $6.00 he is not only paying for The
Journal, but also for the above enumerated enterprises
and other activities in behalf of the medical profession
and the public.
Digitized by
Uoogle
County Medical Societies
REPORTERS OF COUNTY SOCIETIES:
Adams — Hennr Stewart, M.D., Gettysburg.
ALLECHENr — Paul Titus, M.D., Pittsburgh.
ASMSTKONC — Jar B. F. Wyant, M.D., Kittanning.
Beaver— Fred B. Wilson, M.D., Beaver.
Bedford — N. A. Timmins, M.D., Bedford.
Berks — Clara Slietter-Keiser, M.D., Reading.
Blair — James S. Taylor, M.D., Altoona.
Bradford — C. L. Stevens, M.D.. Athens.
Bucks — Anthony F. Myers, M.D.," Blooming Glen.
Butler — L. Leo Doane. M.D.. Butler.
Cambria — Frank G. Scharmann, M.D., Johnstown.
Carbon — Jacob A. Trexler, M.D., Lehighton.
Center — James h- Seibert, M.D., Bellcfonte.
Chester — Henry Pleasants, Jr., M.D., West Chester,
Clarion — Sylvester J. Lackey, M.D., Clarion.
Clearfield — J. Hayes Woolridge, M.D., Clearfield.
Clinton — R. B. Watson, M.D., Lock Haven.
Columbia — Luther B. Kline. M.D., Catawissa.
Crawford — Cornelius C. Laffer. M.D., Meadville.
Cumberland — Calvin R. Rickenbaugh, M.D., Carlisle.
Dauphin — Marion W. Emrich, M.D., Harrisburg.
Delaware — George B. Sickel, M.D., Chester.
Ei.K — Samuel G. Logan, M.D., Ridgway.
Erie — J. Burkett Howe. M.D., Erie.
Favette — George H. Hess, M.D.. Uniontown.
Pramklin — John J. Coffman, M.D.. Scotland. .
Greene— Thomas B. Hill. M.D., Waynesburg.
Huntimcdoh — John M. Beck, M.D., Alexandria.
Indiana — Alexander H. Stewart^ M.D., Indiana.
Jefferson — John H. Murray, M.D., Punxsutawney.
Juniata — Isaac G. Headings, M.D., McAlisterville.
Lackawanna — Harry W. Albertson, M.D., Scranton.
Lancastik — Walter D. Blankenship, M.D., Lancaster.
Lawrence — William A. Womcr, M.D., New Castle.
Lebanon — Samuel P. Heilman, M.D., Lebanon.
LRHini — Martin S. Kleckner, M.D.. Allentown.
Luzerne — Peter P. Mayock, M.D., WilkesBarre.
I.vcoMiNC. — Wesley F. Kunkle. M.D., Williamsport.
McKean — James Johnston, M.D,, Bradford.
Mercer — M. Edith MacBride, M.D., Sharon.
MlPFLiN — Frederick A. Rupp, M.D., Lewistown.
Monroe — Charles S. Logan.- M.D.. Stroudsburg.
MoNTroMERY — Benjamin F. Hubley. M.D.. Norristown.
Montour — Cameron Shultz, M.D., Danville.
Northampton — W. Gilbert Tillman, M.D., Easton.
Northumberland — Charles H. Swenk, M.D., Sunbury.
l^ERRV — Maurice I. Stein, M.D., New Bloomfield.
Philadelphia — Samuel McClary, 3d. M.D., Philadelphia.
Potter — Robert B. Knight, M.D., Coudersport.
Schuylkill — George O. O. Santee, M.D., Cressona.
Snyder — Percy E. Whiflfen, M.D.. McClure.
Somerset — H. Clay McKinley, M.D., Meyersdale.
Sullivan— Carl M. Bradford, M.D., Forksville.
Susquehanna — H. D. Washburn. M.D., Susquehanna.
TlocA— Lloyd G. Cole. M.D., Blossburg.
Union — William E. Metzgar, M.D., Allenwood, R. D. 2.
Venanco — John F. Davis. M.D., Oil City.
Warren— M. V. Ball, M.D., Warren.
Washington — Homer P. Prowirt, M.D., Washington.
WaynS — Sarah Allen Bang, M.D., South Canaan.
Westmoreland— Wilder J. Walker, M.D^ Greensburg.
Wyoming — Herbert L. McKown, M.D., Tunkhannock.
York— Nathan C. Wallace, M.D., Dover.
December, 1920.
COUNTY SOCIETY REPORTS
BRADFORD— OCTOBER
The Bradford County Medical Society met in the
Green Free Library, Canton, October i8th, with
twenty-one members and fourteen visitors present.
Communications were read as follows: From the
liureau of Drug Control, State Department of Health,
calling attention to the instructions of the commis-
sioner of health regarding the Pennsylvania Antinar-
cotic Law and the privileges and responsibilities
connected therewith. From the Publicity Department
of the State Department of Health, offering the free
use of films suitable for public instruction in regard to
venereal diseases. From State Secretary Donaldson,
transmitting with comments copy of a letter sent by
the American Antivivisection Society to candidates for
the state legislature. From Editor Van Sickle, urging
the members to read the advertisements in the Penn-
sylvania Mebical Journal and whenever possible to
patronize the advertisers.
Dr. Henry D. Jump, Philadelphia, president of the
Medical Society of the State of Pennsylvania, was in-
troduced and favored the society with an interesting
and practical talk on "Medical Economics." He called
attention to the fact that this was his first official visit
as president of the state society and said that he would
rather be stricken dumb than have anything he might
say construed as furnishing an excuse for lessening
the spirit of altruism among physicians or for a dis-
continuing of the honorable traditions of the profes-
sion. He thought, however, that the physician while
considering the relief of his patient as the first con-
sideration should also bear in mind how he might
properly increase his income inasmuch as the average
physician has never been adequately recompensed for
his services. The better the fees received the better
the services which can be rendered. We should have
the courage to charge a fair fee and not overlook ad- .
ditional charges for examination of urine and blood,
for medicines and other incidentals. When a patient
requests him to be present at an operation he always
replies that he would be glad to be present in a pro-
fessional capacity and then he charges for attendance.
He emphasized the fact that the making of a prompt
and accurate diagnosis of a condition requiring an
operation is worthy of a fee commensurate with that
of the surgeon. If an operation is necessary the
sooner it is performed, in most cases, the less loss of
time there will be and the less expense for operation
and for hospital charges.
The general discussion following Dr. Jump's address
emphasized the importance of fair fees, business
methods, medical. organization, accurate bookkeeping,
prompt collections, education of the laity, and safe in-
vestments.
Dr. P. N. Barker, Troy, read a concise paper on
"Hemorrhage from Duodenal Ulcer." Diagnosis can
be made usually from pain, tenderness and melena, or
even from the tarry stools alone when pain is absent.
History of increasing anemia, pain, pallor and hunger
pains are important. Hematemesis may occur and the
hemorrhage may be so free as to be fatal. It is not
always possible to differentiate duodenal from gastric
ulcer, and the two may coexist. Hemorrhage from
duodenal ulcer is more serious than from gastric ulcer.
Treatment for acute hemorrhage, either gastric or
duodenal, includes the use of the ice bag and morphia
hypodermically; for collapse, normal saline enema or
hypodermoclysis. Duodenal ulcer is a case for the
surgeon.
Dr.' Carlyle N. Haines, Sayre, read a paper on "The
Significance of Pus in the Urine," which will appear
later in the Journal. In discussing the paper Dr. S..
D. Molyneux, Blossburg, saic|-,|^at every patient with[^
182
THE PENNSYLVANIA MEDICAL JOURNAL
December, 1920
pus in the urine should be examined with the cysto-
scope and roentgen ray. He also emphasized the point
made by the reader that many cases of cystitis are
due to lack of cleanliness in the previous use of the
catheter. Dr. Guthrie, Sayre, said that many cases of
tuberculosis of the kidney would be overlooked unless
urine is examined for pus. Dr. Jump called attention
to the fact that if the urine is centrifugalized for a
length of time the tubercular bacilli will be more
readily found. Dr. Lundblad, Sayre, thought that in
every case of "chronic appendicitis" the urine should
be examined microscopically.
A vote of thanks was extended to Dr. Jump and to
the physicians from Lycoming and Tioga Counties
who had added so much to the interest of the meeting.
C. L. Stevens, Reporter.
BUCKS— NOVEMBER
The Bucks County \fedical Society held its sevetity-
second annual meeting at Doylestown, November loth.
Forty-six physicians attended and the spirit of the oc-
casion was excellent. The society— a rural one — ^has
a membership of 84 in good standing and a credit bal-
ance in the treasury.
The following were elected to office : Pres., Dr.
Frank Lehman, Bristol ; vice-pres.. Dr. John J.
Sweeney, Doylestown, and Dr. Herman C. Grim,
Trumbauersville ; sec.-treas., Dr. Anthony F. Myers,
Blooming Glen.
Herbert L. Northrop, M.D., Professor of .Surgery,
Hahneman Medical College, delivered the annual ad-
dress on "Appendicitis." The lecturer defined the sub-
ject and detailed the anatomy of the parts, gave the
etiology and described the various symtoms: he out-
lined the diagnosis very well and his description of the
differential diagnosis was particularly good. Dr.
Northrop is a splendid lecturer, his diction is fine, and
he possesses the happy faculty of holding his hearers
in an attractive manner.
District Councilor and Trustee, Henry W. Albertson,
M.D.. Scranton, addressed the society upon the ex-
igencies of the day, in the profession.
The society discussed the prevalence of tuberculosis
among the youth and children which is yet in the cura-
ble stage. The society went upon record urging that
the state provide regional or inter -county hospitals for
the care of this particular class of incipient tubercular
cases. Institutions of the sort specified are very much
needed to effectually carry on the fight against the dis-
ease and the cure of those cases still in the incipient
stage.
The following preamble and resolution was pre-
sented and unanimously adopted : The trend of public
opinion is toward voluntary isolation of tubercular
patients. The one great objection in many instances is
the distance the unfortunates are compelled to live
from their family and friends. An objection to a
tubercular annex being built to the various county
homes is that they will be poorly equipped and man-
aged, and that many tubercular patients are not sub-
jects of charity.
Therefore, be it Resolved, That it is the sense of
this society that the time is ripe to start a propaganda
through the State Medical Society, and the various
county societies for the presentation to the next legis-
lature of a bill authorizing the establishing of inter-
county tuberculosis hospitals. Thereby it will be pos-
sible to insure proper equipment and more competent
management, as well as reasonable distance from the
patient's home.
Resolved, That a copy of this minute be sent by the
secretary of this society to the secretary of the State
Medical Society and the various county societies with
the request that every member of each county society
solicit the support of their members of the state legis-
lature to favor the proposed project.
Anthony F. Myeks, Reporter.
BUTLER— OCTOBER
The October meeting of the Butler County Medical
Society was called to order by President R. L. Stack-
pole, Tuesday, October 12, at 9:00 p.m., in the Uni-
versity Club rooms, with ten members present.
Dr. L. R. Hazlett announced that October 28 had
been set for the date of our banquet. This took place,
as scheduled, with a goodly attendance of members
and their wives, and was very much enjoyed. Our
di.«itrict councilor, Dr. Jay B. F. Wyant, was with us,
and gave one of his helpful common sense talks.
Reverting to the regular October meeting. Dr. Stack-
pole spoke on the subject of Venereal Disease. He
thinks there is as much venereal infection in this coun-
try as in France, and that it kills more people, directly
and indirectly, than tuberculosis.
The state is doing much to combat these diseases,
and the doctor hopes to see established a prophylactic
station in every town..
The name of Doctor A. M. Padille, of Butler, was
proposed for membership at the regular meeting,
November 9.
On motion, Drs. Atwell, St. Clair and McCall were
appointed a committee by the chair to interview our
incoming state legislators regarding their views on
proposed legislation on compulsory health insurance,
antivivisection laws and osteopathy.
Dr. L. H. Landon, of Pittsburgh, was an invited
guest, and ably discussed the subject, "Some Practical
Features of Cranial Surgery." In fractures of the
skull, it is not the bone injury that matters, but injury
to the brain, either of lasceration or by pressure, and
the latter is usually the factor present. When pressure
goes above ten or twelve millimeters or more, it be-
comes pathologic. The mistake is often made of wait-
ing till oedema of the vital centers has supervened,
and there is little hope for the patient by operation.
With a certain amount of oedema, compensation .will
take place by stimulation of blood pressure. In brain
injury, the ocular fundus should be often examined.
The clinical condition of the patient as a whole should
be taken into consideration, and not depend on any
one symptom.
These are only a few of the points made in Dr.
Landon's excellent address, which included a discus-
sion of brain tumors and operation on the gasserian
ganglion.
Dr. Landon was thanked by the president in the
name of the society, and adjournment was declared at
10 : 45 p. m. L. L. Doane, M.D., Secretary-Reporter.
CLEARFIELD— NOVEMBER
At a regular meeting of the Clearfield County Med-
ical Society held at Clearfield, Pa., Nov. 10, 1920, the
following report from the Committee on Public Policy
and Legislation having been previously printed in the
Bulletin was submitted and by motion was unanimously
adopted :
The Clearfield County Medical Society declares its
opposition to certain 'proposed legislation^ termed or
commonly known as Compulsory
Digitized by '
Health Insuraace,
I>ECE\IBER, 1920
COUNTY MEDICAL SOCIETIES
183
Because, It destroys the proper relationship between
patient and physician.
Because, It places a premium on cheap, careless,
superficial, hurried physical examinations, bedside ob-
servations and treatments on the part of hired medical
. men.
Because, The medical attendant who is mbst easily
prevailed on to grant certificates of illness will be the
more popular.
Because, It encourages malingering on the part of
the insured.
Because, The bulk of moneys collected go for over-
head expenses.
Because, Only a small percentage of the money col-
lected actually is applied to the benefit of the needy
sick.
Because, It makes no provision for the pauper class
and therefore does not lessen the burden of the state.
Because, It tends to the building of an enormous po-
litical machine of sinister possibilities.
Because, It furnishes place for numerous hirelings,
nonproducers, parasites.
Because, It is obviously, clearly and distinctly, glar-
ingly and obtrusively un-American ; therefore
Resolved. That the Clearfield County Medical So-
ciety declares its opposition to the institution of any
plan embodying the system of compulsory contributory
insurance against illness, or any other plan of com-
pulsory insurance which provides for medical service
to be rendered contributors or their dependents, pro-
vided, controlley, or regulated by any state of the Fed-
eral Government. J. M. Quigley, Secretary.
CHESTER— OCTOBER
A very enjoyable and instructive meeting of the
Chester County Medical Society was held at the
Phoenixville Hospital Tuesday, October 19th. Preced-
ing the meeting the members were entertained at lunch
by the members of the hospital staff under the direc-
tion of the superintendent. Miss Worrest.
The meeting was called to order by President W.
Wellington Woodward. Following a short business
session, the society was addressed by Dr. A. C. Mor-
gan, of Philadelphia, on the subject of "The Post
Influenzal Chest."
Dr. Morgan illustrated very graphically on normal
living subjects the methods used in mapping out the
various areas of the chest which are particularly con-
cerned with the changes produced by influenzal pneu-
monia, lobar pneumonia, and tuberculosis. He stated
that tuberculosis always began in one apex, and ex-
tended downward, involving the other apex secondar-
ily. The pneumonia, whether influenzal or lobar,
produced pathologic changes below a line drawn hori-
zontally through both scapulae at the level of the
spines. The progression of pathologic changes in
pneumonic cases is from below upward in all instances.
These points, he claims, are extremely important in
prognosis as well as in treatment, and are very valua-
ble from an insurance examiners standpoint.
The value of roentgenology in the study of chest
conditions was emphasized very strongly. Dr. Morgan
urged his hearers to take, rather than send their pa-
tients to the roentgenologist in order that they might
personally observe the movements of the chest through
the fluoroscope. He described the typical "tenting of
the diaphragm" seen in cases of pleurisy with adhe-
sions, which is so often mistaken for intercostal neu-
ralgia and so-called "rheumatism." The localization
of encapsulated empyema; is greatly simplified by the
itse of the fluoroscope and radiograph, and often much
valuable time is saved when surgical intervention is in-
dicated.
Dr. Morgan gave a concise outline of Colonel Bush-
nell's rule in the examination of a patient for evidence
of latent tuberculosis namely : "Mouth open ; breathe
out; little cough; deep breath." This rule had
proved of the utmost value in the examination of many
thousand cases in the recent war, and should be
adopted universally in civil practice.
At the close of the meeting a vote of thanks was
extended to Dr. Morgan for his most interesting ad-
dress, and to the management of the Phoenixville Hos-
pital for the excellent lunch. On motion the meeting
adjourned.
Members present: Drs. W. W. Woodward, Bush,
Perdue, C. E. Woodward, Sharpless, Mellor, Smith,
Hammers, Rothrock, Bullock, Hughes, Jacobs, F.mack,
Wells, Rulon. Visitors : Martinez, Sawyer, Greenfeld.
Henry Pleasants, Jr., RejJorter.
ELK— NOVEMBER
Elk County January to November, 1920.— The Jan-
uary meeting was a huge success. Dr. R. P. Heilman
read a "cracka-jack" of a paper on the "Progress of
Medicine the Past Year." It was worth going a long
way to hear. Dr. Mitchell, of Warren, read a paper
on Neuro-syphilis with illustrations. Dr. Donald
Guthrie, of Sayre, gave a mighty interesting talk.
(Whoever was responsible for wishing this councilor
territory on Dr. Guthrie, certainly handed him some
territory, he needs on aeroplane to make it in.) Since
that time we have lived a sort of half-baked miserable
existence as far as the society was concerned.. Once
in a while we would have a paper, interesting and in-
structive.
Dr. Benson gave a very interesting talk on The
Use of the X-ray in Diagnosis of Pulmonary Tuber-
culosis.
Dr. McAllister had a very interesting paper. In
the November meeting. Dr. Shaw gave a short talk
on Goitre. Dr. McCabe had a good paper on In-
fluenza, but we were not able to scare up any excite-
ment over it. So we have just been dragging along,
waiting for the other fellow to do it. The same old
stand by excuses, every fellow for himself. W"e do
not want to realize that we cannot get out of the
S6ciety any more than we put into it. That is prac-
tically the whole story. We are here and pay our
dues, and Andy does the work.
The idea of the group plan is gradually coming
more to the front. There is a growing desire on the
part of many to put Elk County on the Medical Map,
to take our proper place, to use the hospital so that it
will render at least 75 per cent, efficiency, instead of
15 or 25. It is gradually filtering through our domes
that other sections of the state are more progressive,
more up-to-date, and we are possibly in a fair way to
realize that if we want to get anywhere, do more
and better work, be of more benefit to this community,
and incidentally make more and easier money for our-
selves, that we simply must follow out the group
idea to a certain extent at least. As it is now we are
all trying to be a little bit of everything, we all do
whatever we think we can get by with, and that is not
real practice of medicine, does not give the communi-
ties we serve a fair show for their money, etc, etc.
Anyhow "There is hope."
Dr. W. R Palmer died Nov. 3, 1920, as a result of
his car overturning on the state road between John- 1
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THE PENNSYLVANIA MEDICAL JOURNAL
December, 1920
sonburg and Ridgway. The doctor was still con-
scious when taken from behind the steering .wheel,
but died just as he reached the hospital. The Society
attended the services in the Community building at
Johnsonburg in a body. Many other physicians whose
names are not known to the reporter also attended.
Annual meeting in January. We may have a real
worth while meeting or we may have the usual line of
bunk.
If the Society will do something the reporter will
try and get the news to you, but until it does, he has
trouble enough thinking fairy tales to tell his wife,
without trying to think tales for the Society.
S. G. Logan, Reporter.
LEHIGH— NOVEMBER
The November meeting of the Lehigh County Med-
ical Society was held at the Sacred Heart Hospital,
Allentown, Pa., on Tuesday, the ninth. About no
members and guests were present, and everyone felt
amply repaid for the splendid and most instructive
program presented.
The session lasted from 9 a. m. to 12 noon. After a
short and snappy business meeting, the clinical pro-
gram on the "Acute Abdomen" was .ably discussed as
follows: The medical phase was introduced by Drs.
W. D. Kline and T. H. Weaber; the surgical side by
Drs. H. D. Jordan and L. C. LaBarre; while the
obstetrical division was upheld by Drs. C. L. Johnston-
baugh and A. L. Kistler. A splendid talk on the part
the x-ray plays in acute abdominal conditions with
demonstration was given by Dr. T. L. Smyth. The
importance of laboratory findings and assistance, as
related to any acute abdominal condition, was briefly
touched upon by Elmer McKee.
Following the above program and general discussion,
a splendid luncheon was served in one of the spacious
sun parlors of the hospital.
Martin Seler Kleckner, M.D., Reporter.
LYCOMING— NOVEMBER
November 12th was a red letter day for the phy-
sicians of the Lycoming County Medical Society.
We had President Jump with us, and he addressed
the Society on "Medical Economics." He talked about
the bills that may be expected to come before the next
session of the state legislature in which physicians
are vitally interested. Dr. George Reese, of Shamokin,
gave an address on fractures, illustrated by radio-
graphs. He emphasized the liability of physicians in
the treatment of fractures and the importance of al-
ways securing a radiograph of every fracture. There
were fifty-six physicians present.
Another pleasant occasion occurred on the evening
of November 12th, when Dr. A. F. Hardt gave a din-
ner to the members of the Lycoming County Medical
Society at the Country Club. Drs. Jump and Reese
were the guests of honor. Eighty-four plates were
set for the dinner, which was one that will be long re-
membered by those present Dr. Hardt acted as toast-
master. The diners drank a pure fluid to the honor
of the host, Dr. Hardt.
On Friday evening, November 19th, a public health
meeting was held under the auspices of the Lycoming
County Medical Society in the high school auditorium,
the president of the Society, Dr. V. P. Chaapel, pre-
siding. Honorable Emerson Collins, Deputy Attorney-
General of the Commonwealth gave one of his char-
acteristic addresses, emphasizing the progress of med-
ical science. Dr. C. W. Youngman, County Inspector,
discussed local conditions. Dr. Francis N. Maxfield,
director of the Bureau of Psychology, addressed the
meeting on the subject of "Mentality and Its Relation
to Education." Dr. John D. McClain, Deputy Health
Commissioner, emphasized the matters relating to
communicable disease, their relation to mortality, their
importance in economics, and the need of early and
prompt reports on the part of the physician. A specific
illustration was cited, showing what part the State
Department of Health took in combating tjrphoid
fever. W. F. Kunkle, Reporter.
MERCER— NOVEMBER
The Mercer County Medical Society met in the di-
rectors rooms at Buhl Hospital, Sharon, Pa., Thurs-
day, p.m., November 11, 1920, at 1:30 o'clock. The
attendance was small, many of the members were at-
tending meetings which were held in honor of Armi-
stice Day. In the absence of the president and ■vice-
presidents. Dr. Paul T. Hope acted as president. After
the business meeting and election of three new mem-
bers, Drs. Nelson J. Bailey, of Jamestown ; Joseph A.
Doyle, of Greenville, and Dan Pythyon, of Sharon, Dr.
John F. Spearman read a paper on Inguinal Hermia
which was enjoyed by all and a discussion was en-
tered into by those present.
Miss Margaret Gumming, superintendent of Buhl
Hospital, served tea, excellent sandwiches and cake.
Adjourned to meet at Mercer in January, 1921.
Edith MacBride, Secretary.
MONTOUR— NOVEMBER
Dr. Crile at Danville
Dr. George W. Crile, of Cleveland, Professor of
Surgery in Western Reserve University and Surgeon-
in-Chief to the Lakeside Hospital, was the guest of
the Montour County Medical Society on Saturday,
Nov. 13, 1920, before which organization he delivered
an address on subjects pertaining to newer concep-
tions of medical problems particularly as applied to
diseases of the thyroid gland.
The lecture was to be given in the Geisinger Hos-
pital but so large was the attendance that the meeting
place was shifted to the State Hospital.
For nearly two hours Dr. Crile addressed a large
and appreciative audience of Central Pennsylvania
physicians, frequently resorting to a blackboard and a
stereopticon in illustrating his points.
It was stated that, in all probability, goiter is a
geologic disease and results from iodine deficiency in
the food and water supply of individuals living in sec-
tions of the country in which there is but little iodine
to be found. Iodine is as necessary to the proper
functioning of the body as is table salt. Dr. Crile says
that centuries ago Patagonian Indians fed their goi-
trous patients with ground sea-weed thereby often
bringing about a cure which now we know was proba-
bly due to the iodine this marine plant possesses. He
spoke of experiments recently being made in Akron,
Ohio, in which the school children of that city had
been given* small quantities of iodine periodically
which has resulted in almost entirely eliminating
goiter. He believes if such treatment could be made
as universal as is vaccination that the next generation
would be as free of goiter as the present one is of
small pox. He emphasized the faet that goiter to-day
is distinctly a surgical disease and a properly applied
thyroidectomy is one of the most satisfactory of surgi-
cal operations. Dr. Crile emphasized his remarks by
demonstrating several goiter cases brought over from
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December, 1920
COUNTY MEDICAL SOCIETIES
185
the Geisinger and from the wards of the State Hos-
pital.
Following the lecture Dr. Crile held a short recep-
tion following which he returned to the Geisinger Hos-
pital where he made rounds with the staff visiting all
the house patients. He seemed greatly pleased with
all he saw and after visiting the entire hospital re-
marked, "Well we have nothing like this in Cleveland."
In the evening he was the guest of Dr. and Mrs. Foss
at dinner and later left on the sleeper for Cleveland.
C. ScnuLTz, Secretary.
NORTHAMPTON— NOVEMBER
The Medical Society of Northampton County held
its regular monthly meeting on Friday, November
19th, at Seips Cafe in Easton, Pa.
The increasing interest in the affairs of the county
society was shown by the large number in attendance.
Drs. B. M. Hance, of Easton; J. E. James, of
Bethlehem, and W. J. Cathrall, of Bethlehem, were
elected to membership.
Dr. A. B. Thomas, of the University of Pennsyl-
vania, of Philadelphia, addressed the society on "Diag-
nosis and Treatment of Prostatic Hypertrophy" illus-
trating his talk with charts and pictures, which proved
to be a very interesting subject ably handled.
Dr. S. Leon Gans, chief of the Genito Urinary Dis-
pensaries of the State of Pennsylvania, was present
and explained the letter sent out by his department
to the county society in which they ask the profes^sion
to cooperate with the state in the treatment of genito
urinary cases. It was unanimously decided to give
this matter further thought and bring it up at our
December meeting to which meeting a hearty invita-
tion was extended to Dr. Gans.
Dinner was then served and the meeting adjourned.
W. Gilbert Tillman, Reporter.
UNION— JULY
The annual meeting of the Union County Medical
Society was held in July, 1920, and the following of-
ficers were elected :
President, Amos V. Persing, .Allenwood, Pa. ; vice-
president, Weber L. Gerhart, Lewisburg, Pa. ; vice-
president, Charles H. Dimm, MifHinburg, Pa.; secre-
tary and treasurer, Charles A. Gundy, Lewisburg, Pa. ;
reporter, Charles A. Gundy, Lewisburg, Pa.; com-
mittee on Public Policy and Legislation, William
Leiser, Jr., Lewisburg, Pa., and Thomas C. Thornton,
Lewisburg, Pa.; censor, Charles H. Dimm, MifHin-
burg, Pa.; delegates to the State Convention, O. W.
H. Glover, Laurelton, Pa., and A. V. Persing, Allen-
wood, Pa., alternate.
The society desires to go on record opposing com-'
pulsory health insurance. A. V. Persinc, Secretary.
WARREN— NOVEMBER
The November meeting of the Warren County Med-
ical Society was addressed by Dr. Frederick Par-
mcnter, of Buffalo, N. Y., Monday, November isth,
who took for his subject "Adenomata of the Prostate
Gland and their Treatment." The doctor stated that
the mortality attendant on operations on the prostate
had been greatly reduced by improved methods.
Spinal anesthesia according to the Allen method was
to be prefered especially in the aged. Office catheriza-
tion in persons suffering from an enlarged gland is to
be avoided as it may cause an acute retention necessi-
tating operation. The operation should be made in
two stages: First, to produce drainage and after the
patient had convalesced and was built up, the enuclea-
tion of the gland through the former opening.
The external examination of the gland or through
the rectum may not show an enlargement which may
extend inward well into the bladder and cause obstruc-
tion. The cystoscope and fluoroscope may be required
to complete the diagnosis. In the cases that come to
the hospital at least 60 per cent, suffer from acute re-
tention. It is dangerous to empty the bladder fully
and too rapidly. The method of operation was then
illustrated by lantern slides.
The meeting was attended by twenty-three members.
Nearly a record attendance.
Dr. Mitchell, for the Board of Trustees, suggested
that the society contribute one dollar for each member
toward the legislative fund. On motion this action
was taken.
An invitation from the Jamestown Medical Society
was received urging the members of the Warren so-
ciety to attend the former's meetings and requesting
closer cooperation.
The meeting was held in the Science Hall of the
High School and adjournment was made to the Elks'
Club where dinner was served, Dr. Robertson acting
as host. M. V. Ball, Reporter.
PHILADELPHIA— OCTOBER
The meeting was called to order at 8 : 30 p. m. by
the president, Dr. Herman B. Allyn.
The minutes of the previous meeting were read and
approved.
SYMPOSIUM ON NATIONAL HEALTH INSURANCE
Dr. Frederick L. Hoffman, third vice-president and
statistician, Prudential Insurance Co. of America,
Newark, N. J., delivered an address on
"THE MEDICAL ASPECTS OF NATIONAL
HEALTH INSURANCE"
"Mr. Chairman, Ladies and Gentlemen: Obviously
there are at least two sides to this question and I am
afraid that- the conflict of views does not permit of a'
reconciliation. An investigator is likely to find what
he is seeking just as one can usually succeed in finding
the truth as the result of impartial and diligent re-
search. Mr. Teall, in going to Dr. Cox, the Medical
Secretary of the British Medical Association, of
course secured the viewpoint of the panel doctor, who
is a part of the act, and the act, as I have often said
before, has come to stay. The collective viewpoint as
given expression to by Dr. Cox varies widely from the
individual viewpoint set forth in countless contribu-
tions from week to week to the British Medical Jour-
nal. The rising tide of discontent is voiced by the
Medico-Political Union, which is rapidly gaining in
strength, and the Federation of Medical and Allied
Societies, of which Sir Malcolm Morris is the chair-
man.
"The new viewpoint is strongly in favor of the re-
organization of the British medical profession on the
basic principles of a trades union and the adoption of
a fighting platform, including the threat of a strike.
For the only hope for an improvement in the economic
condition of the panel doctor is obtainable through
Parliament, and that requires the entering of the med-
ical profession into the doubtful field of practical poli-
tics. The negotiations in behalf of better terms, of a
modification of the regulations, and of other matters,
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THE PENNSYLVANIA MEDICAL JOURNAL
December, 1920
are practically as endless as they are seemingly hope-
lessly confused. No negotiations lead to the degree
of satisfaction so essential to the proper working of
the system, but the discontent is voiced in practically
every issue of the British Medical Journal, The In-
surance Acts Committee has been defeated in most of
its negotiations for a betterment of terms, as, for il-
lustration, in the case of the income tax limitation,
which was originally fixed at £103, but which has now
been placed at £250 ; or as in the case of the restric-
tion on panel transfers at death, bitterly opposed by
the British medical profession but finally agreed to by
tho Insurance Acts Committee ; or as in the case the
right of an appeal to the courts and the preservation
of common law privileges in case of disputes or con-
troversies, yielding arbitrary power to the Ministry
of Health. Or, finally, -as in the case where the per
capita payment accepted was lis., although the Insur-
ai'ce Acts Committee, in behalf of the medical profes-
sion, has made a strong and apparently irrevocable de-
mand for 13s. 6d.
"I can not do better than illustrate the force of my
remarks by reading to you from a copy of the British
Medical Journal of October 9, 1920, in which there ap-
ptars a letter by Dr. R. D. Howat, reading in part:
*1hat the insurance acts are, under the present ar-
rangement, unworkable and unnecessary is an indis-
putable fact. If a plebiscite wefe taken in this coun-
try, I venture to suggest that the existing scheme
would be voted distasteful by the large majority of
practitioners and insured persons.' And further that,
'One hears and reads much of the decline of the "dig-
nity" of the profession. Is it to be wondered at when
the existing system allows that the less one does the
bigger the profit, and vice versa?' And, finally, 'To
my mind, the only satisfactory solution in the present
state of chaos is the wholesale repeal of the acts.'
"That is not an isolated instance but merely one let-
ter of hundreds contributed to the weekly issues of
the British Medical Journal during recent years. My
own judgment rests largely upon such letters and upon
the fairminded expression of panel practitioners and
others with whom ,1 have come in personal contact
•during my visit to England. I add to the .foregoing a
very brief extract from a still more recent letter by
Dr. Harry Roberts, one of the largest panel practi-
tioners in England, contributed to the British Medical
Journal of October 16, 1920, as follows: 'I am writ-
ing to draw the attention of your readers to a recent
decision of the Local Medical Committee of the Coun-
ty of London, that "the removal of hcemorrhoids is
not within the ordinary competence and skill of a gen-
eral practitioner." Surely, by these repeated attempts
to limit the general practitioner's functions to the pre-
scribing of bottles of medicine, we are stultifying our-
selves in the eyes of the public and losing that claim
we may have had to be regarded by the lay authorities
a.s expert craftsmen. There seems to be a growing
tendency among panel doctors to send to hospital every
case which presents any features of interest or calls
for the slightest manipulative skill.' These letters
contributed within the last few days to current medical
literature will suffice for the time being to answer the
preposterous assertions that panel practitioners
throughout England are satisfied with the workings of
the National Insurance Acts. I am as familiar as any-
one with the fact that a large proportion of panel doc-
tors have derived a material share of pecuniary benefit
from national health insurance. The second doctor,
the third doctor, the sixth doctor, who has never been
known in this coimtry, was happily replaced by a sys-
tem which, regardless of all its inherent defects,
brought a measure of relief in certain important direc-
tions of medical reform. The doctor who practiced
among the poor with a bottle of medicine, and gave,
broadly speaking, largely worthless treatment, no doubt
had a hard time of it in collecting his bills. He hai
now an assured income and need not worry about
competition or the stress and strain of professional
skill. But in place of the old-time discredited doctor
has come the panel doctor, who, with the sanction of
the state, is engaged in lowering the dignity of the
medical profession to the status of a trade bearing the
obvious stain of cheapness.
"According to my analysis of the Manchester experi-
ence under national health insurance, surgical opera-
tions and night calls are an infinitesimal proportion of
the whole. The data reflect a disgraceful condition.
Standardizing medical practice is a perilous procedure.
1'he panel patient is the slave of the panel doctor, and
vice versa, the panel doctor is the slave of the panel
patient, and both are in absolute bondage to the count-
less rules' and regulations of the Ministry of Health.
"No one who values the high status of the medical
profession in America and is determined to maintain
it can contemplate without serious concern the remote
possibilities of a similar state of affairs in this coun-
try. No conclusive evidence has been forthcoming
from any responsible source that public or personal
health in England has been improved in consequence
of national health insurance legislation. Although the
act 'in its preamble emphasizes the viewpoint that the
objective is the prevention of diseases, nowhere in the
act is provision made for methods or means whereby
disease as such can be prevented. This is the view-
point of the foremost British authority on the subject
— Sir James Mackenzie — as set forth in his recent
work on 'The Future of Medicine,' and in a supple-
mentary report to the proceedings of the committee
appointed to inquire into health insurance records.
The health progress of Great Britian has not been
helped but been hindered by the enormous amount of
attention given to the administrative details of health
insurance and the waste of public funds in connection
with schemes foredoomed to failure. The sanatorium
benefit, of which so much was expected, has been a
complete fiasco and has recently been withdrawn from
national health insurance and restored as a public
function cared for by the public health authorities,
where it properly belongs. These are all matters of
fact and of record, to which the -American medical
profession is of right entitled and which to withhold is
merely to give furtherance to the wrongful propaganda
of those who are deliberately misleading the public.
"The outlook in England is discouraging and not far
from desperate. Unemployment is increasing at a
prodigious rate, while poor-law expenditures are
mounting to prohibitive proportions. Just as on the
one hand there has not been the anticipated improve-
ment in public health, so on the other there has not
been the expected diminution in poor relief. A large
and increasing proportion of paupers among insured
persons are cared for in poor-law institutions. The
apparent reduction in pauperization during recent
years is much more than offset by the enormous ex-
penditures on account of noncontributory old-age pen-
sions, which are merely in the nature of supplementary
poor-law allowances. About a million old-age pen-
sioners now receive los. or less a week, and many of
these are insured persons, finding it impossible to nakt
both ends meet on the sickness benefit granted. That
benefit has been increased recently, from 10s, to 15s-,
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December, 1920
COUNTY MEDICAL SOCIETIES
187
just as old-age pensions have been raised to a los.
basis, and unemployment insurance has been increased
from IDS. to 15s., all without the proportionate increase
in the contributions paid by the insured. I have gone
from bedside to bedside of panel patients. I have in-
terviewed scores of panel doctors. I have examined
hundreds of reports of sickness visits, and in my judg-
ment the system is not only a grotesque faijure but a
frightful imposition upon British wage-earners entitled
of right to conditions more effective in promoting
health and longevity. The health insurance acts, the
unemployment insurance acts, the old-age pension acts,
all are in the nature of supplementary poor relief, and
none effectively aim, if they aim at all, at the preven-
tion of disease or economic distress. This is not a
matter to be disposed of by one-sided hearsay opinion,
but only by trustworthy evidence collected by those
who are qualified to do so and who approach their re-
sponsible task without bias or prejudice in favor of
one side of the question or the other. But above all
others, the members of the medical profession and
our wage-earners are entitled to the facts, to the truth
and to nothing but the truth. They have a right to
oppose any and all measures which tend on the one.
hand to discredit the medical profession and to deter-
iorate medical praictice, as on the other they are certain
to pauperize our independent wage-earners and to ac-
centuate wrongful class distinction unworthy of a
place in our American democracy. I thank you."
William Draper Lewis, Esq., delivered an address on
"ECONOMIC CONSEQUENCE OF ILLNESS"
"Mr. President and Doctors: I have been asked to
say something this evening about the economic conse-
quences of sickness. 1 feel a little as if I were talking
to an audience that really knew in a way, all of you,
more about that subject than I do. Perhaps it will
serve a useful purpose if I begin what I have to say
by giving you, as my predecessor has done, something
of my philosophical attitude.
"I regard poverty very muCh as I suppose all doctors
regard sickness. I do not think that any of you here
have a panaciea for sickness and my philosophy is that
there is not one single thing that can wipe out poverty
in a community whether we speak of poverty being
that condition of life which leads to a person being
undernourished, or whether we define poverty as de-
pendency in whole or in part upon public charity.
Poverty has a great many causes and we must deal
with it so it seems to me at least, as you doctors deal
with sickness, not by one panacea for all human bodily
ills, but by analyzing the causes of poverty and elimi-
nating one at a time. Now that was about the only
philosophy I had on the subject, but it led me to be-
come interested in sickness, or rather in the economic
causes of sickness.
"When I started in I knew, as you all know, that
sickness was the cause of poverty just as poverty was
the cause of sickness. I had that idea and I also knew
that in Germany, in England and in other countries
they had something they called Health Insurance,
sometimes voluntary, sometimes compulsory, and it
seemed to me that it was worth while and interesting
to go one step further and even do something about
these matters and therefore I was influsntial in in-
fluencing the appointment of a Health Insurance Com-
mission, which was appointed under the Act of July 25,
1917, by the predecessor of the present governor.
"Now I would like you (as I served on that com-
mission and was somewhat active in guiding its ac-
tivities,)— I would like you to have some sympathy
with the politicians, if you choose, as represented by
myself and associates as to the task put up to us. We
were to investigate, first, sickness and accident of em-
ployees and their families, not compensated under the
provisions of the Workmen's Compensation Act of
1915, the loss caused to individuals and to the public
thereby and the causes thereof ; second, the adequacy
of the present methods of treatment and care of such
sickness and injury; third, the adequacy of the pres-
ent methods of meeting the losses caused by such sick-
ness or injury, either by mutual or stock insurance
companies or associations, by fraternal or other mu-
tual benefit associations, by employees jointly, by em-
ployees alone, or otherwise; fourth, the influence of
working conditions on the health of employed persons ;
fifth, methods for the prevention of such sickness, —
all with a view to recommending ways and means for
the better protection of employees from sickness and
accident and their effects, and the improvement of the
health of employed persons, and their families in the
commonwealth.
"And we were given $5,000 to do the work. Further-
more, we were not only limited to $5,000 but if you
will turn to the members of your committee you will
find that they consisted of two senators, one lieutenant-
governor, who was chairman, one or two persons with-
out any definite political affiliation and one doctor, a
doctor of eminence and common sense. Now it was
manifest to us the moment that we got together and
read that act that we could not do all these things. In
the first place, it is a bad habit in this state in appointing
commissions; they are not appointed when the legisla-
ture passes the act. We were not appointed until De-
cember and we did not really get to work, or could not
get to work until the first of the year and that left us
practically only twelve or fifteen months. Inadequate
preparation, inadequate appropriation, with only a sin-
gle representative of that profession, the medical men,
more vitally interested in the subjects than any other
single group of men. What were we to do ? What we
did was thisi We determined that we could do one of
two things, we could go around the state and we could
hear the learned gentleman who has preceded me argue
against health insurance and we could hear Mr. Ram-
say argue in favor. In other words, we could hear
orations and travel at the expense of the government
of the State of Pennsylvania. We determined that
was useless, that the only useful thing we could do
was to find out the economic consequences of sickness
or. wage-earners. That we probably could do. We
tried to do it and what I want to tell you is how we
tried and some of the results.
"Now we only had $5,000 that was the first limita-
tion. You cannot make a survey of Pennsylvania's
economic consequences of illness on $S,ooo. Therefore
what we did was to go to persons who had the con-
fidence of the persons who were visited in charity and
charity organizations and philanthropic organizations
in the state who would tabulate the result of their in-
vestigations and this whole report of that committee,
which I have in my hand, is the report of the Health
Insurance .Commission of Pennsylvania of January,
1919, is not a discussion, you won't find one word about
a discussion of advantages of health insurance or dis-
advantages, but I think you will find a lot of useful
valuable information in regard to the economic con-
sequences of sickness in Pennsylvania right here now
and to-day.
"Now I said that we were helped in that investiga-
tion. I would like to call your attention to the kind of
help that we got In the first place we got thi
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THE PENNSYLVANIA MEDICAL JOURNAL
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sylvania School for Social Service in Philadelphia to
make a sickness survey of a district in Kensington.
We note this in this book (pointing to report of the
Health Insurance Commission of Pennsylvania) as the
Kensington Sickness Survey. That took the entire
time of some fifty persons who visited between 700
and 800 families and got their sickness history for the
year. Now of course we were not interested in the
kind of sickness they had. What we were interested
in was the number of days lost in sickness, the amount
of medical attendance cost, the amount medicine cost,
the amount of wages lost and the cards were carefully
and I think skilfully prepared and we got out of that
survey of a typical industrial district of mostly native-
born workers in this city a great deal of useful in-
formation which on account of standing by itself was
useful but limited to the investigation of 750 odd fami-
lies who were employed, their sickness history for tfie
year. If carefully done I think you all would think
that would give you some information, but that you will
need more. Now the other investigations were the in-
vestigation of the Sickness and Dependency. A study
of 1,500 of the families in which illness existed, under
the care of the Charity Organization Societies of seven
cities in the state, during 1917. I suppose that investi-
gation, which involves going over a large quantity of
records, cost the society several thousand dollars.
Now this entire investigation of this committee as rep-
resented in this book has cost outside not $5,000, but
very much nearer $100,000. The next was the Sick-
ness History of Working Girls. A study of 502 mem-
bers of the Young Women's Christian Association
Industrial Clubs in seventeen cities of the state.
"The next was the Sickness History of Wage Earn-
ers' Families. A study of 500 families given nursing
service in July, 1918, by the Philadelphia Visiting
Nurse Society. Again I want to emphasize this was
not a medical investigation, it was an investigation of
causes that led these persons to turn to public aid. An
investigation of the amount which they had spent on
doctors and medical supplies and the loss of wages.
"The next was the Sickness History of Wage Earn-
ers. A study of the fatal . illness of the fathers of
families now under the care of the Mothers' Assist-
ance Fund in Lancaster and Lackawanna Counties.
"Next Industrial Diseases in Pennsylvania. Next a
special study of Existing Insurance Facilities of the
Pennsylvania Railroad, J. G. Brill Company, J. B.
Stetson Co. A brief study of existing commercial in-
surance.
"But the first studies to which I called your attention
were the main studies on which the conclusions we
arrived at (and some of which I am going to call
your attention to this evening) were based. Now what
were the main facts? But they were the facts that im-
pressed me as an ordinary layman looking at the result
of that investigation.
"There are in Pennsylvania, or there were in ni6,
about two million eight hundred thousand persons who
are employed on wages. The average loss in sickness
—I am no believer in large wages — the average loss in
sickness as worked out by these various investigations
we made, is probably about six days, or about three
million working days, at $2 a day that is $33,000,000;
at $4 a day it would be $6i5,ooo,ooo. It is probably be-
tween $40,000,000 and $55,000,000. It is a very large
amount taken as a whole.
"Now it is obvious that the loss to the employee
from sickness is the loss of his wages during the time
that, he is sick. It is the expense of that sickness and
it is perhaps as the result of the sickness that .there
is a permanent diminution of his earning power. That
is his loss. The loss to the employers is very much
more. Those of you who have not had actual contact
with industry through establishments realize it is very
great It is the loss to industry as a whole of the earn-
ing power of the workman, it is the loss to the indi-
vidual, who has employed the workman, of his time
and strength and it is the labor turnover when yon
have to put another healthy man in place of the man
who is not healthy. On an average I suppose it may
be said to employ a new man in the ordinary industry,
even a man who does not rise very much above manual
labor, is a dead loss of some $40 to $50.
"Now these being some of the facts, the most inter-
esting and I must confess startling result to me was
this that a chief cause of prolonged illness was the
fact that the wage earner cannot afford to be ill. We
got it from every possible angle. We got it from
practically every doctor whom we had interviewed
who had come in contact with sickness among em-
ployed persons. We got it from every Charity Society
and we got it right on the fact of the statistics. Let
ine show you for instance the result of the Kensington
survey, because it was typical.
"I said the average report throughout the state is as
a rule about six days a year. I said, also, that does
not show you very much and it does not for this rea-
son : when you come down to an individual survey of
-50 odd families we found the average person who
had lost any time investigated, lost an average of 38
days ; now a sickness of two or three days is not seri-
ous, but a sickness of 38 days to a working man with
a family is a very serious thing. In other words, what
really happens from the testimony of doctors— you
know more about that side of this than I do — that is
a man can't afford to be sick; the man stays at work
when he ought not to be at work and as a result when
he gets sick his sickness "is longer and therefore yon
have an average of 38 days in this survey, or an aver-
age of 20 days in another «urvey. In other words, you
have a great deal longer sickness than I had any idea
of when I started in on this investigation.. In case yon
should get perhaps an exaggerated idea of what I
have said I think perhaps this statement would be a
fair conclusion from the investigation that we made
that about one-third of the sicknesses that cause loss
of work among employed persons are comparatively
speaking longer sicknesses, that is to say they last for
a month or more and some of them, of course, are
permanent.
"Now another factor which I do not thing is a very
pleasant factor to dwell upon in a community which
prides itself upon its charity and efficiency is this: I
do not want to blame the class who apparently are re-
sponsible for it, but it was a considerable shock to mt,
we carefully investigated in the hundreds of cases we
investigated how much help had been given by the em-
ployer. For instance, I am an employee of the Uni-
versity of Pennsylvania, if I am taken sick to-day the
University will pay my full wages for a year, they may
pay me even more. That is done repeatedly. If I am a
high class clerk in a business place they will carry .me
for some time. But in the class we were investigating
we found tlvit practically absence from work any more
than a day, it was fortunate if it did not mean loss of
eniplo)rment and practically in no cases at alt, prac-
tically so few that it was negligible, for instance in the
1,500 cases that we ran down by the Organized Charity
and investigated, out of these 1,500 cases only one re-
ceived a few days pay while they were sick and only
33 had received actual .helo, from their employer by
December, 1920
COUNTY MEDICAL SOCIETIES
189
way of charity. Now I do not say there is any legal
obligation to help them, but it is really a commentary,
not a .criticism, upon the manufacturer here, but a
criticism of our social organization which so far sepa-
rates the manufacturer who runs the machine from the
actual man who is doing the work that he does not
help the man who really needs it, but generously helps
officers of his company, or the way we are helped as
professors out at the University of Pennsylvania and
in other educational institutions.
"The next thing that we asked ourselves was this:
What are the agencies that are meeting the economic
problem which falls on the employee when he falls
sick? Now there are certain insurance agencies in
Pennsylvania actively at work. There are the com-
mercial insurance companies, industrial, the fraternals
carrying health insurance, the trade union funds carry-
ing health insurance and the establishment funds car-
rying some kind of health insurance and one of our
tasks was to find out how efficient the actual situation
was being taken care of by these associations. Well,
in the first place, take the industrial insurance com-
pany : I pointed out earlier that there were $33,000,000
at ^ a day lost in wages annually, that it was probably
somewhere between $40,000,000 and $50,000,000. The
industrial companies paid in 1916 seven millions out in
life insurance, that was practically funeral insurance
from $100 to $500 during the same time they paid be-
tween $84,000 and $85,000 out in sickness. The total
benefit given by that class of help is as against a wage
loss of $40,000,000 is somewhere between $80,000 and
$90,000 a year. It may be more in the last year. My
figures are in this respect for 1916. Now in regard to
the fraternals carrying health insurance: I expected
that the fraternals were doing a very important work.
I expected to find it They are not. The trouble is
that the amount they pay is so small. It is smaller
even than the benefits received by the English work-
man, which is not 25 per cent, of his wages at the
present time. That is the time he needs wages most
he only gets 25 per cent under the English Act. Now
fraternals where they paid sick benefits (he had to be
in complete good standing before he got it) practically
gives only $5 a week for 13 weeks. There is practic-
ally no medical attendance that really amounts to any-
thing. There are 47 fraternals who have doctors and
these doctors have a dollar per year per member, all
the fraternals give a certain amount of medical aid, but
that is the end of it Now the fraternals are doing a
great deal better than the trade tmions. The trade
unions sometimes give about $5 to those who fall sick
for 13 weeks, or 26 weeks. Sometimes there is med-
ical aid, but very seldom. The trade unions are ordi-
narily organized to fight and not for sickness benefit
The most efficient agency at the present time, as of all
those who have come in contact with one of them
know, is the establishment fimds. They are sometimes
supported by the men, the administration, supported by
the employer as the Pennsylvania Railroad fund ; they
are sometimes supported generally and run generally;
sometimes they are supported entirely by the establish-
ment, but however they are run they are usually run
in the large, high class industrial establishments and
they do give to a considerable extent an efficient med-
ical treatment to them, and they do this they encourage
in many instances the laborer who feels sick to go to
a medical attendant and get free advice as to whether
He should stop work or not and the most efficient work
is done by the establishment funds. But of course the
establishment funds reach primarily that class of
workmen in the high class establishment is a great deal
better off than the average workman of the same
grade throughout the community. Now we come to
the final conclusion that we reached.
"I said that I was interested in this investigation be-
cause I believed there was a way to get at poverty and
dependency in the community, so to separate the causes
of poverty and try to eliminate them one by one and
the question we asked ourselves was from these facts
that we have gathered can we get any picture of the
percentage of poverty, if you define poverty as actual
dependency, and .that is the only kind of poverty that
you can get actual statistics about, that is due not to
drunkenness, laziness or subnormality, but to an em-
ployed workman getting sick.
"Well, we get some figures on that situation. I do
not know whether figures are particularly enlightening.
Certainly yofi have the causes of poverty, poverty
causes sickness and sickness causes poverty, but when
you look, for instance, at the cases which come before
the Organized Charities of this city, the thousands of
cases, of cases that seek public relief of that kind and
you trace these histories back, as we have, you will
find that in 40 odd per cent sickness is the main cause.
Do the same thing for the Hebrew Charities, as we
did it, and sickness was 63 per cent, of the main cause
of poverty, the main cause of that dependency. In
other investigations, for instance, in the Visiting
Nurse Society it ran to 28 per cent, but it .never fell
below 25 per cent in any of the investigations. There
is no man on that commission who has gone through
that investigation — and I defy anyone to take this in-
vestigation and go through with it and see the evidence
on which the statement is based not to come to this
conclusion that the sickness of the employed workman
is the greatest single cause of poverty, meaning de-
pendency, in the community. That it is always with
us and that it is greater than out-of-workness in slack
time and out-of-workness is the next cause of poverty
unquestionably, although it does not operate evenly,
but that in good season and in bad you have great
cause of dependency on public and -private charity in
sickness of the man who is employed and the economic
consequences of that sickness.
"If you can wipe out these economic consequences
even if doing so you do not reduce the amount of
sickness by one day, you would make a long efficient
step forward to get at what produces, what has been
called the submerged tenth, what makes the man who
was an independent self-supporting citizen the de-
pendent citizen.
"Of course, in the course of our investigations we
came across tale after tale of how a man became de-
pendent who was self-supporting and self-respecting
and how he became dependent in the community. I
remember one tale which is typical of thousands. It
was of a man who was called John Callahan. I call
him that, that wasn't his name. He happened to live
in this city. He married as a young man and was em-
ployed by one of the larger companies in this city. He
was a steady workman, never lost a day. He and his
wife had four children, they saved money and that
means a good deal. He was not a skilled worker, but
he was above the mere manual labdrer. His children
were healthy and he and his wife were healthy and he
realized that sickness might put him down and out and
therefore he reached out His company, in the first
place, ran an insurance fund and he himself, not satis-
fied with that, also joined one of these fraternals antl
he carried insurance in case of death for a decent
funeral and he was bringing up these children all right
and one day he was taken sick, he had a cold and
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THE PENNSYLVANIA. MEDICAL JOURNAL December. 1920
nevertheless he kept on. He couldn't afford quite to
be sick. That cold grew worse, it developed into pneu-
monia and he had to stop and he was very ill. Now
he never had turned to public charity, there was no de-
sire to turn to public charity. He first ate up his sav-
ings and then he turned to the second great carriers
of sickness in the community, and I think you doctors
will appreciate the pleasure that it gave us to realize
that they were the carriers, the fellow who keeps the
corner store and the doctor. That doctor who at-
tended that family, the mother got sick from over-
work and one of the children, attended weeks after
there was any possible hope that he would receive a
penny from that family. That case is typical over and
over again. The man who ran the corner store ad-
vanced the money until there was no hope. He knew
there was no hope and the neighbors came in and
helped and yet that was a sizable family, there were
four children, and John Callahan did not get welL
The end came, it always comes in these cases in one
way or another. In his case it came by the youngest
child getting very ill, by taking that child and the
mother to the hospital and one of the social workers
getting hold of that family, practically taking care of
that family, nursing the wife back to health and the
iiusband back to partial health. What is the result?
The result of the whole economic burden' of John
Callahan tailing on John Callahan, self-respecting, in-
dependent American workman, was that he was ulti-
mately obliged to seek charity. That cost to the state
of taking care of one of the children in one of its in-
stitutions. That the cost is loss of earning power, for
he is not now a well man ; cost of wife's weeks in bed.
All that cost seemed to me as I looked at that case,
which I mention because I personally knew about it,
is utterly unnecessary — ^as writing across our civiliza-
tion inefficiency!
"All I have come here for this evening is this: I
come here to simply show you that the economic prob-
lem, or consequences of sickness produce in any com-
munity org^anized as any western industrial community
is, a problem which has to be faced. We have got to
face the problem of John Callahan. It is the problem
par excellence almost of society to-day. We have got
to face it. That was the conclusion of the first Penn-
sylvania Commission. Now in facing it we want the
help of the doctor, we don't want compulsory health
insurance rammed down your throat, or anyone else's.
We want you to help us to help the Insurance Com-
mission find out what is the best remedy and so when
this new Health Insurance Commission was appointed
by the present governor what we determined to do
was this : We determined to ask the medical societies
of Pennsylvania to appoint representatives to come
and sit down with us and discuss these various things
with us. That was our first move and the second move
was to take our chairman, Mr. Ramsay, who had no
earthly idea whether health insurance was a good or
a bad thing, and to send him to Europe to try and find
out as far as he could what was the reaction of the
people on the other side of the Atlantic as to the ac-
tual practical woricings of the English act. With all
respect to my predecessor in speaking here, we realize
as he realizes, that with all his earnestness he went
over to England a prejudiced man. Now supposing I
had gone over people would say that I had been asso-
ciated with Col. Roosevelt and that I was prejudiced
in favor of it. You remember he said the very mini-
mum that you could do was to have this sickness bene-
fit for the workman. We are not by any means sure.
What is the solution? I want the help of the manu-
facturers. I want the help of the employees. I want
the help of the doctors to enable me to make_^ up my
mind.
"So we sent our chairman over and he is going to
be here to-night to. speak. I did not know until this
morning what the result of his investigation was. We
get contradictory reports. We have people conae to
us and say that the act is a success in England and
that those who are opposed to it they cannot under-
stand how they could remain out of an insane asylum.
That there was no agitation for the repeal ; that every-
body was enthusiastic for the act, except that it was
not extensive enough. Then we have the learned gen-
tleman who preceded me telling of the widespread op-
position to the act in England and of its evils. We
sent Mr. Ramsay abroad and I believe he is going to
be here later in the evening. The report is here and I
have been looking at it this aftemon and it makes very
interesting reading and he came back with certain
definite impressions as to the attitude of the medical
profession in England and the attitude of the people
generally on the English act
"Above all we want this: That you as doctors
should appoint your most intelligent committees, spend
your money to do exactly what Dr. Hoffman wants
you to do, in this I agree he is right, to verify what he
said. To send your own committees to Europe and
find out and find out one of two things: •^re they on
the right track of solution, or are they wholly wrong.
If they are on the right track what are the defects of
their administration. It matters not whether from
Germany, or Hungary, or England if on investigation
it is good, but if on 'investigation it is not good then
let us turn to something else. The present conditions
are not conditions which throw any credit upon the
community as a whole, upon the employers of labor as
a whole, on the labor unions as a whole, or on the doc-
tors."
The president. Dr. AUyn, announced that he had re-
ceived a telephone message from Mayor Ramsay, of
Chester, stating that the automobile in which he was
coming to the meeting had been mired and he would
be unable to attend, and also that Mr. Tead, who ac-
companied him on his trip to Europe and was familiar
with the findings, was present and would probably ad-
dress the meeting if called upon.
Dr. J. E. Sweet read a paper entitled
"NATIONAL HEALTH INSURANCE FROM
THE PHYSICIAN'S VIEWPOINT"
"I do not clearly understand why the 'Powers that
Be' should have asked me to present the medical side
of such an important question ; for certainly no mem-
ber of the profession could possibly be less affected
by the enactment of such a measure than the man
hidden away in the laboratory. Nevertheless I have
presumed to undertake the task, feeling that an intense
interest in the problem may atone for most decided
breaks in my knowledge of the subject
"My remarks will be based upon a study of the bill
drafted for the State of New York and sponsored by
Senator Davenport, therefore commonly known as the
Davenport bill. I have several reasons for limiting my
discussion to this particular bill. As medical men we
are accustomed to always consider two questions;
first does disease exist; second, can the disease be
cured without killing the patient? My personal in-
clination is, therefore, to pass over the discussion of
the need for National Health Insurance ; for no mat-
ter whether the body politic be diseased or not there
is no object in devising a treatment which will make
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December, 1920
COUNTY MEDICAL SOCIETIES
191
it sick if it be well, and make it far worse if it be sick.
"A further reason why I shall confine my remarks
to this particular bill is that I can see no way iii which
it could be improved upon,— except by hitting it hard
upon the head; I mean that it is a carefully worked
out plan, and apparently all the objections to such a
scheme such as are manifestly inherent in the competi-
tive bidding schemes, — the panel systems, — of the con-
tinent, have been carefully considered and avoided.
"Let us take this Davenport bill, then as an example
of what statutory law could do, when enacted in the
best conceivable form.
"The first break in an orderly sequence of known
facts at my disposal comes with the very first ques-
tion,— why do the proponents of these measures want
them? Is it that the spirit of socialism is seeking a
convenient roosting place where she may rest her
weary wings, — for if the spirit of socialism has been
hovering over Russia, she must surely be weary? Is
it that the working classes are really receiving such
poor medical service that the state must needs take a
hand?
"I confess I do not know ; so I have made it a point
to see Senator Davenport personally, and to ask him
why he became interested. The senator is the Pro-
fessor of Political Science in the college of which I
have the honor to be a graduate ; he was not there in
my day, which doubtless explains my lack of under-
standing along many lines of Political Science. In
reply to my question, he told me that he had known of
a certain employer of labor, who, during the influenza
epidemic employed a physician to look after the em-
ployees, with a very distinct saving of labor hours, and
probably of life.
"Therefore, without stopping to contemplate the
difference between what can be done in the handling
of an acute, epidemic disease, and what can be done in
the handling of everyday disease, or of chronic dis-
ease,— shall we say influenza on the ()ne hand and
psoriasis on the other; without stopping to consider
the difference between a private scheme and the gov-
ernmental application of the same scheme; and with-
out the slightest knowledge of the peculiarities inher-
ent in the practice of medicine, our political economist
would apply a plan which undoubtedly did work in a
certain peculiar instance, under private management,
to conditions under which the plan cannot possibly
work, least of all under state mana£;ement.
"Incidentally, how can they still go on, coupling the
two words 'politics' and 'economy'?
"I make the assertion that such a scheme cannot
work because it is unjust to the insured, and because
it is in conflict with the fundamental principles of
medical practice. A bold assertion needs support, and
this I will give. First, however, I would like to make
plain to the medical men just how the plan is to be
related to the doctor. I have heard violent discussion
based on the assumption that the state was planning
to force contract practice upon its licensed practition-
ers of medicine; and other points have been empha-
sized which do not exist in this Davenport bill, nor, I
think, do they exist in the minds of any of the pro-
ponents of such measures.
"I can make more clear the exact relationship of
the doctor to the scheme of health insurance by thi
use of a simple diagram.
The Governor
The Senate
The Assembly
The Industrial Commission
Bureau of Health Insurance
under
Physician or Surgeon
Funds — Seven Directors
3 Employer members
3 Employee members
I elected hy majority vote
of the SIX above
Medical Officers — "who shall not practice medicine in
any capacity under this chapter.
Employee, or Patient Any Physician or SnrgeoiT.
"Free choice among all legally
qualified physicians and sur-
geons, subject to the right of
any physician or surgeon to re«
fuse patients."
"At the head of the plan, as is right and proper,
stands the existing final authority of the state gov-
ernment,— the Governor, the Senate, the Assembly,
Under this head there is in New York State an exist-
ing Industrial Commission ; to its duties is to be added
that of creating a Bureau of Health Insurance, which
shall be under the charge of a duly qualified physician
or surgeon. Thus far no complaint is justifiable; it is
eminently right and proper that matters of health
should be under a physician or surgeon. In fact, we
must accede the framers of this bill unusual medical
interest and medical intelligence, in that they did not
place the bureau under a sanitary engineer, or under
a professor of geography.
-.1 "Under the Bureau of Health Insurance, the state is
to be divided into districts, corresponding perhaps to
the county divisions, and in each district a local fund
is, or in the discretion of the bureau, one or more
trade funds are, to be established. A 'fund' is defined
for the purposes of the act as 'an incorporated local or
trade fund or an establishment fund.' These funds
are to be administered by a Board of Directors three
of whom are to be elected by the employers, three by
the employees, and one by a majority vote of the six
above named. The duties of this board of directors
are those which one would naturally expect to devolve
upon any group organized to administer what is in
essence a trust fund,— levying and collecting payments,
auditing disbursements, making investments, and so
on, — and receiving not more than five dollars per day
for each day of attendance upon meetings of the board.
"So far, so good. In addition to the financial duties
of the board, it shall employ one or more medical of-
ficers, who shall be legally qualified physicians, and
who shall possess such other qualifications as the
bureau, with the approval of the commission, may pre-
scribe. Article 2, Paragraph 19, states further: 'Xo
medical officer shall practice medicine in any capacity
under this chapter.'
"We see, then, that there is thus far no attempt to
force the services of physicians; the physicians em-
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THE PENNSYLVANIA MEDICAL JOURNAL
December, 1920
ployed are to be 'full-time' men, to use a term which is
somewhat obnoxious, but clear in its meaning to all
medical men. These medical officers are to personally
examine patients, obtain statements from the attending
physician, and then are to issue certificates of disabil-
ity; the physician in charge does not issue these cer-
tificates. One can see here a beginning- of trouble for
the general practitioner, — disagreements as to degree
of disability, etc. ; and yet it would seem that some
such officer must exist, to guard the finances of the
fund against abuse, and therefore the act seems to be
thus far right and proper.
"Since the medical officer has a certain oversight, —
and must have, under any such scheme,--— over both
patient and physician, I place in my diagram the in-
sured and the physician under and in equal relation-
ship to, this medical officer. The employee, or the
insured, or the patient, is defined as 'an employed per-
son entitled to compensation for injury under the
Workmen's Compensation Act,' who is not otherwise
insured, as under a private scheme of the employer,
and who is automatically, by virtue of being an em-
ployed person, insured without physical examination.
"Now, at last, is where you and I come in. Para-
graph 12 of Article 2 states : 'Medical Service. Local,
trade and establishment funds shall furnish medical
and surgical attendance as provided in the previous
section, by offering free choice among all legally quali-
fied physicians and surgeons, subject to the right of
any physician or surgeon to refuse patients.'
"This certainly does not sound like an attempt to
force contract practice, even though it be true that the
practice, if accepted, must be accepted under condi-
tions, and these conditions may indeed be open to dis-
cussion. But it seems to me that we must grant that
the proponents of this measure have honestly tried to
avoid strictly contract practice, and that they have
tried as honestly to reach a fair basis of dealing. The
act provides that the bureau shall reach a mutual basis
of agreement with the local bodies of medical men, the
county medical societies, as to the proper conditions
of service. We must grant that there is no other body
familiar with local conditions and with any semblance
of authority other than the bodies to which this act
turns, — the county medical societies.
"But I do not intend to discuss details, such as
proper fees. Let us grant that a business body would
have to reach some kind of a business agreement with
somebody; and let us grant that the framers of this
act have done wisely, and, in fact, have done the best
anyone could do, in their effort to handle a vexed ques-
tion. Yet I feel that we can leave details aside, for
details will not need to worry us, if, as I believe, the
entire scheme is inherently impossible.
"I stated that such a plan is unjust to the insured.
I arrive at such a conclusion from a consideration, not
of the bill itself, but from a consideration of the facts
of disease. It is ti;ue that under such conditions as
prompted Senator Davenport's interest in this meas-
ure, the presence of an acute epidemic disease, much
can be done by the physician. It is in such circum-
stances possible to obtain concerted action against a
visible, common enemy. The conditions are only com-
parable to the conditions in a country when that coun-
try is at war; and we are all still thirsting, not for,
but because of, the concert of action only possible dur-
ing the war times.
"This difference is peculiarly evident to the medical
man, who sees the reaction of the people to the in-
fluenza epidemic, and the absolute apathy of the same
people in the presence of a still more deadly scourge,
— tuberculosis. The one is like the common enemy b
war, — almost visible; the other is insidious, familiar
to the point of contempt, therefore we get no action.
"Very well. Would not such a scheme, even if a
failure in handling the disease of every day, be justi-
fied for what it might accomplish in times of epidemic,
and for what it might accomplish in protecting work-
ers in dangerous trades? Certainly not; for epi-
demics must be handled not by local action but by
state-wide or by Federal action ; and for this we have
our State Boards of Health, and I hope will soon have
a Federal Board of Health ;_ for the special instances
we have our factory laws and factory inspectors. If
anything is needed here it is decidedly not more ma-
chinery, more law, but smoother working of existing
machinery, better enforcement of existing law.
"In the presence of the common enemy it is right to
force concerted action, everyone must help; there is
no room for the pacifist and the slacker. But the dis-
ease of every day is not justly comparable to such
conditions, as I see it
"For example: Why should the sensible working
woman pay sick benefits to an insurance scheme, and
at the same time buy (at present prices) underclothes,
stout shoes and rubbers, and stockings that actually
cover; while her sister, the working lady, wears noth-
ing much but a waist which exposes her gallbladder to
the chill blasts of winter, wading through the slush in
high-heeled slippers, and exposes her calves in a man-
ner which should constitute cause for action by the
Society for the Prevention of Cruelty to Animals?
"Why should the young nkarried man, struggling to
maintain a home for his growing family in these days
of house-rent as it is, pay sick benefits for his fellow-
worker who has acquired a chronic urethritis by sitting
in the rain watching a football game, or in some of the
other innumerable ways so well-known to the general
practitioner ?
"This seems to me to be peculiarly hard upon the
working woman with the stout shoes; for as the Law
•of Life is written, she will probably be a self-support-
ing employee all her life; while her sister of the
chilled gallbladder will marry the man of the unfor-
tunate experience, and these twain will immediately
proceed to contribute their quota of sickly, senseless
children to the public care.
"It is true that someone must care for the ignorant,
the careless, the unfortunate. But if My Lady of the
Limousine will insist upon setting the example of
clothing herself, quantitatively, in inverse proportion
to the cost of her automobile, then she should bear
some of the cost of caring for her sister, who has
tried to emulate My Lady's example, but in the un-
heated street car.
"In other words, sickness due to municipal and to
individual ignorance, to municipal and to individual
carelessness will be always with us, and will constitute
the greater part of the burden of disease. Therefore
the cost of combating such sickness, the cost of caring
for the unfortunates, must be borne by all of us, not
by the employer and the employee alone.
"It may be said in answer to this argument that
after all the cost will be shared by everybody ; that the
employer will raise wages to cover the payments de-
manded from the employee, add to this increase of
his payroll his own contribution, and tack both on to
his overhead charges, thereby incidentally cutting down
his excess profits tax ; then he will raise the price of
his manufactured goods enough to cover all this,—
and then some. This may be true in times of rising
prices; probably not when labor is plentiful, markets
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COUNTY MEDICAL SOCIETIES
193
well supplied and competition keen. And, after all,
my al-gument really turns on the thought that I would
make the individual pay the cost of treating the re-
sults of his own carelessness; maybe then he will
learn.
"I have said that this act is in conflict with the fun-
damental principles of the practice of medicine. The
act provides that all employees, under the meaning of
the act, shall be insured without medical examination.
This means that the malingerers and the chronic in-
valids will be the first patients of a physician who un-
dertakes to work for the fund. Now a practitioner of
medicine or surgery succeeds in proportion to his suc-
cess, and his success is measured by the cases he can
cure. No man can afford, — and I use the word afford
in its broad meanipg, not in its mere financial sense, —
no man can afford to undertake to treat a clientele
composed of malingerers and the hopelessly ill. Even
the success of the best of physicians may be placed in ,
jeopardy by a small series of fatal cases.
"In addition to this conflict with the principles of
practice, another serious one arises under the provi-
sions of the act, namely, the necessity of practicing
under the supervision of the medical officer. No self-
respecting physician will treat a patient "and then have
some third person step in to control' and pass on his
work; not because the physician fears to have his
work passed on, but because he knows that the relation
between doctor and patient is a personal relation, and
is so recognized in law. The entry of a third person
destroys this acknowledged relationship.
"Or, to put the matter in a different way, suppose a
surgeon is called to see a case of fulminating appen-
dicitis; if he operates immediately, he may save the
patient, and the surgeon is willing to take that chance.
But hold, we must first get the medical officer's con-
sent to hospital treatment, and he is out of town, at-
tending the State Convention of Medical Officers.
The next time that surgeon is called to see a case, he
will first inquire if the patient belongs to a fund, and
if the patient does, the surgeon will refer him to a
colleague whom the surgeon does not love.
"The insured will therefore be unjustly forced to
pay for the cost of his neighbor's carelessness ; and,
an even greater injustice, he will be forced by the
natural workings of such a measure into the hands of
the very young in the profession or into the hands of
the older incompetents; instead of obtaining better
medical service he will inevitably obtain worse service
than he does to-day. The act does not provide for
hospitals, therefore we but add to the existing eco-
nomic burden. The dispensary doctor to whom this
sort of scheme may at first appeal, with the thought
that he may obtain, under the workings of such an act,
some recompense for what is now a thankless service,
may reap a small, immediate financial return, but at
the cost of his professional self-respect, and to the
ruin of his future career.
"Let us turn for a moment from a consideration of
the act itself to the broad question of health insur-
ance, and assume, for the purpose of the argument,
that a need for some change does exist, that the public
is not receiving to-day as good medical attention as
it should ; why is this so, and what can be done about
it?
"Suppose we look upon the matter in the light of an
attempt at constructive criticism ; thus far we have
been destructive. But a constructive effort may show
still more plainly the defects of the proposal before
us, and may point the profession toward the solution
of the difficulty.
"The fault, I am inclined to believe, lies in the fact
that we have been educating our medical men away
from the human side into the scientific side. We are
so keen and prompt in the laying on of the microscope
that we forget the laying on of hands. In these days
of autogenous vaccines we forget that the acne bacil-
lus,— if there be such a thing, — needs in order to thrive
at all, a skin properly fertilized with cake and candy
and pie. In infectious disease two factors are always
necessary, — the specific infectious agent and a recep-
tive host, — a run-down condition, if you will; we are
strong on our hunt for the bug, — are we as wide-
awake to the condition of the host, — to the human ele-
ment? We teach thoroughly the diagnosis and treat-
ment of pernicious ansemia, but our knowledge of the
common cold has not advanced in the last fifty years.
The perfection of the technique of appendectomy leads
us to forget that a green-apple bellyache can and does
exist. Now do not go from here and say that I said
we were teaching our students too much science; let
the practitioner shove in all the science he can get,
but let him remember that he is shoving it into a
human being, not into a test-tube; don't delegate all
the hand-holding to the nurse. Where is the man to-
day who feels himself in position to go to the mother
of the girl of the chilled gallbladder, and to say to her
in the Shakespearian language of the old family doc-
tor,— 'My good woman, you are a damned fool, you
haven't sense enough to raise a kitten'?
"It is said to be a fact of present-day employment
that men seeking work ask but two questions : 'What
is the pay?' and 'Who is the foreman?' It must some-
what chill the ardor of the International Welfare
Workers that these men do not ask at all concerning
the welfare work, and whether the toilet rooms are
equipped with silent sanitary systems. The only ques-
tion beside the natural one concerning the pay is a
question concerning the human being with whom they •
will come in most intimate contact. If this is true of
their everyday work, how much more will they crave
human sympathy in sickness? I know at the moment
of a chief surgeon of a large corporation who is seek-
ing a surgeon, and the main specification is that the
surgeon shall be a man capable of taking a human in-
terest in the men.
"An analysis of the causes of absenteeism of the
workers in a large industrial plant reveals that of the
17.1 days lost per employee, 11 days are lost for per-
sonal reasons and because of sickness of less than
three days' duration. We see, therefore, that the pre-
dominant source of illness in industry, — and this we
know from the facts of everyday practice, — is not
cancer nor tuberculosis nor typhoid, but the colds, the
indigestions, the things mostly due to personal ignor-
ance and personal indiscretion ; conditions, therefore,
which are not improved by sunny rest rooms for the
women and sanitary smoking rooms for the men ;
conditions which can only be improved by a return to
the old relationship between the family and the family
doctor. The old family doctor used to occupy a po-
sition of more influence in the intimate affairs of the
family than did the parson. I believe that the people
of the present day are dissatisfied because they want,
not more scientific diagnosis, but more human sym-
pathy.
"To put it in a different way, the trend of modern
medical teaching is toward a method of practice such
as we saw in the army; but if you wish to apply your
army methods to your private practice, you will last
as practitioners of medicine just about fifteen min-
utes. My objection to such schemes as national
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THE PENNSYLVANIA MEDICAL JOURNAL December, 1920
i
htalth insurance is that they unavoidably tend to create
conditions of practice approaching the army condi-
tions ; and to correct existing defects we must go fur-
ther away from such conditions, not try to approach
tiiem.
"It is possible to apply such methods to the people
of the continent; we used to see them thoroughly ap-
plied to the military trained people of Germany. But
it will not do with the American public. An English
physician has recently written : 'But it is to be re-
membered that the medical education of the lay public
here is in striking contrast to that of Great Britain.
The casual laborer is not content with a "bottle of
medicine," but expects a systematic physical examina-
tion.' Because of this higher level of general medical
education, and for other reasons, the conditions of
medical practice in America are unique, and absolutely
unlike those in any other country of which I have
knowledge.
"Other countries have had their country doctors, and
have justly celebrated them in story and in song; yet
I believe that the relations which existed a few years
ago between the doctor of the old school and his peo-
ple in no other country of the world could have in-
spired the lines in that poem of Carleton's :
" 'When so many pined jn sickness, he had stood so
strongly by,
Half the people felt a notion that the doctor couldn't
die;
They must slowly learn the lesson how to live from
day to day.
And have somehow lost their bearings — now this
landmark is away.'
"I am therefore not interested in the success or the
failure of such schemes in other countries. The send-
ing of commissions to study the workings of these sys-
tems in foreign countries is a waste of the public
money, — we must work out our own salvation.
"I would like to call the attention of the Interna-
tional Welfare Workers, — the I. W. W.'s of the higher
social order, — to the fact which seems lost sight of
to-day. -AH basic law is the outgrowth of custom;
that which had become established by long years of ..
usage became the law. Law does not establish custom ;
custom, when finally established, becomes the law. If,
therefore, the pendulum of medical custom has swung ■
to the point of the arc farthest from the human equa-
tion, then we must wait until it swings back, as swing
it will.
"The point I wish to drive home is that we must
attain a more intimate contact between the doctor and
the patient, — a relationship, however, which is not to
be influenced in any positive way by legal enactment.
Custom, now become law, regulates the broad rela-
tionships of marriage; but law cannot dictate the
breakfast-table conversation. Custom, now become
law, defines the broad relationship between the doctor
and the jiaticnt ; but no law can ever favorably influ-
ence in the least degree this intimate, personal rela-
tionship, the existence of which characterized the
practice of the old family doctor, the lack of which, I
believe, results in present-day dissatisfaction on the
part of the public.
"Such measures as national health insurance will
only make this relationship still less intimate; they are
unjust and exceeding futile."
Mr. Ordway Tead, New York City, N. Y. : I was
not asked to speak and am not prepared to go into the
subject thoroughly at this time. I think it is only fair
to state, however, that Mayor Ramsay has the data
about the working of the act and that either he or I
be allowed to make a presentation before you when
your minds are not wearied by listening to so man\
people. It is an enormously important subject. I did
not come prepared to make a speech about it, although
my mind is full of ideas on the subject I hardly know
how to say anything without going so far into the dis-
cussion. I heard almost everything that transpired at
this meeting from the middle of Dr. Hoffman's ad-
dress. Certainly the conclusions Dr. Hoffman has
reached about the duty of the medical profession of
England towards the operation of the British act are
pot in accordance with the attitude of the English
medical profession. There is a great deal that might
bo said as to what we did find and why the doctors
think as they do about it, but I submit that I think it
would be fairer to allot a time to Mayor Ramsay and
myself when we may give an adequate presentation of
our findings. These findings might be briefly laid be-
fore you. I am not an extemporaneous speaker. I
have the dope, as we say, and I would like to give it to
you, but I do not feel prepared to do justice to the
subject in this rather extemporaneous way. I regret
exceedingly that Mayor Ramsay could not get here to-
night to give- you his findings of this. I.^t me sum-
marize in a word our findings from a month's stay in
England. We found a negligible number of individua'
people, not any group, that had any strong reasoned
opposition to the British Health Insurance Act. We
found no organized group. The employers, laborers,
doctors, saving perhaps the commercial insurance com-
panies, that had any reasoned conviction as to the
Health Insurance Act of Great Britain. One may say
among certain groups, for instance, employers there
is a degree of indifference. Then the trade union*.
17,000,000 all, corroborating, very enthusiastic for ex-
tention of benefits which the act offers. As to the
doctors: This is what I heard from Dr. .Mfred Cox.
who is secretary of the British Medical Association.
Those of you who know him and the reputation he
bears will agree with me when I say he voices in a
very honest way the opinion of the majority of the
medical profession of Great Britain. When Mr. Ran^-
say in conversation with Dr. Cox asked his opinion
he said: "You can't drive the British doctors awav
from the British Insurance Act with a crowbar."
There are between 23,000 and 25,000 in Great nritain,
14.000 of these doctors are on the so-called Panels
practicing under the act on full or part time. There
are doctors for the medical work for -school children,
for the medical work done for tuberculosis, for vene-
real diseases, for maternity and prenatal care provided
for by joint basis of contribution of the national gov-
ernment and the local authorities. There are about
18.000 doctors who are in a m.ore or less salaried posi-
tion to the national government of Great Britain.
They recently appointed another to have the decision
about the borderline cases of sickness and eligibility
for cash benefits. They recently appointed thirty.
There was sharp competition, no less than 1,300 phy-
sicians applied for these thirty positions. That one
instance represents the very typical attitude of the
present-day medical profession in England towards
the British Insurance Act. So far as my discussion
with Panel doctors in England goes, so far as Dr.
Cox, the secretary of the British Medical Association,
goes; so far as the secretary of the Medico-Political
Doctors Trade Union of Great Britain is concerned,
the doctors of Great Britain are for the insurance act.
I was not sent over for that purpose. I was selected
for presumably unprejudiced ability to go after facts.
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COUNTY MEDICAL SOCIETIES
195
regardless of whom they hit. The doctors of Great
Britain, gentlemen, are not opposed to health insur-
ance so far as I found out. They were ten years ago.
They offered all the reasons and more that your learned
colleague did in his paper. Dr. Cox would like to
come here and tell the American doctors what the
British doctors think. They will tell you with one ac-
cord that the British doctor is better off economically
practicing under the act than he has ever been before.
There are more doctors more comfortably fixed, more
•doctors utilizing their private machines and with better
homes now that the problem of collection has been
done away with by Panel practice. The problem of at
least the minimum of his income has been decided be-
cause that minimum is assured and is paid for in lump
sum by the government. He does not have to worry
and he is not worrying about his economic status at
every turn. Up to a certain point if it has a certain
number of practitioners on this government Panel his
income is to that extent assured and the testimony is
universal among the doctors that they are better off
professionally and economically than they ever were
before. The only opposition we found among the
doctors — understand we were there only a month and
manifestly there would be objection — the organized
opposition we foimd to the act was not among those
who opposed the extension of medically available serv-
ice, to the people of Great Britain; it was, on the con-
trary, among those 500 doctors vigorously agitating
for full time, salaried state medical service, which, of
course, you are not contemplating at all, and goes
much further than ever thought of being under con-
sideration in this country. The only organized oppo-
- sition comes from them, save individual doctors Dr.
Hoffman has cited very rightly, people who write in to
the British MediccA Journal. The 500 men flood the
country with their pamphlets and they carry on an
intelligent campaign. I am anxious to leave with you
the statement that we did not find the doctors of Great
Britain opposed to the British Health Insurance Act.
Dr. Henrv D. Jump, President of the Medical So-
ciety of the State of Pennsylvania: This has been
very instructive and enlightening. I am a good deal
in the position oJf Dr. Sweet in saying except for the
moderate comparison, the condition of affairs in -Eng-
land does not concern us here for if the Davenport
■bill as offered in the New York Legislature is the last
word which has been given in regard to this matter we
must judge of its effect upon us of such an act by the
Davenport bill and not by the working of the act in
Kngland. But before going further there were one or
two points made in the last speaker's address which
ought to be answered. Dr. Cox may be the mouth-
piece of the medical profession of Great Britain. I
imagine, however, that he is no more the mouthpiece
of the physicians of Great Britain than Alexander R.
Craig is in Chicago voicing the opinions of the physi-
cians in this country. He has his own opinions and we
have ours and hp is not telling the profession what they
think and I imagine the analogy is probably almost
perfect. I believe it is true — to discuss for a moment
longer the English attitude — that many of the British
physicians are satisfied because there is more or less
of an established income and you have to look simply
to the physicians' income in our mining towns to see
perhaps the same sort of attitude, but it is not con-
ducive to good medical practice to work under such
conditions and that the County Medical Society are
standing for good practice rather than for increase of
income or assurance of income. (Applause.)
Apropos of that a man told me to-day that he had
been called in consultation by a man whom I know to
be rather prone to expansion, or to size of practice,
rather than to quality, who had a Packard automobile
to go about and see his patients and he, the consultant
bowled up in a Ford I (Laughter.) So that the mat-
ter of assurance of income and of largeness of income
plays little or no part perhaps in regard to the satis-
faction of the work or the character of the work which
is done.
As Dr. Lewis has pointed out, I take from his ad-
dress, two particular points upon which he bases his
advocacy of such legislation : First, of these, that sick-
ness is the cause of dependency in a greater percentage
than any single cause. Let us grant that this may be
and I have no statistics to disprove his statement, but
is the remedy that which is offered? Is it not rather
more adequate return for service rendered, better
wages rather than more charity? And I have raised
the word charity there and it was brought out by Dr.
Lewis in his address as the ultimate condition of the
individual who becomes dependent. Can we say that
compulsory health insurance in which the workman
pays but about forty per cent, of the cost is anything
but charity cloaked in other words? The employer
pays a part and the state pays a part. It seems very
much like charity to me.
The second point that impressed me in his address
was that the workman could not afford to be ill. He
can if he is being paid. And will he be better cared
for, or can he afford to be cared for by the sort of
physicians that I understand from observers other
than Dr. Hoffman or Mr. Tead, he gets from the
English Panel physician? Will his lot be better if he
quits and puts himself under that kind of attention?
The point made by Dr. Sweet that under the Daven-
port bill the sick man had the choice of physicians, but
that the physician is under constant supervision of the
full-time medical officer is a point which you have got
to bear in mind constantly if you consider this matter
in its fullest effect upon you. Are you going to give
the best sort of medical service if all of your acts, if
all of your prescriptions, all of your decisions have to
be supervised, have to be viseed, have to be sub-
jected to the onerous restrictions of these laws?
If we approve of insurance for sickness why ought
not we to provide against sickness by providing an in-
surance fund for coal because if the individual is not
properly warmed he may become sick and by the same
token let us provide this poor devil of a workingman,
who according to the New York law gets $2.00 a day,
let us provide for his clothing. He needs an overcoat
and he ought to be fed, let us provide him with meat
and potatoes and carrying the thing to the ultimate
conclusion, or the reductio ad absurdum, he has only
a paper value in his wages, the beneficent state pa<-
ternally decides what shall be done with the various
proportions of that $6.00 a week which he* makes.
How perfectly absurd if that be the case. This is a
move in the right direction. Mr. Tead said that they
are clamoring for full salary. Do you want to take
the first move for patemaUsm, government ownership
of the medical profession ? I don't believe we do.
WiLUAM Dkapbr Lewis, Esq.: I feel, gentlemen,
that the hour is so late that I shall take only one min-
ute of your time to tell you the impression which this
discussion has made on me. I came here not to discuss
whether compulsory health insurance was a good thing,
not above all, to discuss whether a part of the scheme
of health insurance you should have a whole panoply
of medical doctors; whether medical attendance
should be part of that scheme or not. I came merely
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196
THE PENNSYLVANIA MEDICAL JOURNAL
December, 1920
to put before you a great social problem, merely to
wake you to the fact that it had to be solved — the
problem of John Callahan. I have. been interested as
much as you as to the testimony first on one side and
then on the other. You said, Dr. Hoffman, that I
came here advocating a health scheme. I do not. I
defy anybody to point to a line that I have ever said
in favor*of that. I came here merely to show you the
problem. Now I have been very much impressed with
one thing that you said and that was when you argued
whether the best medical results could be gotten under
a system where there was a certain amount of control
of the individual doctor by a prominent government
official who is also a doctor. That is just the kind of
testimony that we on the commission want to test
what remedies are best. I was interested in the testi-
mony in Dr. Sweet's paper, while I do not agree with
the attitude for one moment that you cannot learn
anything abroad. Why it seemed extraordinary when
he said sitting practically in his closet that some things
were impossible that actually went on all over the
world, except America. That kind of investigation
which does not go out into the world to seek facts, I
do not go with him there. I may have misunderstood
him, but I do go with him when he tries to get at the
question, which is a question medical men alone can
solv'e, the way of getting at the remedy, which is to
create a semi-official body which will attend to sickness
is a wise part of the insurance scheme. I do take this
position contrary to you, doctor, when you state that
it was charity in disguise. Correctly said that the
cause of sickness as a whole was a combination of in-
dividual ignorance and carelessness with community
ignorance and carelessness and I think some experi-
ence of industrial conditions, what was also industrial
conditions, under feeding as a whole, for instance, in
a community, that that combination in a state or the
community, the industry and the individual of were
responsible for sickness in some relative proportion
and therefore it is not charity if that is true. To throw
the economic cost of the sickness as a whole partly
on industry, partly on the employer and partly on the
community as a whole. It is a sound economic trans-
mission, if you will, of the costs in the case. It is not
charity. I do not agree with that. I do say this that
there is nothing fundamental in America's institutions '
which requires a condition which will take a self-
supporting man and throw upon him a burden which
any reasonable charity can meet and turn the inde-
pendent man into the dependent man and that we are
doing day after day. Speaking for the members of the
commission I think I can go this far when I say
whether we are prejudiced. Dr. Hoffman, or not that
is for other persons to judge. We have not at the
present time, as far as I know, any definite remedy,
but we do see the evil and we want enlightenment
from the workmen, from the manufacturers and from
' the do<flors. There is on?y one point we have gotten
to and that is this: by some device or other the full
incidence of John Callahan's sickness shall not fall on
John Callahan because it was not John Callahan's fault
entirely. It was the fault in part of John Callahan, in
part of the industrial community in which we live and
in part of the community as a whole and these three
elements which cause that sickness should in some
way take over John Callahan's least of all able, to bear
the burden that he is unable to bear. That does not in
the least mean that you have an English or German
Panel system for medical care. That side is a prob-
lem for you doctors to face. We want your help. We
have invited you to try and help us. That is the atti-
tude that I think every commission of the kind should
take in every part of the state. If you don't come in
and help us and give testimony that you doctors gave
us to-night why you have only got yourselves to blame
if in the end some legislation is put through in ignor-
ance of the fundamental principles, as Dr. Sweet
would put it, of the healing art.
Dr. J. E. SwBET, Philadelphia: I would like to ex-
press my admiration for any man, or any group of
men, who can in one month's time find out what a real
Englishman thinks about anything. (Applause.) I
have just recently come back from twenty-two months'
service behind the British front with the British Med-
ical Corps. I do not recall that I found among the
medical officers of Great Britain any who were in
favor of the British Panel System and I do not think
any of them were Panel doctors. I suppose the Panel
doctors were so busy — any way they were not at the
front. Dr. Lewis has mentioned my sitting in a closet
and refusing to go out and get facts. The medical
degree I hold I obtained in Germany and I worked
afterward in France. A point I wish to make is estab-
lished by the very fact that you do not send inquirers
to China and Japan to get information concerning
health insurance. Why not? Because you instinc-
tively realize that the fundamental conditions of life
in China and Japan and South Africa would not
agree with conditions in America and if you analyze
the point is if you compare English medical customs
with American medical customs they are not analo-
gous. I don't know what you are going to do about
John Callahan. We have hospitals to which he could
have gone and gotten 'care. It is very necessary to
consider this question and I have an instinctive feeling
that health insurance is bound to undermine the entire
practice of medicine as we know it, as we want to see
it develop and as we only could practice it.
Thb PrSsident, Dr. .\ixyn: The Chair would like
to express the profound indebtedness which the society
feels to these men who have so much enlightened us
as to the problems which face us not only as to sick-
ness and poverty, but as to the remedies. I would be
very glad if those who remain would rise in a vote of
thanks to the speakers of the evening. (A rising vote
of thanks was thereupon tendered the speakers.)
Thartk you very much.
STATE NEWS ITEMS
DEATHS
Dr. Pbrcv H. Eaier, of Philadelphia, died October
17, 1920.
Dr. W. W. Moodv, . Sunbury, a member of the
Northumberland County Medical Society, died Octo-
ber isth.
Dr. William Thomas Bishop, of 211 Pine Street,
Harrisburg, died on Saturday, Nov. 28, 1920^ at Ebens-
burg after an illness of more than eight weeks. He
was more than eighty years of age. He was a charter
member of the Medical Society of the State of Penn-
sylvania.
Mr. Joseph Gass, father of Dr. Horatio W. Gass,
of Sunbury, president of the Northumberland County
Medical Society, died at Plum Creek, October 16th, at
the age of 75.
Dr. Charles Spencer Kinney, of Easton, Pa., died
October 27th, aged 65. Dr. Kinney was a graduate of
the New York Homeopathic Medical College, class
of 1879, a specialist in psychiatry and a member of
the American Medico-Psychologic Association.
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STATE NEWS ITEMS
197
Dk. I. W. Nbwcombt, aged 78 years, well-known
physician of Stouchsburg, and a member of the Berks
Coimty Society, died from ptomaine poisoning, with
which his entire family was also afflicted. Dr. New-
coraet was a graduate of the University of Pennsyl-
vania, and had practiced his profession in Stouchsburg
for 54 years.
Dr. George S. Gerhard, of Philadelphia, died in the
Bryn Mawr Hospital, October 27th, from heart dis-
ease, aged 71. Dr. Gerhard was a graduate of the
University of Pennsylvania, 1870, a member of the
state society, and one of the founders and for twenty-
seven years physician-in-chief of the Bryn Mawr Hos-
pital.
• FuNERAi, SERVICES were held November i6th, at
Chambersburg, for the late Dr. John H. Deavor, the
Rev. Dr. I. W. Hendricks, pastor of Zion Reformed
church, officiating. The honorary pallbearers were
Dr. C. F. Palmer, Dr. J. C. Greenawalt, both of Cham-
bersburg; Dr. J. B. Amberson, of Waynesboro, and
Dr. D. M. Unger, of Mercersburg. Burial was made
at Fort Loudon.
August Robinson, one of the best-known young
men of Scranton, son-in-law of Dr. S. P. Longstreet,
was killed October 31st in an automobile accident in
Taylor. Mr. Robinson, with two friends, was return-
ing from Wilkes-Barre, and just as the machine was
passing a truck a tire blew out. The automobile was
overturned, and Robinson's neck was broken, while
his two friends were seriously injured.
Dr. Wili,iam Pai,mer, head of the surgical advisory
board of the Ridgway Hospital and nationally known
as a surgeon, was killed near Johnstown, November
3d, when an automobile in which he was riding upset
on the new state highway. Gustav Florin, a wealthy
contractor of Johnsonburg, who was riding with Doc-
tor Palmer, was probably fatally injured. The state
road about two miles from the village had been under
repair and was just completed. Doctor Palmer and
his companion were the first to ride over it. The
roadway was wet and slippery, and it is believed that
Doctor Palmer, who was driving to Ridgway, lost
control of the car, causing it to skid from the roadway
and overturn in a ditch. The occupants were pinned
beneath it A party of motorists hurried to the rescue.
Doctor Palmer and Florin were taken to the Ridgvvay
Hospital, where the surgeon died without regaining
consciousness. Doctor Palmer is survived by his
wife and daughter, both of Brockwayville, and two ■
sons, Russell and Francis.
ITEMS
Dr. J. E. DwYER, of Polk, Pa., has taken up a new
location at 1633 Boston street, Tulsa, Okla.
Dr. Clark S. Long, of Mainville, has rented a resi-
dence in Benton, where he will move in a few days to
practice his profession there.
Dr. M. L. RaEmore has been elected to the surgical
staff of the Williamsport Hospital to fill the place
made vacant by the death of Dr. G. Franklin Bell.
Dr. Walter F. Donaldson, Secretary of the Med-
ical Society of the _ State of Pennsylvania, recently
stistained painful injuries to the muscles of his back.
Dr. H. J. Donaldson, of the Lycoming County So-
ciety, recently entertained about forty physicians of
the ■ county at his beautiful summer home up the
Loyalsock in a most royal manner.
Crossing a road near HoUidaysburg, Dr. H. E.
Crumbaker, of Altoona, 54 years old, was struck by
an automobile and is in the hospital in a critical con-
dition with concussion of the brain.
Drs. R. B. Hayes, R. H. Bmin, J. L. Mansury, B.
P. Chaapel, John A. Klump and W. S. Brenholtz
were guests at the October meeting of the Bradford
County Medical Society at Canton.
The Wayne Soldiers' and SAaoRs' Memorial Hos-
pital at Honesdale was opened on October ist,_ with
a capacity of twenty-five beds. Miss Irene Bishop,
R.N., has been appointed superintendent.
On November 3d Dr. John J. Gilbride, of Philadel-
phia, delivered a most interesting and instructive ad-
dress on the Surgery of the Stomach, before the
Lancaster City and County Medical Societies.
Dr. Peter L. Swank has moved to Clearfield County
and his property at Salisbury (Elk Lick Post. Office)
is for sale. Any one looking for a location can get
information by addressing his Elk Lick home.
Miss Vivienne, daughter of Dr. and Mrs. Qarence
Bartlett, of 1435 Spruce street, Philadelphia, was pre-
sented to society at a tea on November nth. Dr.
Bartlett is the editor of the Hahnemannian Monthly,
At a meeting of the Board of Education of Oly-
phant, held November ist. Dr. E. F. McGinty, of that
place, was appointed medical inspector to fill the va-
cancy caused by the death of his brother, Dr. James
McGinty.
On October 27th Dr. E. Bosworth McCready, of
Pittsburgh, gave an address, by invitation, before the
Medical Society of the District of Columbia, entitled
"The Nervous, Delicate and Backward Child as a
Medical Problem."
Dr. J. W. Bruner, of Bloomsburg, Columbia Coun-
ty, during October attended the Tenth Censorial Clin-
ical Congress of the American College of Surgeons
at Montreal, at which session he was elected to fel-
lowship in the college.
In reviewing the publications of the County Med-
ical Societies, it is noted that there is a steady in-
crease of membership. This is as it should be; the
total membership of all our societies should be 8,000
in the next twenty months.
Dr. C. H. Swenk, Sunbury, has been appointed
chief of the child health clinic of the State Depart-
ment of Health in Northumberland county and Dr.
John Henry Steams, Stroudsburg, chief of the Mon-
roe county genito-urinary clinic.
Dr. AND Mrs. W, Marshall Bland, of Washington,
D. C, who were guests of the latter's parents, Mr.
and Mrs. John F. Lutz, 1819 Berryhill street, Harris-
burg, have returned to Norfolk, Va., where Dr. Bland
has been appointed assistant surgeon at the Base Hos-
pital.
Dr. and Mrs. S. F. Hazen, of Hartstown, Craw-
ford County, are sick in City Hospital, Meadville,
with t3rphoid fever. There is an epidemic of this dis-
ease in that community, fifteen cases having already
developed. The infection was traced to a chicken pie
social.
Dr. and Mrs. B. M. Garpinkle, 1219 North Second
street, had as their g^uests for several days recently
Mr. and Mrs. Hamburger, of New York City, who
were on their wedding trip to Niagara Falls and Can-
ada. Mr. Hamburger is a well-known attorney of
New York.
Miss Hazel Lucille Peck, daughter of Dr. and
Mrs. Vernon Peck, of Singer Place, Wilkinsburg,.and
Edison C. Speer, of Pittsburgh, were united in mar-
riage November nth, in the home of the bride. The
ceremony was a simple one, owing "to illness in Mr.
Speer's family.
Dr. Raymond J. Bower, of DuBoistown, Lycoming
County, who crossed the ocean 20 times during the
war as a surgeon on our American transport, has
completed a term of service at the Bryn Mawr Hos-
pital, and has located in Williamsport with offices at
324 Court street.
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THE PENNSYLVANIA MEDICAL JOURNAL December. 1920
Dk. G. O. Keck, of Mercer, who has been assistant
director of the Mont Alto sanitorium for some time,
has been named by Col. Edward Martin, commissioner
of health, to succeed Col. T. L. Hazlet, who re-
signed to accept a position with one of the big Pitts-
burgh industries.
Ths physicians of the lower end of Lycoming
County held a meeting at Mtmcy a short time ago
and decided by a unanimous vote to raise their fees
to correspond to the fee bill adopted by the county
society. They also decided to form an organization
to meet. regularly for their mutual benefit.
On November 17th, in the Protestant Episcopal
Church of The Ascension at 7 o'clock. Miss Marion
Thorpe, daughter of Dr. and Mrs. Francis N. Thorpe,
of Bayard street, Pittsburgh, and Dr. Isaac Slaymaker
Diller, of Fifth avenue, were united in marriage, with
Rt. Rev. Cortlandt Whitehead officiating.
Dr. J. E. WuRSTER, formerly of Montoursville, hav-
ing completed special courses at New York and Phila-
delphia, has located in Williamsport, with offices at
430 Pine street. ■ Dr. Wurster has been appointed chief
of the state venereal clinic, which is held at the Wil-
liamsport Hospital three days each week.
Dr. S. M. Rinbhakt and his wife, Mrs. Mary
Roberts Rinehart, novelist, of Sewickley, narrowly
escaped injury late on November 3d, when their auto-
mobile straddled a wooden guard beam on the high
bridge connecting Pittsburgh and Bellevue. The front
wheels and axle of the machine were torn off.
It is reported that John G. Bowman, formerly for
three years president of the State University of Iowa
and since 1914 director of the American College of
Surgeons, has been elected Chancellor of the Uni-
versity of Pittsburgh, to succeed Samuel Black Mc-
Cormick, who has resigned because of ill health.
The pollowing medical inspectors of schools have
been appointed by Colonel Edward Martin, state com-
missioner of health: Dr. C. C. Spangler, York, for
East Hopewell township and Cross Roads borough,
and Dr. C. W. Tressler, Shickshinny, for Shickshinny
and Union and Hunlock townships, Luzerne county.
The friends of Dr. Charles P. NoWe will be pleased
to learn that with health restored and energies re-
newed, the doctor has again resumed practice at 1832
Spruce street, Philadelphia. Some years ago. Dr.
Noble was obliged to give up his practice, owing to ill
health, and is to be congratulated on his return to an
active life in the profession.
Dr. John W. Ruskin, a noted traveler and explorer,
who was a member of the Harry Payne Whitney ex-
pedition which went to the rescue of Dr. Frederick A.
Cooke in the northland, recently addressed the com-
bined Rotary and Kiwanis clubs of Williamsport,
showing many instructive and entertaining pictures
taken in the north on his journey, which extended
over three years.
Miss -Emma High, choir director of First Presby-
terian church, Pottstown, tendered her resignation
and left November ist for Constantinople, Turkey, to
become the bride of Charles Wylie, son of Dr. Charles
R. Wylie, of Pottstown. lyir. Wylie is a high school
graduate and a former captain of Lehigh University
football team. For several years he has been in
charge of the Standard Oil Company's interests in
Turkey and Syria.
On October 13th the Bureau of Medical Education
and Licensure brought to trial E. Parker Read, of
Philadelphia, on the charge of practicing medicine
illegally without a state license. He was convicted
by the jury, appealed for a new trial, which was on
October 29th refused, and a jail sentence of six months
in the county prison imposed. The case was later
appealed to the Superior Court, but at this writing,
no action has been taken.
Dr. SAMim. D. Ingham has resigned as Clinical
Professor of Neurology in the School of Medicine of
Temple University and Neurologist to the Samaritan
and Garretson Hospitals, Philadelphia. Dr. Eugene
Lindauer has been elected to fill the unexpired term
of Dr. Ingham. Dr. Ingham is leaving Philadelphia
December 3, 1920, to enter upon professional duties in
Los Angeles, Cal. He will join a medical diagnostic
unit which has been organized in Los Angeles by Dr.
Isaac H. Jones, formerly of Philadelphia.
Dr. Robert Grier Le Conte, of 1530 Locnst street,
Philadelphia, who was a lieutenant commander in the
naval medical corps, has received his third citation.
Josephus Daniels, secretary of the navy, conferred on
Doctor Le Conte recently the distinguished service
medal in recognition of his services in the World War.
Just a week previously Doctor Le Conte received the
Order of Leopold from the Belgian government, and
about a year ago the* French government conferred
on him the cros of the Legion of Honor.
Doctor Le Conte organized and took to France the
United States Base Hospital Unit No. 5, which was
one of the finest of its kind in France.
Dr. and Mrs. Robert G. Le Conte gave a dinner,
followed by a theater party on Friday, December loth,
in honor of Mrs. Le Conte's debutante daughter. Miss
Masie H. Stewart.
The Washington State Board of Chiropbactic
Examiners, according to Northwest Medicine, recent-
ly wanted to curb the board of drugless examiners
from licensing another variety of healers who call
themselves "Sanipractic" and who, under this designa-
tion, encroach on the exclusive privileges of the Chiro-
practic. The judge pronounced a weighty decision,
the substance of which was in effect "it can't be done."
The lucidity of the Einstein theory of relativity sug-
gests itself, according to the editor, when the different
drugless healers clash.
Dr. Thomas W. Jackson, assistant to Col. Edward
Martin, the state commissioner of health, has been
granted leave of absence for a year to engage in pub-
lic health work in this country and in South American
republics. "The services of Dr. Jackson were asked
by the United States government and he has been
granted a leave for a year to carry out work for which
his talents were desired," said Col. Martin. "I con-
sider that the State of Pennsylvania has been hon-
ored by the request for his services and we have
'loaned' him for a year."
Dr. and Mrs. W. L. Harvison announce the mar-
riage of their daughter, Zora, and Harold E. Sutton,
of St. Clairsville, Ohio, which took place Wednesday
afternoon, October 27th, with Rev. E. G. Forrester of
the East McKeesport United Presbyterian church of-
ficiating. Miss Hazel Cooke, of East McKeesport,
was her cousin's attendant, and Richard Johnson, a
cousin of the bridegroom, was best man. The wed-
ding music was played by Miss Jennie O. Cook, of
Homewood. Mr. and Mrs. Sutton will make their
home in St. Clairsville, Ohio.
The Editor is delighted to receive, under date of
November 19th, the following letter from Dr. John
M. St. Clair, Indiana, Pa., and wishes the same might
be said of some of the other brother physicians who
have not been, but might well be, reported as dead to
the benefits to be obtained by a lively interest in die
work of the Society : "You have reported me as being
dead in two different articles in your November num-
ber, which is not the case as I see it. I weigh 209
jwunds and work every day, and never enjoyed aiiy
better health than I am at this present writing."
From the Berks County Bulletin we quote: "The
G. U. Section of the State Department of Health has
submitted a scheme for the operation of its dispen-
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GENERAL NEWS ITEMS
199
saries in the different cities, to the officers of the
State Society, and opinions are being obtained, and
when this is done it will be made .public. On the
whole the scheme seems reasonable and if conducted
along the lines suggested no harm will come to the
profession and much good to the sufferer who is
placed in such financial circumstances as to be imable
to pay for treatment and up to this time has been re-
fused admittance to the hospitals of the state."
On November 17th Miss Mary E. Mock, a niece of
Mr. and Mrs. Charles M. Schwab, was married to
Dr. Paul H. Walter, of 60 East Broad street, Bethle-
hem, Pa., at the Riverside Drive residence of Mr.
and Mrs. Schwab in New York City. Both Dr. Wal-
ter and Miss Mock formerly resided in Pittsburgh.
Dr. Walter attended I^afayette College and received
his medical training at Jefferson College, graduating
there in 1913. He is an ear, nose and throat specialist
and is head of that department at St. Luke's Hospital.
The couple will be at home after December isth for
a time making their home at the residence of Mr.
Schwab on Fountain Hill, Bethlehem.
Miss Dorothea Rambo Brander, daughter of Mr.
and Mrs. John J. Brander, of Pemberton, N. J., and
Dr. Alexander Stewart, son of Colonel and Mrs.
George H. Stewart, of Shippensburg, Pa., were mar-
ried Saturday afternoon, November 20th, in the Arch
Street Presbyterian church, Philadelphia, with Dr.
Clarence Edward McCartney officiating. The imme-
diate families were the only guests present. Follow-
ing a luncheon, at the Bellevue-Stratford, the couple
left for New York and other eastern cities to spend
their honeymoon. Dr. Stewart is a graduate of the
University of Pennsylvania, class of 1919, and will, in
the near future, open offices in Shippensburg for the
practice of medicine, being the third Dr. Stewart of
the same family to follow the practice of medicine
within the past generation. He is a nephew of Justice
John Stewart, of the State Supreme . Court, and a
brother of George H. Stewart, Jr., recently elected to
the State Legislature from Cumberland County.
The FOLtowiNG RESOLUTIONS on compulsory health
insurance legislation were adopted by the Pennsyl-'
vania State Chamber of Commerce, at the second an-
nual convention, held at Harrisburg, September 27-28 :
Whereas, The agitation in behalf of the adoption
of a State Compulsory Health Insurance Law has
led to the appointment of a legislative commission to
study the subject and make a report at the coming
session of the legislature, and
Whereas, The Pennsylvania State Chamber of Com-
merce has made an exhaustive study of the subject, the
report of which has been published, which furnishes
convincing evidence of the unwisdom of such legisla-
tion ; therefore, be it
Resolve^, That the Pennsylvania State Chamber of
Commerce, in convention assembled, is of opinion
that there is no general demand for the enactment of
such legislation, and no useful purpose would be
served by it.
GENERAL NEWS ITEMS
The .^LL-.^ merican Conference on Venereal Dis-
eases was held in Washington, December 6th to nth,
immediately following the Institute on Venereal Dis-
ease Control and Sex Education.
Nervous and Mental Patients in the Marine
Hospital.— The United States Public Health Service
will soon convene in Pittsburgh a board consisting of
Dr. A. J. Ostenheimer, of Philadelphia; Dr. T. Diller,
of Pittsburgh, and the officer in charge of the Marine
Hospital to arrange for the setting aside in the hos-
pital of a section for the diagnosis of neuro-psychia-
tric patients from the third district of the Service,
comprising the States of Pennsylvania and Delaware.
Dr. M. p. Ravenel, of Columbia, Director of Pre-
ventive Medicine at the State University, was elected
president of the American Public Health Association
at the annual meeting held in San Francisco recently.
The Venereal Disease Division of the State Board
of Health has established twenty-one venereal disease
clinics throughout the state for the free treatment and
education of persons unable to pay for private treat-
ment.— Missouri State Journal.
St. Louis University, the Oldest Seat of Le.min-
INC west of the Mississippi River, has for the first
time in its more than a century of endeavor made a
public appeal for funds, the larger portion of which
are to be applied to the support of the Colleges of
Medicine and Dentistry. The university has asked its
alumni and friends to raise the sum of $3,000,000 as a
Centennial Endowment Fund, in commemoration ot
the one hundredth anniversary of the founding of
the institution. The anniversary occured in 1918, buf
because of war conditions existing at that time, with
over 3,000 of the undergraduates and alumni of the
medical department of the university having answered
the call to arms, the celebration was postponed until
conditions were more nearly normal. More than fifty
per cent, of the faculty and forty-three per cent, of
the alumni of the medical department of the univer-
sity held commissions in the army and navy at the
time the actual centennial date fell.
Dr. C. W. Burrill. of Kansas City, was elected
Surgeon-General of the Grand Army of the Republic
at the national encampment which was recently held
in Indianapolis. Dr. Burrill was medical director.
Department of Missouri, of the G. A. R., in 1919, and
was reelected to that position this year. He has prac-
ticed in Kansas City for over forty years and was
elected an honorary member of Jackson County Med-
ical Society last February. — Missouri Stale Journal.
Enlargement of Hospital at Tucson. — The United
States Public Health Service is enlarging its hospital
at Tucson, Ariz., so as to provide for 200 more pa-
tients than it now accommodates, and for the neces-
sary increase in hospital personnel. The enlargement
is necessary to accommodate the large increase in the
number of patients in this vicinity.
Physicians and Legislation. — "The Jeremiad of
Dr. John B. Hawes on the little influence medical men
have on legislative proceedings and the pessimistic
attitude taken by our honored president lead me, by
instinct, an optimist, to open my mouth at possibly
some sacrifice of my modesty.
Do gentlemen expect to obtain legislative action
without hard work?
Do they expect that everything that appeals to them
as right is instantly to be accepted by the legislative
mind, absorbed by the legislative brain, and enacted
into law without reflection? If so, they expect more
than they will ever get, far more than any other body
of men will obtain, or ever did obtain, and when they
state that medical opinion has no influence with those
who legislate for us, that practically no laws have
been passed in our own state through the efforts of
our legislative committees and our physicians, I beg
most emphatically to differ with them.
Let us remember that the measures which appeal
most to us are almost invariably opposed by strong
interests adversely affected by them. Let us remem-
ber that legislators cannot remain in the legislature
unless kept there by the votes of their constituents.
Let us remember that by no means every proposed
law succeeds or fails on its merits only, whether it
has to do with the practice of medicine or is entirely
foreign to it, that human nature is human nature, that
physicians are not always absolutely unselfish in their
desires, and we may have more kindly feelings toward
those whom we select to legislate for us." — Boston
Medical and Surgical Journal.
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THE PENNSYLVANIA MEDICAL JOURNAL
December, 1920
Recruiting Nursbs. — Owing to the impending lack
of trained nurses to staff the new hospitals that are
being opened by the United States Public Health
Service the superintendent of nurses will make an
effort during her pending tour of inspection to obtain
recruits to fill the vacancies. Public Health Service
hospitals exist in all parts of the country and offer
opportunities for patriotic service in the care of dis-
abled soldiers of die great war.
Hospitals Take Place op Jails in Housing
"Drunks." — A veteran Salvation Army worker in
Chicago is reported as saying that empty jails are no
criterion of die good results of prohibition, and that
there are more drunks now than before the Eighteenth
Amendment went into effect, "but the reason is that
all the drunks now adorn cots in the hospitals. The
stuff they sell for booze sends men to hospitals atid
cemeteries." — Medical Record.
Gift to Society for Prevention of Cruelty to
Children.— A gift of $4,000,000 has been made by Mr.
and Mrs. August Heckscher to the Society for Pre-
vention of Cruelty to Children. The gift comprises
a plot at Fifth Avenue and One Hundred and Fourth
Street, with a new building endowment sufficient for
maintenance. Within two years, it is estimated, the
society will have a complete new plant with a capacity
for the care of more than double the present number
of waifs and mistreated children that come under its
protection. — Medical Record.
Students in American Medical Schools.— The
House of Delegates of the Michigan State Medical
Society authorized an extension drive for membership
during the month of October. The reasons given
were as follows:
1. Our State Society should include and be repre-
sentative of all the eligible physicians in Michigan.
2. Organized effort, influence and prestige alone will
s^-rve to conserve our individual interests in these days
of changing relationship in the social and industrial
3. Legislature measures affecting our relationship
to the public and our personal prerequisites will be
introduced into the legislature this coming session.
Our committee, protecting your interests, will exercise
greater influence and accomplish desired results if they
can exhibit their requests as coming from the entire-
profession of Michigan. . , „ . i- •
4. Larger county societies, composed of all the eligi-
ble physicians in the county, will accomplish greater
ife.'iults in the respective localities.
Michigan State Medical Society has a membership
of 2,70?-nonmembers eligible to membership 261.—
Iowa Stale Medical Journal.
United States Public Health Service Hoswtals
AND Tuberculosis.— Several of the largest general
hospitals of the United States Public Health Service
arc being provided with special facilities for the diag-
nosis of tuberculosis and for the study of patients to
determine which Public Health Service hospital is
best suited to their needs. These hospitals will be-
come clearing houses for the diagnosis and placement
of tuberculosis patients in their vicinity, especially
for those with doubtful diagnosis or with complica-
tions requiring expert care. At each of them physi-
cians skilled in this specialty will be on duty and the
most modern methods will be in use. All Public
Health Service hospitals, however, are open to tuber-
culosis cases; and admission is never denied because
of lack of special facilities.
Special centers are already functioning in the Pub-
lic Health Service Hospitals at Fort McHenry, Balti-
more. Md.; Fox Hills, Staten Island, New York,
and Hospital 35. St. Louis, Mo. Other centers will
be organized as soon as possible.
Foreign Doctors Invade Spain.— Foreign practition-
ers, particularly Austrians, have invaded Spain in
such numbers that native physicians and surgeons
have appealed to the government to make regula-
tions making it obligatory that foreign practitioners
acquire a medical degree in Spain before being i>er-
mitted to practice. — Medical Record.
Resign prom Medical Faculty Marquette Uni-
versity School op Medicine.— Ten members are re-
ported to have resigned from the faculty of the Mar-
quette University School of Medicine of Milwaukee,
Wisconsin, on account of a disagreement between
them and the president of Marquette University over
several ethical questions, one of which is that of sac-
rificing unborn infants when necessary to save the life
of the mother. Those resigned arc :
Drs. Louis M. Warfield, professor of clinical medi-
cine; John L. Yates, professor of clinical surgery;
Emerson A. Fletcher, director and professor of genito-
urinary surgery; Carl Henry Davis, associate pro-
fessor of obstetrics and gynecology'; Chester M.
Echols, associate professor of obstetrics and gyne-
cology; Frederick J. Gaenslen, director and associate
' professor of orthopedic surgery ; James D. Madison,
associate professor of medicine ; Arthur W. Rogers,
associate professor of neurology; Charles H. Stod-
dard, associate professor of medicine. — Iowa State
Medical Journal.
A Great Scarcity op Nurses exists in England.
The refusal of many of the best hospitals to accept
nurses for training under the age of twenty-three is
said to be the cause. — Northumberland County Med-
ical Society Notes.
An Idea op the Enormous Population of the Chi-
nese Nation is given by an English writer, who de-
clares that if, in a war, an enemy started killing Chi-
nese soldiers at the rate of 1,000,000 a year, and if
China were using 10 per cent, of her population in
that war, it would take 50 years to destroy her first
armies, and in that time two further Chinese forces of
50,000,000 each would grow up to face the enemy. —
Northumberland County Medical Society Notes.
Dr. Isadore Dyer, op New Orleans, La., died of
• heart disease on October 12th, at the age of fifty-
five years. He was graduated from Tulane Uni-
versity of Louisiana, School of Medicine, in 1889,
served as interne in the New York Skin and Cancer
Hospital and lecturer in the New York Post-Graduate
Medical School and Hospital, returning to New Or-
leans in 1892. He became affiliated with Tulane Uni-
versity School of Medicine as lecturer on dermatology,
1892 to 1905, associate professor from 1905 to 1908,
and professor from 1908 to the time of his death. He
also served as associate dean and dean of the same
institution. From 1893 to 1905 he was professor of
dermatologn^ in the New Orleans Polyclinic.
American Journal op Obstetrics and Gynecology.
— The discontinuation of publication in February, 1920,
of the American Journal of Obstetrics and Diseases of
Children made vacant a field in journalism that was
needed for men practicing these specialties.
The American Journal of Obstetrics and Gyne-
cology has taken the place previously occupied by the
former journal, and the October issue. Volume I. No.
I, of the American Journal of Obstetrics and Gyne-
cology has been presented to the readers of medical
literature.
This is a well constructed journal, and we believe
that its success will be manifest by a wide circulation.
The Journal is published monthly by The C. V.
Mosby Company, St. Louis, under the able editorship
of Geo. W. Kosmak, M.D.
The model American "settlement house" established
by the American Red Cross, in 1917, in the heart of
the Paris slums, where the average child mortality
has been between thirty and forty per cent, for years
past, has won a striking victory in its campaign against
disease and death.
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BOOK REVIEW
201
BOOKS RECEIVED
Books received are acknowledged in this column,
and_ such acknowledgment must be regarded as a suffi-
cient return for the courtesy of the sender. Selections
will be made for review in the interests of our readers
and as space permits.
Physiology and Biochemistry in Modern Mbdi-
CIN8. By J. J. R. Macleod, M.B., Professor of Physi-
ology in the LFniversity of Toronto, Toronto, Canada ;
formerly Professor of Physiology in the Western Re-
serve University, Cleveland, Ohio. Assisted by Roy
G. Pearce, A. C. Redfield and N. B. Taylor. Third
edition with 243 illustrations, including 9 plates in
colors. St. Louis: C. V. Mosby Company. Price
$10 net.
Repkaction and Motility op the Eye With Chap-
ters ON Color Blindness and Field Vision. De-
signed for students and practitioners. By Ellice M.
Alger, M.D., F.A.C.S., Professor of Opthalmology of
the New York Post Graduate Medical School, etc.
With 125 illustrations. Second revised edition. Phila-
delphia : P. A. Davis Company, Publishers. London :
English Depot, Stanley Phillips, 1920. Price $2.50 net.
Short Talks on Personal and Community
Health. By Louis Lehrfeld, A.M., M.D., Agent for
the Prevention of Diseases, Department of Public
Health, Philadelphia, with introduction by ^ilmer
Krusen, M.D., LL.D., Director (1916-1919) Depart-
ment of Public Health and Charities, Philadelphia.
271 pages. Philadelphia: F. A. Davis Company, Pub-
lishers, 1920. Price $2 net.
An Introduction to Bacteriology for Nurses. By
Harry W. Carey, A.B., M.D., Assistant Bacteriologist,
Bender Hygienic Laboratory, Albany, New York
(1901-1903) ; Pathologist to the Samaritan, Troy and
Cohoes Hospitals, and City Bacteriologist, Troy, New
York. Second revised edition. 150 pages. Philadel-
phia : F. A. Davis Company, Publishers. London :
English Depot, Stanley Phillips, 1920. Price $1.25 net.
Proceedings op the Connecticut State Medical
Society, 1920. 128th Annual Convention, held at New
Haven, May 19 and 20, 1920. Editor, James Frederick
Rodgers. Published by the Society, September, 1920.
The Story of the American Red Cross in Italy.
By Charles M. Bakewell. Illustrated. 253 pages.
New York: The Macmillan Company, 1920.
BOOK REVIEW
OPERATIVE GYNECOLOGY. By Harry Sturgeon
Crossen, M.D., F.A.C.S., Associate in Gynecology,
Washington University Medical School, and Asso-
cite Gynecologist to the Barnes Hospital ; Gynecolo-
grist to St. Luke's Hospital, St. Louis Maternity
Hospital, and Bethesda Hospital; Fellow of the
American Gynecological Society and of the Ameri-
can Association of Obstetricians and Gynecologists.
Second Edition; 717 pages; 834 original illustra-
tions. St. Louis: C. V. Mosby Co., 1920. $10.
This book is devoted exclusively to operative treat-
ment of diseases of the'female genital tract. It con-
tains a systematic presentation of the various opera-
tive procedure available, a description of the details
of operative technique in each case, and a discussion
of "the adaptation of operative methods to the exact
pathological conditions present in the individual pa-
tient." SELECTIVE TREATMENT is the keynote
of the work. This discussion of the comparative
values of the various operative procedures is especial-
ly valuable to the general surgeon. The present vol-
ume is the second edition. Considerable new matter
has been added to that contained in the old, notably a
detailed classification of prolapse operations showing
the relation of the operation to the anatomical struc-
ture involved. Such a classification of retrodisplace-
tnent was made in the earlier edition. So helpful has
this classification proved that the author now adds 4 -
similar table of prolapse operations. About sixty il-
lustrations were also added. H. F. S.
A SHORT HISTORY OF NURSING.
As to be expected any writing under the name of Miss
Lavinia Dock will be worthy of reading and instructive.
This Short History of Nursing is both. The style is clear
and interesting and, as it is a small book, if one starts
reading the book she will not put it down until it is fin-
ished. Every pupil nurse should be reasonably familiar
with the story of the development of nursing, and in
this comprehensive volume she can get all the salient
facts of the subject. It certainly should accomplish its
purpose, to fire her zeal and make her more earnest in
her nursing endeavors. The book should be read by
nurse and physician and especially the last chapter oi)
The Past and Future, should have the consideration
of every one interested in the problems of Nursing
and Medicine. There may be honest differences of
opinion as to whether the efforts to build up the pro-
fession of nursing may not over-step the real purpose
of the nurse to be skilled in the art of nursing the
sick. J. B. McA.
SHORT TALKS ON PERSONAL AND COM-
MUNITY HEALTH. By Louis Lehrfeld, A.M.,
M.D., Agent for the Prevention of Disease, -Depart-
ment of Public Health, Philadelphia. Philadelphia:
F. A. Davis Company, Publishers, 1920. Price $2.00
net.
This book presents to the lay public, in plain lan-
guage, a resume of facts on public health that should
be known by every family. The contents are divided
into seven parts. Under each heading there are short,
concise statements in relation to the prevention of
disease, season conditions to guard against, holiday
hints, miscellaneous topics in regard to sanitation,
food and water. An extremely interesting section is
devoted to infants and children, which should be of
great importance to mothers in the home. Part VII
is devoted to "First Aid to the Injured." This work
of 271 pages_ contains so many valuable suggestions
that we feel it fills a position in home literature to be
desired. V. S.
BACTERIOLOGY FOR NURSES. By Harry W.
Carey, A.B., M.D., .Assistant Bacteriologist. Bender
Hygienic Laboratory, Albany, New York; Patholo-
gist to the Samaritan, Troy and Cohoes Hospitals,
and City Bacteriologist, Troy, New York. Second
revised edition. Philadelphia: F. A. Davis Com-
pany, Publishers, 1920. Price $1.25 net.
A reasonable amount of instruction in bacteriology
is given in every course of training to the graduate
nurse. Many of the publications upon this subject are
too exhaustive to be comprehended during the brief
course of instruction given to this subject in training
schools of hospitals. We find, however, in the con-
tents of this work by Dr. Carey a sufficient amount of
information in relation to the history of bacteriology,
the classification and distribution of bacteria, methods
of sterilization and disinfection. The treatise is very
concise as to infection and immunity. It treats of dis-
eases that are caused by the molds, yeasts, and higher
bacteria. A chapter is devoted to bacteria in water
and milk. The technique of the laboratory is given in
very plain language, with sufficient illustrations to be
comprehensive. This book should be in the hands of
every student nurse. V. S.
THE STORY OF THE AMERICAN RED CROSS
IN ITALY. By Charles M. Bakewell. New York:
The Macmillan Company, Publishers, 1920. Price
$2.00.
The presentation of this work to the American pub-
lic at this time is extremely apropos, as the Fourth
Red Cross Drive, now being conducted in the United
States, brings to the attention of every one the work
202
THE PENNSYLVANIA MEDICAL JOURNAL Decemuer. 1920
and needs of this organization. The story presented
by Mr. Bakewell is one of intense interest. It leads
the reader through Italy, beginning with the entrance
of Italy into the great World War, and the formation
of the Red Cross Emergency Commission, whose man-
agement so effectively cared for the sick and wounded
during that great campaign. It graphically describes
America's entrance into the World War and its re-
lation to Italy, the conduct of the Red Cross in can-
teens, the management of the Red Cross stations and
a tour through Italy in the wake of the Red Cross
Corps. It describes the work of American troops in
Italy, the Battle of Vitterio Veneto, and gives a de-
scription of the ambulances and rolling canteens;
how soldiers were fed and invalids cared for. The
last chapter deals with the method of. concluding the
work of the Red Cross at the end of the war, and
gives an appendix showing the expenditures durmg
the campaign. It also gives the American personnel
from September, 19:8, until the end of the war. This
is a valuable contribution to the Red Cross literature.
TRUTH ABOUT MEDICINES
Quinin and Urea Hydrochlorid for Local Anesthesia.
— Quinin is a protoplasmic poison, and tissue necrosis
may be caused by strong- solutions of quinin salts.
That this deleterious reaction actually does occur and
has mitigated against the general use of quinin and
urea hydrochlorid is confirmed by the report of the
Committee of the A. M. A. on the Advantages and
Disadvantages of Local Anesthesia in Nose and Throat
Work. The committee reported that the only local
anesthetic that produces edema and sloughing is quinin
and urea hydrochlorid. The committee found that, as
this local anesthetic has been abandoned in other fields
of medicine, so it has been discarded for use in nose
and throat operations. Two physicians who had pub-
lished articles extolling the value of quinin and urea
hydrochlorid in nose and throat operations now state
that they h»ve discontinued its use, though they had not
published this unfavorable conclusion (Jour. A. M. A.,
Aug. 21, X920, p. 559).
More Misbranded Nostrums and Drug Products.—
The following products have been the subject of
prosecution by the federal authorities under the Food
and Eh-ugs Act: Tonic Remedy, a nostrum of the
alcoholic type was misbranded because the label failed
to show the quantity or proportion of alcohol present.
Big C. said to be "A Compound of Borated (Golden-
seal," was essentially a watery solution of boric acid and
berberin. Plantation Sarsaparilla consisted essentially
of potassium iodid, alcohol, plant material, sugar and
water. Magic Eye Salve consisted essentially of zinc
oxid, benzoic acid and petrolatum. Femenina con-
sisted essentially of alcohol, sugar, water and uniden-
tified material with indications of valerian. Balsam
Copaiba, Salol Compound, and Methylene Blue Comr
pound (The Evans Drug Mfg. Co.), were capsules
which were below standard in strength and purity.
Pabst's Okay Specific consisted essentially of volatile
and fixed oils, plant extractives, including cubebs,
balsam of copaiba and buchu, and more than 29 per
cent, of alcohol. Liebig's Diarrhoea Cordial consisted
essentially of a solution of morphin sulphate, catechu,
tannin, oil of cassia, oil of peppermint, sugar, alcohol
and water (Jour. A. M. A., Aug. 28, 1920, p. 623).
lodex and Liquid lodex.— The A. M. A. Chemical
Laboratory examined lodex in 1915 and found that it
contained only traces of free iodin, though claimed to
contain "5 per cent, therapeutically free iodin." Even
the total quantity of iodin was shown to be only about
one-half of the 5 per cent, claimed to be present as
free iodin.
An analysis of the lodex sold in 1919 demonstrated
that the preparation is essentially the same as that sold
in 1915, that is, it was found to contain no free iodin
and only about three-fifths of the total amount of
iodin claimed. The laboratory points out that the
synonym used for lodex, "Ung. lodi., M. and J." is in
obvious conflict with the Food and Drugs Act in that,
though sold under a name recognized in the U. S.
Pharmacopeia, it does not conform to the standards
for Ung. lodi. of the pharmacopeia. The laboratory
further reports that Liquid lodex, sold with the claim
that it is a preparation having the properties of free
iodin, is a reddish liquid with an odor like oleic acid,
containing but little (0.16 per cent.) free iodin and
only about three-fifths of the total iodin claimed (Re-
ports of the A. M. A. Chem. Lab., 1919, p. 104).
I. G. O. — According to Dr. H. S. Lambdin, Peru.
Kansas, I. G. O. is : saturated solution of iodin gas in
petrolatum at 130 degrees with oil of eucalyptus. The
heat of the body liberates the iodin and it is absorbed
as free iodin. The A. M. A. Chemical Laboratory re-
ports that the sample of I. G. O. was a black ointment,
green in thin layers, with a slight odor like crude
petroleum, containing but 0.59 per cent, of free iodin
(Reports of the A. M. A. Chem. Lab., 1919, p. 106).
Internal and External Antisepsis. — Despite the nu-
merous efforts to demonstrate the %fficacy of this or
that chemical agent or drug as a gastro-intestinal an-
tiseptic, the outcome has been that the supposed bene-
fits were due to catharsis in most instances rather than
to any real effect upon the bacteria in shu. Similarly,
J. F. Norton, in an investigation made for the Council
on Pharmacy and Chemistry, has shown that- the value
of "antiseptic" and "germicidal" soap depends on the
soap and not on the antiseptic or germicide contained
in them. In fact, ordinary toilet soap and the green
soap used by surgeons was more efficient, evidently
because the added antiseptics and germicides inter-
fered with the lathering qualities of the soap (Jour.
A. M. A., Aug. 14, 1920, p. 478).
PERSONAL EXPERIENCE IN THE TREAT-
MENT OF INTERNAL HEMORRHOIDS
ALOIS B. GRAHAM, M.D., P.A.C.S.
Indianapolis, Ind.
The writer said that careful preoperative prepara-
tion is essential, and should be the same regardless of
the operation of choice, the anesthetic used, and the
place where the operation is to be performed. The
best results imply careful preoperative preparation.
Soap water enemata, because of their irritating effects,
have been abandoned. The' same is true of high
enemata and the colon tube. Normal salt solution
enemata given through a soft rubber catheter secure
satisfactory results. No preoperative dressings are
applied nor are the parts shaved except in cases where
large external hemorrhoids are to be excised. The
iodin-alcohol method of sterilization is employed.
Preliminary narcotics, hypodermically, one-half hour
previous to the scheduled operation are a routine pre-
operative procedure. Nitrous oxide combined with
oxygen is the anesthetic of choice. Local anesthesia
preferred to either ether or chloroform. If the injec-
tion method is used quinine and urea are preferred to
carbolic acid. For radical removal, the ligature method
is the operation of choice. No. 2 chromic catgut for
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December, 1920
TRUTH ABOUT MEDICINES
203
the ligatures meets all requirements. This method
secures an absolute cure, is as free from danger as any
surgical method devised, and can be performed under
either local or general anesthesia. No rectal plug of
any kind is used. Gauze impregnated with sterile
vaseline is kept in contact with the anal region. It is
essential that post-operative pain be relieved and this
is one of the most important services that can be ren-
dered by the surgeon to his patient.
Dressmgs are removed and the parts cleansed twice
daily. Olive oil and normal salt solution enemata,
given through a catheter, employed for emptying the
bowel on the third and fifth day. Catheterization, if
necessary, is a standing order. The average confine-
ment to bed is five days. Until a complete cure is
effected, the finger protected and well lubricated is
introduced weekly into the anal canal to ascertain
that no post-operative contraction has resulted. The
average time for a cure is three weeks. These sur-
gical methods of choice are the result of the writer's
personal experience in 1,200 cases where radical opera-
tions for cure of internal hemorrhoids have been per-
formed.
Of 1,127 nursing infants treated at the Red Cross
foundation, during a period of ten months, only 39
died. Under ordinary circumstances 394 of these
children would have, succumbed. The total mortality
among the children cared for by the institution has
been thirty per cent., as against forty per cent, for the
other children of the same district.
CHIROPRACTIC PATHOLOGY
A "chiropractor" of Waukesha, Wisconsin, emits
(at advertising rates) the following words of wisdom
on the pathology of gallstone and kidney stones:
Gallstones are due to an excessive amount of heat
in the gallbladder which crystallizes the calcerous ma-
terial in the bile and forms stones. This excessive
heat results from the loss of calorific or heat control
of nerves due to nerve pressure in the middle dorsal
vertebral region. Adjustment of the causative sub-
luxation restores the condition to normal. Renal
stones are caused in the kidneys in the same manner.
This is the sort of medical "information" that is
being fed the public by the cult calling itself ''chiro-
practic" ; and unfortunately the public is not in a posi-
tion to realize its grotesque nonsense. But even to
suggest that those who would treat human ailments
should be grounded in certain educational fundamen-
tals is to violate the tenets of "medical freedom"! —
Jour. A. M. A., Oct. go, 1920.
TOTAL HYSTERECTOMY IN FIBROID
TUMORS OF UTERUS
The technic employed by John Osbom Polak, Brook-
lyn {Journal A. M. A., Aug. 28, 1920), has been so
planned as to obviate and overcome the criticisms of
total removal and the claims for the incomplete opera-
tion; and the end-results have been so satisfactory
that he has come to consider total hysterectomy as one
of the curative measures that can be offered the
woman with extensive fibroid disease. His technic is
described in detail.
. FUNCTIONAL SCOLIOSIS IN COLLEGE MEN
It is stated by William Lawrence Estes, Jr., Bethle-
hem, Pa. (Journal A. M. A., Nov. 20, 1920), that func-
tional scoliosis has been shown to occur in from 10 to
20 per cent, of men of college age, the left-sided curve
predominating (70 per cent.). This scoliosis results
chiefly from flatfoot, occupational or developmental
peculiarities, and from shortening in one lower ex-
tremity. This shortening may exist in Bryant's line,
or in a trochanter to external malleolus measurement.
A mild coxa vara, and variation in length of the fem-
oral, and sometimes the tibial, shaft have been sug-
gested as the most likely explanation of this short-
ening.
MELTZER-LYON METH IN DIAGNOSIS OF IN-
FECTIONS OF BILIARY TRACT
George E. Brown, Miles City, Mont. (Journal A.
M. A., Nov. 20, 1920), has found the direct examina-
tion of aspirated bile, by means of the Meltzer-Lyon
method, of great value in the diagnosis of early chole-
cystitis. The fresh bile shows definite evidences of
infection. Cultures are ust^lly positive. The value
of the bile examination grows less as the cholecystitis
becomes more chronic. In the later lesions, the bile
may present a normal appearance. Cultures are usually
negative.
INDEX TO ADVERTISERS
Armour & Company cover p. 4
B. B. Culture Laboratory 11
Bauer A Black > v
Betz, Frank S., Company t1
Brady, Geo. W., A Company Iv
Bnme Brae xrll
Dental ft Surgical Supply Co xUl
Deutscb, Max, The Oi'avld Shoe xviU
Devitt's Camp i:vlll
Farm Colony and Sanatorium xrtU
Pelck Brothers Company Iv
Ooodell, J. E., laboratory xlli
Horllck'e Malted Milk Company x
Hynson, Westcott ft Dunning xlx
Intra Products Company x
Jacobl, Prescription Blanks xvllt
Jefferson Medical College XT
Kenwood Sanatarium xvlt
Kraus, A. H., Prescription Blanks xlx
Ijangner Laboratory, The xti
McDonald, Jos. J ix
Maltble Chemical Company Ix
Manhattan Eye Salve Company xlU
Massey Hospital, The xvlll
Mead Johnson ft Company tU
Medical Protective Company Ill
Mercer Sanitarium xvH
Mets, H. A., Laboratories, Inc il
Moore's Hospital xlx
Moran, Jos. A xvlU
Mosby, C. v., Company '. vll
Mulford, H. K., Company xlT
Mutual Pharmacal Company, Inc Ir
Parke, Davis & Company cover p. .4
Physicians Supply Company Ix
Physicians A Surgeons Adjusting Association xlx
Pomeroy Company xx
Quaker Hill Nurseries xvlll
Quaker Oats Company lit
Radium Co. of Colorado xvl
Radium Laboratory Iv
Sounders, W. B., Co cover p. 1
Schering & Olatz, Inc xvl
Storm, Katherine L., M.D xlx
Sunnyrest Sanitarium xvU
Taylor Instrument Co xx
United Synthetic Chemical Corporation xlU
University of Pennsylvania xT
Victor X-Ray Corporation vlll
Wlnthrop Chemical Co xx
Woman's Medical College of Pennsylvania xv
Zemmer Company, The xvl
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VOLUMB XXIV
XUUBEK 4
212 North Third St., Harrisburg, Pa., January, 1921
Subscription :
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ADDRESS
sinus disease and ocular
involvement*
GEORGE B. JOBSON, M.D.
FRAKKLIN, PA.
I wish to thank you for the honor conferl-ed
upon me by electing me to the chairmanship of
this section, and I also most heartily thank you
for your response in the contribution of papers
which has made it possible to submit the splendid
programme before us.
As it is customary for the chairman to present
an address on such an occasion as this, I have
chosen to speak briefly upon the principal nasal
conditions which are contributory to pathological
ocular affections; a subject which I am sure
will interest both the rhinologist and the oph-
thalmologist. I do not profess to present any-
thing new along this line, but the subject is of
such vital importance that it will bear repeating,
for by doing so, it will help to keep us on the
alert, and by remembering the pathologic inter-
relation between the nose and eye, we will be
more able to diagnose cases which otherwise
seem obscure.
It is but slightly over a decade since observers
established a definite connection between diseases
of the nasal pass^es and their accessory sinuses,
as causative factors in ocular inflammations and
derangements. Onodi of Buda-Pesth in a paper
entitled "The Disturbance of Vision and Devel-
opment of Blindness of Nasal Origin Induced
by Disease of the Post Accessory Sinuses,"
which was read at the seventy-second annual
meeting of the British Medical Association held
in Oxford, July, 1904, stated that in answer to a
questionnaire which he sent out to leading Ger-
man ophthalmologists, with the exception of one
or two who thought that disease of the sinuses
might cause optic neuritis, the rest of the men
said they had never associated sinus diseases
and ocular involvement. This shows how meagre
was the knowledge along this line, at that time.
Much painstaking work has been done since this
paper was read by Onodi abroad, and by Fish,
•The Chairman's Address, delivered before the Section on
Eye, Ear, Nose and Throat Diseases, of the Medical Soc'ety of
the State of Pennsylvania. Pittslmrgh Session. October 5. 1920.
Holmes, Dixon, Loeb, Posey, Packard, Sluder,
Ewing, Skillern and others in this country, so
that now common knowledge is established of
the relationship between diseased nasal and ocular
conditions.
In 1900 Ewing and Sluder were the first to
call attention to an eye condition, the symptoms
of which were briefly described as : "Inability to
use the eyes for near work because of headache
which is produced thereby, and which is not re-
lieved by glasses or eye treatment." It is accom-
panied by a tender point in the upper inner angle
of the orbit (Ewing's Sign), the etiology of
which according to Sluder is "that secondarily
to closure of the frontal sinus, there arises a con-
gestion of the lining membrane in which the bone
takes part to a degree which, however slight, is
sufficient to render the thin wall of the sinus
sensitive to even very slight external pressure.
The pulley of the superior oblique is attached to
this thin wall. The function of this muscle being
to turn the eye downward, it is called into use
for most of the acts of accommodation; so for
close work there continues more or less of a tug-
ging at this tender point." This class of cases is
as a rule not accompanied by nasal symptoms,
unless they be produced by some lesion other
than the one closing the sinus. "Headache with
eye symptoms may arise from closure of the an-
terior labyrinth of the ethmoid, and is in every
way similar in its mode of establishment to the
frontal sinus headache just described," says
Sluder.
Another class of ocular cases which manifest
dull eye pain, photophobia, and conjunctival irri-
tation, not relieved by glasses, may be due to a
deflected septum or septal spur with impinge-
ment of a swollen turbinate. The asthenopia in
these cases disappears as soon as the rhinological
condition is relieved. Before the publication of
Uffenorde's work on the ethmoid labyrinth
which appeared in 1907, this structure was con-
sidered as one of the accessory sinuses of the
nose. Uflfenorde did not view this mass of cells
in this light, but compared them to a sponge, with
a mucous membrane which is exceedingly loose
and tender, and which often reacts in a most vig-
orous manner to the noxious elements which en-
ter the nose. He divided diseases of the ethmoid
into:
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206
THE PENNSYLVANIA MEDICAL JOURNAL
January, 1921
1. Acute inflammation.
2. Chronic inflammation: (a) hyperplastic
ethmoiditis with polypi, (b) suppurative eth-
moiditis, mention of which sufficiently describes
the pathology of this portion of the nasal adnexa
which is most vulnerable to noxs entering the
nasal pass^es. The principal occular manifes-
tations of acute ethmoiditis are epiphora, weak-
ness of vision and scintillations. In severe cases,
ciliary and orbital neuralgia may be present.
Dr. Ross Skillem in a paper which he read at
a meeting of the American Academy of Ophthal-
mology in 1909, says: "The orbital manifesta-
tions of chronic hyperplastic ethmoiditis are of
especial interest, not only on account of the ob-
scure picture which they often present, but also
on account of the frequency with which they ap-
pear. These are usually of mechanical origin,
due either to the intracellular pressure from
hypertrophied mucous membrane or from stasis
in the hematogenous or lymph channels or both,
and may be enumerated as follows :
1. Interference with the mobility of the globe.
2. Irritation of the optic nerve through pres-
sure.
3. Changes in refraction.
4. Disturbance of physiological lachrymation.
The subjective symptoms are neuralgic pains
in the. eye, ciliary neuralgia and photophobia.
In severe cases of vasomotor disturbances, as
hyperemia of conjunctiva and edema of eyelids
and periorbital tissues may occur. The appear-
ance of these reflex neuroses is to be expected,
when one recalls that the orbital and nasal cavi-
ties are supplied by the same sensory nerve.
Posey and Packard mention a class of cases
"which present not only asthenopia, but other
ophthalmologic symptoms as well, which are un-
doubtedly attributable to old sinus trouble, but
in which, at the time they are seen by the rhinolo-
gist, no pus is to be found in any sinuses, al-
though the history points to sinus origin of the
patient's trouble." This is in line with Axen-
feld's statement that "in cases of orbital cellulitis
in which the nasal examination is negative, the
original sinusitis which occasioned the orbital
condition may have healed by evacuation into
the nose, while the orbital condition is progres-
sive, on account of the absence of drainage."
Partial or complete blindness may be due to
infection of the sinuses, the blindness in all
probability being due to absorption of toxic ma-
terial from the diseased sinuses. So when we are
dealing with an intractable case which complains
of pains in the eyes, progressively impaired
vision, scintillating scotoma, spoken of by the pa-
tient as a "glimmering," with central scotoma
for red, let us recall the probability of pus in the
posterior ethmoid cells or sphenoid sinus and act
accordingly. I have operated upon four such
cases, three of which were followed by return of
vision to normal, while the fourth was not im-
proved, as blindness had been almost complete
for over a year, and the optic nerves showed
atrophic changes.
Much more might be said upon this subject,
but time does not permit me to discuss it further.
ORIGINAL ARTICLES
SCHOOL MYOPIA; ITS PREVENTION,
IMPORTANCE OF EARLY RECOG-
NITION, AND TREATMENT*
WILLIAM W. BLAIR, M.D., and
JAY G. LINN, M.D.
nTTSBURGH
The relation between school life and the de-
velopment of ocular defects has been recognized
for many years, and much has been done to
ameliorate the conditions known to be contribut-
ing factors in setting up eye troubles of various
kinds, yet it has seemed to the writers that the
medical profession, educators, and the general
public have not taken advantage of the known
results of careful studies which have been made
in this field, nor have they been alive to the defi-
nite benefits to be derived from various reform
measures proposed.
The educational program elaborated by enthu-
siastic, though well intentioned professionals,
has become so broad, that with manual training,
domestic science, music, mechanical drawing,
and what not, piled upon the three R's, the poor
child has but little time left for outdoor work or
play. We know, furthermore, that all this in-
door application means work for the eyes at
what we call the reading distance. The question
arises as to whether civilization may or may not
be paying too high a price for the mental devel-
opment of the rising generation, a price that may
be reckoned in crooked spines, diminished lung
capacity, bad eyes, and generally enfeebled re-
sistance. The subject is one which merits ex-
tended inquiry, but would run far beyond the
scope of this paper.
We realize that any attempt to amend the pres-
ent school program would be hopeless. Our task
then has been to discover, if possible, how, under
to-day's schedule, the eyes of our school children
might be in a measure safeguarded.
In all previous studies of this subject, a num-
ber of features have invariably stood out, the
'Read before the Section on Eye, Ear, Nose and Throat
Diseases of the Medical Society of the State of Pennsylrania,.
PitisDurgh Session, October 5, 1920.
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SCHOOL MYOPIA— BLAIR AND LINN
207
importance of one of which has impressed all ob-
servers— myopia or "short sight." So constant
has been this finding where a large number of
school children have been examined that oph-
thalmologists now commonly refer to the condi-
tion as school myopia, meaning thereby that
progressive condition of short sight which mani-
fests itself early in the child's life and shows a
steady increase in amount as long as the close ap-
plication to books is sustained. So prevalent is
this condition amongst the studiously inclined,
that myopia has been referred to as "the melan-
choly privilege of the professions" and it as-
suredly does seem to be an acdompaniment to in-
tellectual progress.
So much being granted then, it would seem to
be imperative to find how much is an absolutely
necessary evil, and to what extent this evil can
be avoided.
We must assume that under continued stress
at the so-called reading distance, a certain num-
ber of eyes will succumb. It is also known that
a definite regime, which includes a prescribed
manner of lighting the school room, improved
seating devices, uniformly printed textbooks,
definite rest periods, etc., will furnish an educa-
tion without sacrificing that priceless possession,
eyesight, without which all else is valueless.
Since no very recent investigation has been
carried out in this country as to the prevalence
of myopia among school children, the authors
have made a careful survey of the pupils of one
reasonably large city district comprising sixteen
hundred pupils of the Manchester School. The
results of this study will be shown you in tabu-
lated form.
Following the method laid down by Cohn in
Breslau, one of the first and most active workers
in this field, and of our own Risley, whose work
has never been surpassed, we have taken the pu-
pils by grades, whereupon it is seen that we can
fully confirm the results of Cohn, Ware, Risley,
Erisman, and others : first that myopia increases
directly in proportion to the hours of close ap-
plication, and second, that once started it has
a constant tendency to increase as long as the
pupil is in school. A point of value which
I think we may claim for the present work, is,
that the state of refraction was determined both
objectively and subjectively ; that is, by the test
cards of Snellen, and by the retinoscope. Furth-
ermore in each case an ophthalmoscopic exami-
nation of the ocular fundi was made and the re-
sult recorded, i. e., a note was made as to the
presence or absence of choroidal hyperaemia,
choroidal stretching, or scattered areas of chori-
oditis. Upon examination of the chart we have
prepared, it is at once apparent that the conclu-
sions reached by other observers are in the main
corroborated.
Of the findings generally agreed upon, some
are of importance: first, it is seen that among
school children presenting ocular defects, the
hypermetropic state is by far the most frequent
among the younger individuals, then with con-
tinuance of school life, myopia- becomes with
each school year increasingly prevalent ; second,
where myopia has developed in a young child,
the amount increases with the duration of school
attendance. As we very well know, myopia does
not always show increase with successive years,
yet it is equally well known that such is its ten-
dency, and moreover that tendency is more
marked in children of tender years than in those
who have passed the line dividing youth from
adult age.
In the study of this question, many factors in
school life have been scrutinized with the view
of evoluating these as special causative factors
in the development of myopia.
Among these elements we must first consider
the effect of long continued application of the
eyes at the so-called reading distance. From the
accepted theories regarding the origin of myopia,
we must conclude that this is one of the most im-
portant factors. Here the application of known
features of ocular hygiene would seem to be
plainly indicated; namely, short hours at near
work frequently interrupted, large print for text-
books, etc.
Second, illumination. In this respect much
has been accomplished in rendering the work of
the pupils more comfortable, thus protecting the
eyes from undue strain — and let it be said that
all hygienic measures which have for their ob-
ject the prevention of eye strain, whether from
poor lighting, glare, or other causes, are just so
many aids in the prevention of myopia.
Third, suitably printed textbooks. Certainly
a great reform in this respect has come about,
and though there is still room for improvement,
one does not often see the wretched, small,
blurred printing which was so common in the
school books of our parents and of our early
school days.
Fourth, proper seating devices. These are
now the rule rather than the exception, and have
for their purpose the improvement of the child's
general condition as well as the protection of the
eyes.
Fifth, a really worth while examination of the
eyes of all school children at stated intervals, cer-
tainly as frequently as once in each school year.
Sixth, the segration of all myopia into classes
which should have a schedule of their own, quite
apart from that adopted for these pupils whose
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THE PENNSYLVANIA MEDICAL JOURNAL
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eyes are sound. It will be seen at once that this
part of the program would be entirely unwork-
able without a thorough examination by a com-
petent physician. With this latter provided, how-
ever, it should entail no hardship in the city
schools at all events. In a way, it is simply an
extension of the so-called Batavia plan of pro-
viding from one to three or four teachers in a
school, according to requirement, whose sole
duty it is to take charge of those pupils who have
fallen behind in their class work, from whatever
cause, and bring them up to their respective
grades. At first, this idea, was scouted as en-
tailing too much expense. Later, however, on
trial it has been found to work admirably, and is
being adopted generally.
As an example of what might be developed in
the way of special class work for children with
defective vision, whether from refractive or
other anomalies, we might readily borrow the
idea conceived by Mr. Thomas McAloney, su-
perintendent of our local School for the Blind.
Mr. McAloney found in his school a number of
pupils who had so much vision as not to be
classed as totally blind, and yet not sufficient to
permit them to attend regular class work in the
public schools. Rather than send these children
home to idleness, he established a class desig-
nated as pearly sighted. A large well lighted
room was set aside and was placed in charge of
a special teacher, whose equipment consisted of
blocks, cards, charts and books, the characters
and pictures shown being very large, the black-
board work and desk writing being also corre-
spondingly expanded to such a size as to be
readily taken in by the pupils whose vision was
reduced to almost the minimum. The progress
made last year by these children under a patient
and enthusiastic teacher was so gratifying that
the method will probably be shortly introduced
for trial in a number of our public schools. The
idea then occurred that the same method, per-
haps less rigidly applied, but with the same, or
some modification of the same textbooks, writ-
ing forms, etc., could be most admirably adapted
to meet the needs of the myopia child, who, under
our present methods, is forced to leave school,
or to struggle on in Jjis class, either with or with-
out glasses, to the almost certain detriment of
his vision. The books which I will show you
give some idea of the size of print used.
From this brief outline, it is readily seen that
myopia is sufficiently prevalent among our chil-
dren of school age to place it among the more
important problems of school hygiene. We know
that the myopic eye is an unhealthy eye, that
structural changes in the organ itself are the rule
rather than the exception in the presence of this
refractive state. Moreover our knowledge of
the matter points very clearly the way toward a
solution of the trouble, if we can but get educa-
tors and public health officials, as well as the gen-
eral public, to grasp the situation.
In order to place before you something which
shall be at least suggestive, let me use an illus-
tration : What is the method of procedure when
a parent, either very much disturbed or perh^s
very little disturbed, brings to the ophthalmolo-
gist, a child of eight or ten, with the statement
that the youngster is unable to see what is writ-
ten on the blackboard in school? The proper
handling of such a case means a careful inves-
tigation of the child's refraction, the muscle bal-
ance, the state of the ocular fundi, and the gen-
eral health.
If a beginning myopia state is demonstrated,
I take it that in addition to the prescription for
correcting lenses, the child is taken under obser-
vation, frequent examinations are made, and if
the myopia is steadily increasing, the child is
taken from his books and kept employed at tasks
which do not involve the use of the eyes at the
reading distance. This period lasts until the
oculist is able to satisfy himself that the myopia
is no longer progressive,, when the patient is per-
mitted to cautiously take up his work again,
though always under the supervision of the
oculist in charge. Some such method is produc-
tive of much good, but it is applicable only in the
cases which are fortunate enough to fall into the
hands of a conscientious ophthalmologist.
Where the method fails is in its application in
the case of the general run of school children.
To-day throughout the states, excepting in rare
instances, the ophthalmological care of school
children consists simply of the most cursory kind
of an examination, which may or may not reveal
the presence of ocular defect, the nature of which
is not revealed. If, in the course of the routine
physical examination, a child shows defective
vision, he is recommended to go to a doctor or to
a clinic to have the eyes examined, and there the
matter may rest until another year goes by, when
the same performance is gone through again.
An excellent plan would be to have a compe-
tent ophthalmologist make a real examination of
all these children, whether showing defect of
vision or not ; for we all know that cilliary strSin
sufficient to cause headache, engorged f undii, etc.,
can be caused by a low degree of HM which may
not cause any defect in vision. The ophthal-
mologist, recognizing that myopia is a disease, in
which state the altered refraction is but a symp-
tom, would see that all such cases receive the
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SCHOOL MYOPIA— DISCUSSION
209
care such a condition demands — something more
than the prescribing of glasses. Under such
competent advice as only an oculist could give,
special classes could be arranged so that these
unfortunates would get an education without the
impairment of their vision. Also under proper
guidance the school hygiene, as far as the eyes
of the pupils are involved, could be so developed
as to reduce the amount of myopia among the
school children, and to properly safeguard the
eyes of those who already have the disease.
In conclusion it remains to insist that there is
a necessity for most drastic reform in the
method and scope of the present day slack and in-
efficient plan of medical inspection in schools, in
so far as it touches hygiene of the eyes. In the
city of New York, where the whole subject has
been a very live one during the past few years,
upon investigation it was found that among the
school children of the city, roughly eighty per
cent, presented some physical defect, sixty per
cent, of which defects were removable through
competent professional care. These conditions
consisted of bad teeth, defective eyes, crooked
spines, adenoids, diseased tonsils, skin affections,
and other minor ailments. As to whether it was
advisable to load the educational budget further
by the addition of the seemingly great expense
entailed by efficient medical inspection and care,
it should be said that the removal of certain
physical defects was followed by such marked
improvement in the mental activity of the indi-
vidual pupils concerned, that there followed an
almost startling drop in the number of pupils
who failed of promotion at the end of the year.
So positive was this result, that it can easily be
shown that proper medical inspection is not in
any sense an extravagance, but represents a defi-
nite saving in expense, for it is easily seen that
the entire cost of a child's education for a year
is lost if the pupil is forced to repeat the year's
work, so that with each year's failure to pass, an
additional year's expense is added.
The proper c§re of school children's eyes be-
gins and ends with the maintenance of a care-
fully worked out system, whereby a worthwhile
examination of the eyes of each pupil is made
once in each year. Thus, under a proper record-
ing system, we should soon arrive at an appre-
ciation of the importance of the early recogni-
tion and correction of all ocular defects, and the
cooperation of the parents and teachers would be
assured. Furthermore, under the guidance of a
competent school oculist all of our schools could
be so constructed and so lighted that the condi-
tions tending toward the development of ocular
defects could be practically eliminated.
DISCUSSION
Dr. J. Ferdinand Kwnedinst (York) : Drs. Blair
and Linn are to be commended for this survey of the
eyes of the 2,000 pupils to determine the numbers of
myopic children. This is an important study, and is
the only one made in this country in about 25 years.
Comparing their figures with previous investigators
we do not find any decrease in the percentage of school
myopia, although we have made great advances in the
study of errors of refraction, and their correction.
It must, of course, be remembered that the ophthal-
mologist does not get all the cases of myopia; many
are refracted by the nonmedical refractors, and there-
fore we cannot get exact figures, but it occurs to me
that we do not see so many cases of myopia in the
country districts as in the city. Why there should be
any difference I cannot understand, imless it is the
fact that country children as a rule do not study so
much at night as do city children. They go to bed
earlier and get up earlier, and therefore probably do
their studying by daylight. Whether studying by arti-
ficial light has anything to do with the genesis of
myopia can be proved only by investigation.
Another cause may be found if one will go into the
schoolroom and note the position in which the chil-
dren sit at their desks, particularly the lower grades.
The child is bent over and assumes an unnatural po-
sition owing to improperly adjusted seats.
If you go into the moving picture shows you will
find that quite a number of small children try to get
into the front seats, looking upward at an angle at
the picture, which of course is bad, causing strain of
the ocular muscles. This is probably due to the curi-
osity of the child to get up in front where he will see
better.
Then the position of the blackboards in the school-
room is important. There are some schoolrooms in
which the blackboard is in a position where the light
is reflected from a window, producing a glare, and it is
almost impossible for one facing the board to detect
figures or writing on the board. That is one cause of
eyestrain to a myopic eye.'
Now the question is, how can we prevent myopia?
As Doctor Blair has said, careful correction of errors
of refraction will help. No doubt if every child with
a congenital error of refraction had it carefully cor-
rected tinder atropine at the time he enters school that
would be a great help in preventing an increase in
myopia. It is supposed that some children have an
anatomical and perhaps congenital cellular malforma-
tion of the tunics of the eye which predisposes it to
stretching, and given eyestrain, stretching of the sclera
takes place, with the development of myopia.
One figure on the chart that struck me is the 2.6%
myopia in kindergarten. We know that usually chil-
dren are put in kindergarten under six years of age.
Why should children at that age develop myopia?
How much better it would be if those little children
were out in the open air developing their physical con-
dition rather than trying to bring on a condition of
eyestrain ! Of course the most of kindergarten work
is with beads and straws — work done at close range.
Also in the lower grades we find myopia. I have been
told by the Superintendent of Public Instruction of
York that there is no occasion for children to do a
great amount of home study under the sixth grade, so
there must be some fault — at home probably some par-
ents are forcing the younger children to study at night.
We must take all these things into consideration in
order to determine how we can prevent myopia in
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THE PENNSYLVANIA MEDICAL JOURNAL
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these young children with all its distressing effects
later in life.
Dr. MicHAEt V. Ball (Warren) : I want to bring
out this point : Is it not a fact that some of the worst
cases of myopia are found among Italians? In our
neighborhood there are many cases of myopia in In-
dians who cannot read or write and who lead an out-
door life and have probably never been in school. It
seems to me there is a racial problem involved, more
than the so-called educational problem.
Again, is it not possible that instead of studious-
ness causing myopia, myopia might be considered a
cause of studiousness? We know such children are
naturally handicapped and cannot take part in out-
door sports. We find it very hard to keep such chil-
dren from studying, simply because there is nothing
else for them to do. I have not been able to stop
progressive myopia by taking the children away from
their books. That has been my experience.
Dr. William Campbcll Posev (Philadelphia) : I
have been much interested in the subject of school
myopia for a great many years and have examined the
eyes of many school children. For many years I ex-
amined annually the eyes of the pupils in some of the
private schools of Philadelphia, also the eyes of the
students entering the University of Pennsylvania.
Thus in 1917 I examined the eyes of 883 imiversity
men, of whom 633 were in the lower classes. Of this
number, 87 per cent, were farsighted, and 13 per cent,
were nearsighted. These young men had an averajge
age of probably seventeen years. Of 261 men in the
upper classes, 80 per cent, were farsighted, and 20 per
cent nearsighted. The average age of those examined
was 21 years. My statistics showed an increase of
about 2j4 per cent, of myopia for each year during
the four years of college life. Five per cent, more
myopia was found in the medical school than in the
collegiate department. I accounted for that by the
fact that the majority of men in the collegiate depart-
ment were city boys who had had their eyes properly
tested, and who had gone through their classes and
carried on their work under better facilities than the
boys in the rural schools. As has been said, there is
a certain hereditary tendency to myopia, so that proper
care of the eyes will not blot out all myopia. There
are a certain number of us who are predisposed to
myopia primarily by the shape of the skull. As is
well known, the myopic eye is found in an orbit which
is too long anteroposteriorly, and certain races such
as the Hebrew and German, are predisposed to myopia
on account of possessing that shaped skull. Some of
the most pronounced cases of myopia I have ever seen
were in the Irish.
Myopias must be refracted under atropine. There is
a certain class of men who are allowed to refract eyes
but are not allowed to use drops. I fear that untold
harm is often done by such men in placing on children
too strong myopic lenses. We should insist upon it
that careful refraction under atropin should be a sine
qua non in correcting the myopic eye.
Another important thing is that all children should
have their eyes tested before they enter school, not
the vision alone, but ophthalmoscopically, to detect
high degrees of farsightedness.
Doctor Blair has dwelt upon schools for the partial-
sighted. Within the last two weeks I had a child sent
to me from one of the homes of the city, who was
practically blind in one eye, and in the other the
vision was reduced to about one-third. The child had
had no school life because she was said to be too blind
to go to an ordinary school. Fortunately, we have in
the city now several classes for the partial-sighted.
She was immediately entered in such a school and will
be taught, using her eyes as little as possible at close
work, most of the teaching being oral or illustrated
on the blackboard. Mr. Bishop Harmon, a British
ophthalmologist, has gone into this subject very thor-
oughly and in my little book on the Hygiene of the
Eye I have given full details regarding the scope of
this work hoping to increase interest and diffuse
knowledge about this excellent work.
The three great requirements for reducing myopia
are adequate lighting, proper seating facilities, and
suitable books. Not long ago I was consulted regard-
in; one of the most fashionable schools in the suburbs
of Philadelphia from which all direct light was pre-
vented from entering the schoolrooms by porches
overhanging the windows. Proper lighting, both day-
light and artificial, must be insisted upon, also desks
of such a height that the child may use his eyes at
fourteen or fifteen inches from his work. It must be
remembered that very farsighted children have a ten-
dency to bring their books too close to the eyes.
Desks of a proper height and slant tend to obviate
this, and by giving a normal posture to the body, les-
sen the risk of spinal curvature.
Dr. Harry O. Mateer (Pittsburgh) : I am not an
ophthalmologist, I am one of the inspectors in the city
schools and I would like to say a few words about the
way we find the schools in this particular.
In the first place, our work is mostly contagious in-
spection, devoting fifteen hours a week to the con-
tagious phase of it against ten devoted to routine
physicals in which the examination for defective vision
enters as part of the routine. We find a high percent-
age with refractive errors in the cursory examination
which time and equipment available permits. All such
cases are brought to the attention of the family in writ-
ten recommendation and are followed up by the school
nurse, effort being made to secure the necessary cor-
rection either by having the child taken to a private
physician, or to one of the various clinics. Occasion-
ally we find a child who, under the very same routine
as others examined, is apparently tmable to read below
the forty or thirty-foot line of the Snellen chart placed
at twenty feet, and he or she is accordingly recom-
mended for a more comprehensive examination, and
not infrequently we have the child returned with a
note, sometimes none too courteous, that the vision is
normal. I want to ask everyone in attendance when a
child is referred by one of the school physicians to
give the school physician a fair show and recognize
that he is many times working under very great dis-
advantages, therefore an explanation and a good word
will go far toward protecting us.
THE PHYSICIAN AND THE PUBLIC
SCHOOLS*
THOMAS E. FINEGAN, M.A., Pd.D., Litt.D., LL.D.
Superintendent of Public Instruction, Commonwealth of
Pennsylvania.
HARRISBURG, PA.
Mr. President, and Members of the Medical So-
ciety of the State of Pennsylvania:
It is not only a great pleasure, but a great
privilege and opportunity which is accorded me
•Read before the General Meeting of the Medical Society of
the State of Pennsylvania, Pittsburgh SessiOQ, October s, 1920.
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January, 1921 PHYSICIAN AND PUBLIC SCHOOLS— FINEGAN
211
in being invited to address you this morning.
Within the last five years we have all realized
that the effective power of a nation is measur.ed
in large terms by the health of its people. In the
year 1916, before America entered the war, 130,-
000 of our young men applied for admission to
the army. The authorities of the government
accepted 31,000, the others were rejected. In
other words, of these young men presumed to be
in the best physical condition possible, 70 per
cent, were found not to meet the standards
which the surgeons of the Uniteid States Army
prescribed as essential for service in the Army
of the United States. Only 30 per cent, were
accepted. Now I understand, of course, that
there were undoubtedly among those who were
rejected many who were in good health, but who
failed to meet certain physical standards, such as
height or weight, which the government had pre-
scribed. But it is also true that many of those
who did not reach these physical standards might
have reached them had certain minor physical de-
fects and certain habits of early life been cor-
rected when they were children.
The function of the school is no longer re-
garded as simply that of a classroom. A public
school, wherever it is maintained in America, is
an institution which is to serve every intellectual
necessity of the people who maintain that school.
We are not content, therefore, in teaching chil-
dren reading and numbers, and history and the
usual subjects which have been carried in the
curriculum for years, but we are to develop and
train all the faculties of the child — intellectual,
moral and physical. One of the first and most
essential things to be given consideration in a
school program, therefore, is the health of the
child. A public school, wherever it is main-
tained, either in the city or in the most remote
section of the state, should be itself one of the
greatest health agencies in the commonwealth.
It should be an institution whose influence will
reach into every home of the commonwealth and
be an example in itself of the rules of sanitation
and personal habits which are to promote the
health of the people. I need not tell this body of
men that many of our public schools are not the
type of institution which I have described. A
public school should always be an example, an
inspiration and an agency in the development of
every uplifting power of the community — moral,
physical and intellectual. You know that many
of these institutions, because of their neglect and
their shameful condition, instead of being this
type of institution, are institutions in which dis-
ease and immorality are disseminated. Now, are
we to continue to tolerate this condition of af-
fairs, or are we to remedy it ?
We have had in America for a quarter of a
century what has generally been known as medi-
cal inspection. This work in the schools has
served two great purposes : first, it has been an
effective agency in jegulating and checking the
spread of infectious and contagious diseases
among children; second, it has brought very
forcibly to the consideration of those who have
been students of child health the actual facts re-
lating to the health of children throughout the
entire country. Wherever the results of medical
inspection have been properly tabulated by
school or health authorities, and wherever other
institutions interested in the health and educa-
tion of children have made an investigation of
the health of large masses of children, certain
facts have been revealed which may be made the
basis of an accurate estimate of the number of
children in attendance upon a local or state sys-
tem of education who have physical defects
which should be corrected. On the basis of
these investigations we know that there are in
the state of Pennsylvania enrolled in her public
schools to-day at least 17,000 children who are
mentally deficient. These children should be
segregated from the other children in the school,
and given that scientific attention which your
profession knows they should receive in the
early part of their life. There are at least 88,000
children in the schools of the state who either are
in the incipient stages of tuberculosis or are pre-
disposed to these conditions.
This situation presents two questions which
we must consider. We must consider, of course,
the physical needs of this great body of children.
But we must also consider the larger body of
children who are compelled to be associated in
the same class rooms with the two groups of
children just described.
In Pennsylvania, as well as in every other
state in the Union, compulsory attendance laws
are being more effectively enforced than ever be-
fore in our history. Parents have no control
over this subject whatever, and children are
given no discretion. They are compelled, under
the statutes, to attend school, and this is a thor-
oughly sound policy for a state to pursue. In
other words, the state, through its strong arm,
reaches out and in its own protection virtually
says to every parent in the commonwealth, "The
interests of the state require your children to be
under instruction in a public school or elsewhere
for a. certain period every year within specified
ages of the child's life." If a great state like
Pennsylvania writes in its statutes' a compulsory
attendance law of this character, as it should,
then is not the state also obligated to take every
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THE PENNSYLVANIA MEDICAL JOURNAL
January, 1921
precaution possible to protect the safety, the
health, and the morals of its children?
On the same basis of computation we find that
there are in the schools of Pennsylvania at least
17,000 children suffering from defective hearts,
and we also find that there are at least 445,000
children who have defective vision, at least 262,-
000 children suffering from lack of proper nu-
trition, at least 260,000 children suflfering from
the effects that come from adenoids, defective
tonsils, glands, etc., and an equal number of chil-
dren suffering from weak arches, defective
spines, joints, etc. This, of course, does not in-
clude the great number of school children who
are suffering from defective teeth. It is unnec-
essary to point out to a group of physicians such
as are gathered here this morning what effect de-
fective teeth have upon the general health of
children. It is wholly within proper estimate to
say that at least 50 per cent, of all the children
enrolled in the schools of the state are suffering
from defective teeth. You are as well informed
on this subject as I am, for the information
which I have is based largely upon what men
ill your profession have said. Are not these
health conditions of the children of the state
and of the nation a reflection upon, not only our
civilization, but upon our system of public edu-
cation? How are we to correct the situation?
We must not expect that it is going to be done
in a year or perhaps in a generation, but it is a
situation toward which a great state like ours
should set its face with the determination that
proper remedies are to be applied. Every health
agency in the commonwealth should be united
upon a plan which will permit them all to coop-
erate in devising means to provide adequate
health instruction for the children of the state.
But upon what basis may we organize a sys-
tem of health instruction in the schools of the
state which will teach children how to observe
and practice the fundamental principles of
health? The subject of physiology and hygiene
has been taught for years in the public schools of
the country. I should like to have any one of
you men reflect upon the days when you were in
attendance at the public school whose curriculum
carried the subject of physiology, and try to de-
termine just what benefit you received from the
instruction in that subject. This question has
been the cause of much thought and consultation
between Colonel Martin, head of the State
Health Department, and the speaker. There is
an entire agreement between us upon the course
of procedure, and it is the splendid cooperation
which he and his department have accorded me
which gives me the courage to believe that the
plan which I am about to suggest is one that may
be successfully carried into operation.
In this plan of instruction, there are two main
purposes which must be given careful considera-
tion, and on which thorough plans must be for-
mulated. These two elements are the courses of
study to be inaugurated, and the teachers who
are to give the instruction.
May I say, therefore, that in my judgment we
shall never have a proper solution of this health
question until we begin to teach a child the fun-
damentals of health the moment that child enters
school. This instruction should be as regular
and as scientific as the instruction which is given
the child in reading or writing or English or his-
tory or any other subject in the curriculum, and
I would not write this subject in the syllabus of
the public school under the caption of "physi-
ology" or "hygiene." I believe there is some-
thing in the psychology of terminology, and I
should therefore name this subject in the sylla-
bus as "health." I think it is a misnomer to say
that a child must be given a "physical examina-
tion" or a "medical examination." I think we
should call it a "health examination." In other
words, I would emphasize health wherever it is
possible. We shall, of course, have in our pos-
-session the information as to the number of chil-
dren having physical defects for our professional
and scientific use, but instead of emphasizing all
the horrors which result from the physical de-
fects which children possess, let us constantly
hold before the child, the school, the home, and
the public the joy and satisfaction that comes
from good health, and that good health may be
maintained only by living and practicing con-
stantly correct health principles.
Because of the limited number of trained
teachers which we have in the subject of health,
it will be necessary to prepare a syllabus upon
this subject, and this syllabus must be prepared
with the same scientific care, thoroughness and
deliberation with which a syllabus is prepared in
the subjects of reading, numbers, history or any
other subject in the curriculum. For several
months I have had three of the leading experts
in the country at work on this subject, and in a
short period of time we shall have a general out-
line of the syllabus which shall form the basis of
instruction when the child enters school, and shall
be adapted to the intellectual development of the
child for each of the eight years of the elemen-
tary school course and each of the four 3(ears of
the secondary school course. In a few weeks.
Colonel Martin and I are going to ask a repre-
sentative of your society and of every other
health agency in the state to sit down with us in
a conference to take up this syllabus to criticize
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January, 1921 PHYSICIAN AND PUBLIC SCHOOLS— DISCUSSION
213
it and to modify it until we get it as nearly per-
fect as our limited knowledge of the situation at
this time will permit. This document will then
form the basis of instruction in health in every
public school in Pennsylvania.
A record should be made of every child when
he enters school, shdwing the age, the family his-
tory, the peculiarities and the health ' condition
of the child. This card should become a per-
manent record of that child's history and devel-
opment through the school. It should travel
with him as he goes from grade to grade through
the school. Such additional record should be
made as the physical and mental development of
the child requires. It should have the careful
attention of the classroom teacher as well as the
health expert employed in the school system. If
the child goes from one school to another school,
the card should be transferred to the new school
where he becomes a pupil. If he goes from one
city to another city in the same state, or in an-
other state, his record should go with him so
that those who are responsible for his intellec-
tual and physical development and growth may
know his history and have before him his com-
plete record.
We must, of course, have trained teachers in
health if we are going to carry forward a suc-
cessful program of the type which I have out-
lined. Pennsylvania could make no better in-
vestment to-day than to employ immediately two
thousand health teachers in the schools of the
state ; she could make no investment that would
yield greater returns in dollars and cents. The
benefit which the state would receive in cash re-
turns would be sufficient to pay the expenses of
these teachers. Of course, these teachers are not
available. But we may train them just as we
train other teachers. We have the facilities in
these days to train any type of teacher which the
public school demands. We can train teachers
for health instruction just as teachers are trained
for medical instruction. The feasibility of train-
ing school nurses has been established in recent
years. Through proper cooperation of the state
and local health and educational authorities and
such agencies as your organization, together with
the medical schools, the universities and colleges
of the state, it is entirely feasible to train an
adequate supply of teachers for health instruc-
tion. We must, therefore, have a syllabus which
shall be the basis of training health teachers.
This subject is now receiving prominent atten-
tion from the great medical profession. There
are in this profession many men who have ex-
pert knowledge of this great field of education.
I should like to emphasize, if possible, the ap-
preciation which I have of the need of proper
professional expert service in the administration
of this great health problem from an educational
standpoint. It will never be possible to admin-
ister the system of health instruction which I
have attempted to outline in the brief time al-
lotted me without adequate expert supervision
from men trained in the medical profession. My
main plea this morning is that we shall, as before
stated, bring into harmonious cooperation in the
State of Pennsylvania every health and educa-
tional agency for the administration of a system
of health instruction which shall be upon a sound
educational and scientific basis. Every state in
America should set up health standards for her
children in times of peace which shall be the
equivalent of the health standards which the gov-
ernment has prescribed for its soldiers in times
of war.
DISCUSSION
Dr. Edward Martin (Philadelphia) : There is a
type of mind and a style of man who when he sees in
his path of duty a great mountain, measures it, knows
its difficulties and says, "I will surmoimt them," and so
does. There is another type, who seeing even a little
mountain, says "it can't be done," and stays where he is.
The type which is willing to do or die leads in all prog-
ress. Dr. Finegan has called upon all the State Depart-
ments, and I think every man here is with him in ac-
complishing what one-third of the people at large say
cannot be done, the other one-third say may be done, and
the leading third say will be done, and proceed to do it.
The State Department of Health is your department;
its members are your executive officers ; there can be
no antagonism between that department and you ; there
must be cooperation. There is talk of paternalism ;
when the public school system started there was such
talk. There is some talk of the state interfering with
the right and the honor and prerequisite of the doctor.
The state has strengthened and helped the doctor. In
York and Homestead, where for the purpose of a
study of summer diarrhea we sent and held engineers,
inspectors and twelve nurses for observation on a thou-
sand babies in each place, more than twice as many
babies have been brought to the doctors in private
practice than ever were before. In as far as the doc-
tors' private interests are concerned these are exhanced
by an active cooperation by an efficient Health Depart-
ment. In this great campaign for health education,
which has been briefly outlined, and which your de-
partment is enthusiastically determined to make suc-
cessful, we begin before the baby is bom. We do our
most effective work in the period of infant and child
life before the child goes to school, through the agency
of a wholesale child welfare campaign, maternal pre-
natal clinics, baby clinics, surveys of the children, call-
ing on the doctor at the very beginning of illness.
With this preventive early correction program state-
wide, your medical problems will be less numerous
and much easier of successful solution. With your
help and the enthusiastic and steady support of that
great new power, the power of organized womanhood,
we will accomplish something of our ultimate aiip,
that every citizen shall have his or her opportunity for
their maximum of health, not in a generation, but in a
decade.
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214
THE PENNSYLVANIA MEDICAL JOURNAL
January, 1921
NEW CONCEPTIONS RELATIVE TO
THE TREATMENT OF MALIGNANT
DISEASE WITH SPECIAL REF-
ERENCE TO RADIUM
IN NEEDLES*
WILLIAM L. CLARK, M.D.
PHILAOeUHIA
Those of us who are engaged in studying and
treating malignant disease realize that much is
yet to be learned before the problems of malig-
nancy are entirely solved ; yet realizing our defi-
nite limitations, we know that much more can be
accomplished by combined methods of attack
than could be accomplished in the past when
operative surgery alone was relied upon. When
the etiology of cancer is finally determined, per-
haps some specific, analogous to antitoxin in
Fig. t.— Exemplifying usual recurrence after surgical excision
of an epithelioma of the lip and dissection of metastatic cervical
glands without preliminary preparation with radium or x-rays.
The migratory cells in the lymphatic ducts drained into the tis*
sues of the neck and diffuse recurrence soon took place.
diphtheria or quinine in malaria, may be found,
but from present knowledge local attack is most
fruitful of positive results. Operative surgery,
electrothermic methods (desiccation, coagulation,
cautery), radium and x-rays, alone or in combi-
nation, are the most important methods to be
considered, and they have been found to be of
the greatest practical value in combating malig-
nant disease in its various manifestations. Since
it is almost impossible for one man to be pro-
ficient in all these methods, co6f)eration among a
group of men, each expert in his own specialty,
is desirable. To accomplish, however, the maxi-
mum of success with these available weapons, it
is necessary to revise some fallacious ideas which
*Read before the General Meeting of the Medical Society of
the State of Pennsylvania, Pittsburgh Session, October s, 1920.
are still considered orthodox by many, perhaps
by a majority of the medical profession. The
use of combined methods in the treatment of
cancer has been shown from clinical experience
to be sound practice. The physician who em-
ploys only one to the exclusion of all others,
while he may have limited success with certain
types of cancer, can not obtain so brilliant re-
sults in a wide range of cases as he who uses
various methods judiciously combined.
The problem of basal cell epitheliomata or
rodent ulcers involving cutaneous surfaces, es-
pecially about the face, eyelids, etc., growths
which seldom metastasize even though advanced,
has been solved. Total eradication of the lesion
by any method will result in clinical cure. Epi-
theliomata involving the skin of the extremities
are treated less successfully because of the
greater tendency of such growths to metastasis.
The method, or methods, to use in these cases is
a matter of personal preference. An operator
who is a master of his own method will succeed
where others using the same method will fail be-
cause of imperfect technic.
The squamous cell and glandular tj^pes of can-
cer are the most difficult of management, because
they usually progress rapidly, metastasize early,
and because the migratory cells in the ducts can-
not be reached by surgical treatment. Malig-
nant disease of the lip, buccal surface, tongue,
floor of the mouth, alveolus, antrum, tonsils, soft
palate, pharynx, ejnglottis, larynx, esophagus,
stomach, breast, uterus, rectum, etc., taxes the
skill of the surgeon ; but frequently brilliant re-
sults are obtained even in these cases by the use
of combined methods, results that were impos-
sible of accomplishment in the past before the
newer methods were available. This is true also
of the various types of sarcoma.
Excision or other treatment of primary ma-
lignant lesions of the types which metastasize,
together with block dissection of apparently jun-
involved glands, for prophylaxis, or of palpable
metastatic glands for the purpose of total eradi-
cation of the disease, no matter how thoroughly
executed, is certainly not sufficient. The migra-
tory cells in the lymphatic ducts must also be
taken into consideration and rendered innocuous
by appropriate measures to be discussed later,
else they will drain into the tissues after the
glands, nature's safeguards, have been removed,
and early recurrence and rapid progress of the
disease will usually result. Operative surgery,
without preliminary preparation, is unsafe in
these cases, and the patient, if denied the benefits
of preliminary treatment, will usually live longer
and in greater comfort if the disease is left to run
its course without interference. That migratory,
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January, 1921 MALIGNANT DISEASE AND RADIUM— CLARK
215
malignant cells do exist is not a mere hypothesis,
but a reality recognized by pathologists, and
measures must be adopted to destroy the micro-
scopic cells in situ before attempting surgical or
any other treatment of the perfectly apparent
lesions.
The lethal action of radium, and in a lesser
degree of the x-rays, upon malignant cells of all
nant cells from the laboratory standpoint:
"Wood and Prime showed that exposure to beta
and gamma rays for a time just too short to
kill the tumor cells caused a marked slowing in
the growth of the cells. They cannot explain
the variabihty in lethal action of the rays except
to say 'that it is exhibited only in groups of
young cells undergoing, or which have recently
w
n
\
^^^Hn ^k
"^ ' (iy^
HKsi^m^
1
1
^^Vi^^^^Tm
i.
i
^^ ' '
^%^' \
"l|
It
Fig. 3. — A, B, C, small round cell sarcoma, shown from different angles, involving frontal region, bone.
frontal sinus, eyelids, and nose. Recurrence after surgical operation, when growth in the sinus was curetted
through opening in frontal bone. D, result of radium needle treatment. Note total retrogression without
destruction of tissue, and conservation of eyelids. No recurrence in two years.
types — some types resisting more than others —
has been proved both in the laboratory and in
practice. The following quotation from a paper
by Sonnenschein, "The Use and Possible Abuse
of Radium in the Treatment of Malignant Tu-
mors of the Nose and Throat," published in the
Journal of the American Medical Association,
September 25, 1920, embodies present knowl-
edge regarding the action of radium upon malig-
undergone mitosis, and that older cells escape to
grow in the tissues of the host and produce tu-
rhors.' They found that 80 to 100 mg. of ra-
dium element would kill cancer cells in seven
hours. To get lethal action in the depths of the
tissue the gamma rays are essential. That im-
mature cells or those in a state of subdivision
are more sensitive to radiations than those which
have already acquired adult morphological and
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216
THE PENNSYLVANIA MEDICAL JOURNAL
January, 1921
physiological characters is the law propounded
by Bergonne and Dribondeau, and quoted by
Knox. Radium acts on normal tissues by stimu-
lating in small doses, with Iju-ger amounts pro-
and length of exposure. Ionization of the nuclei,
alteration in type of the cells to a more benign
form, the production of antibodies, etc., are some
of the thories advanced by Ewing, Lazarus-Bar-
Pig. 3. — A, inoperable carcinoma of the breast and axilla. Referred by Dr. Wm. Benham Snow, New
York City, and Dr. F. A. Jewctt, Brooklyn. B, result of radium needle treatment. "Total retrogression in six
weeVs, small ulcer remaining. This subsequently healed and the patient appears to be free from disease six
months.
ducing early congestion and later fibrosis. If
the exposures are prolonged and the filtration is
insuiKcient, the action of the rays may become
caustic, or the process may go on to necrosis or
low. Wood and others, to explain the action of
radium on the tissue cells."
It is recommended, after observing the good
results in practice, that at least one maximum
Fig. 4. — A, basal cell epithelioma involving the ear and mastoid region. Referred by Dr. F. C. Tice, Roanoke,
Va. B, retrOKression of ETOwth after radium needle treatment.
sloughing. With proper exposure there will be
inflammatory reaction, which slowly subsides,
fibrous tissue forms, cutting off the blood supply,
with necrosis if the action is rapid, or atrophy if
it is slower. Radiation effects depend on quan-
tity of radium, filtration, distance of application
radium treatment with proper technic be given
preparatory to any other procedure, especially
before a surgical operation, for the purpose of
first inhibiting and finally rendering benign the
migratory cells in the ducts, and producing
glandular fibrosis. It has been the author's cus-
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January, 1921 MALIGNANT DISEASE AND RADIUM— CLARK
217
torn to allow a week or more to elapse between
the radium treatment and whatever operative
work is undertaken; but, if it does not seem
prudent to temporize with a rapidly growing
lesion, this may be modified. At least three
quantity of radium is not available. Most phy-
sicists and most radiumologists believe that there
is little choice between the activity of radium
element and the emanation, milligram for milli-
curie. The emanation, however, decays and loses
A B
Fig. 5. — ^A, baaal cell epithelioma of the dorsal surface of hand involving tendons and bloodvessels and
adherent to bone. Patient aged 76. Reterred by Dr. H. B. Baxter, Philadelphia. B, retrogression without
great impairment of motion of the hand after radium needle treatment. This did not heal completely and
finally amputation was done to guard against metastasis upon the advice of the attending surgeon.
cross-fire radium treatments, averaging six
weeks apart should also follow any operative or
other procedure for further inhibitory and lethal
action upon any malignant cells that may still re-
main. The x-rays, though less potent, may some-
its potency from day to day unless renewed,
while the element is permanent in its activity.
The folly of depending upon any one method
alone in cancer with metastasis and the wisdom
of pre- and post-operative treatment have been
Fig. 6.— A, glioma of the retina, recurrence after enucleation. Referred by Dr. Paul Pontius, Philadelphia.
Pathological examination by Dr. Nelson M. Brinkerhoff, Philadelphia. B,. entire retrogression and disappearance
after radium needle treatment. Free from recurrence six months, when the other eye became involved with
disease. Patient died without further treatment.
times be used to supplement this treatment, cross-
firing through other skin areas, thus adding to
the potency of radium. Hard x-rays from a
Coolidge, or other suitable tube may be used ad-
vantageously to reach deep structures, if a large
amply demonstrated by various workers in this
field throughout the country.
If the invaded glands have not broken down,
they will usually disappear under judicious
cross-fire radium treatment. If the glands are
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218
THE PENNSYLVANIA MEDICAL JOURNAL
January, 1921
small, treatment may be given externally; if
large, radium needles should be inserted directly
into the glands. It is often difficult and may be
impossible accurately to determine whether the
glands are simply inflammatory or whether true
metastasis has taken place; but the indication
each containing some radium salt — preferably
the sulphate — representing a known quantity of
radium element, has revolutionized radium tech-
nic. (The author uses needles containing 5 to
lo milligrams.) These needles are used for in-
sertion into malignant growths and glands, or
A B
Fig. 7. — A, glioma of the retina in child 9 years old. Referred by Dr. G. Oram Ring, Philadelphia.
Pathological examination by Dr. C. Y. White, Philadelphia. Recurrence after enucleation of eye. B, result
two months after electrocoagulation operation. The condition later healed very much more. Child died in
• nine months of spinal metastasis without local recurrence.
for radium is the same in either case, for no
chances should be taken. If degenerated in the
parenchyma, the glands will reduce in size, but
not entirely disappear, and radium treatment will
convert the gland capsule into benign fibrous tis-
.sue. This has been frequently demonstrated by
laboratory study and by gross examination.
into an organ contained in the peritoneal cavity
after exposure of the lesion by laparotomy — ^the
pylorus for example. Results are obtained by
this method of radium application that cannot be
secured by the application of radium in capsule
or plaque. This method of application is more
accurate and a comparatively small quantity of
A II
Fig. 8. — A, basal cell epithelioma in which the eyeball and the bones of the orbit were involved. Referred by
Dr. E.' Kapeghian, Philadelphia. B, result of one electrocoagulation treatment. Complete exenteration of the
orbit was accomplished without hemorrhage immediately afterwards. No recurrence in three years. Note
slight contracture and regeneration of tissue.
Then the gland may be incised, curetted, or
drained with comparative safety to the patient,
after which a tube of radium properly screened,
or radium needles, may be inserted through the
capsule of the gland into the adjacent tissues as
an additional safeguard.
The adaptation of hollow, metallic needles,
radium applied in needles will produce even
more favorable results than a large quantity ap-
plied from the outside or inserted in capsule
form into the malignant tissue through an in-
cision. Under the latter condition the action is
too concentrated at the point of contact and the
advantage of cross-firing is not obtained. The
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January, 1921 MALIGNANT DISEASE AND RADIUM— CLARK
219
capsule and plaque, however, have their special
and even indispensable uses when radium must
be applied from the outside or in a cavity. The
needles are particularly efficacious in the treat-
ment of growths too large for radiiun penetra-
tion from the outside by capsule or plaque, and
in the more resistant forms which have been
After experimentation with various metallic
elements, including gold-plated steel, platinum,
irido-platinum, Monel metal, stellite, and an alloy
of steel and nickel known as "noncorrosive
steel," the last named has been adopted as most
durable and possessing the proper filtration qual-
ities for the purpose of radium application.
Fig. o. — ^A, sarcoma involving the sclera and cornea. Referred bjr Dr. Burton Chance, Philadelphia.
Fathological examination by Dr. Nelson M. Brinkerhoff, Philadelphia. Excision was practiced twice with
recurrence each time. B, result of one desiccation treatment under local anesthesia, rree from recurrence
four years.
found unresponsive to radium from the outside.
As many needles as necessary may be inserted
20 to 25 millimeters apart, to any depth into the
tissues, thus taking advantage of concentric
cross-fire radiation from needle to needle. If a
sufficient number of needles are available, they
These needles have been made to order in lengths
varying from 20 to 30 millimeters. Some are
round with tapering point, others have cutting,
trocar points; and yet others are compressed
until they are slightly flattened though still
maintaining the hollow center, so that they may
Fig. 10. — A, basal
cell epithelioma adherent to the bone, of 20 years duration. Referred by Dr. Wm. P.
Heam. Philadelphia. B, result of one electrocoaxulation treatment.
may be grouped together and put into a capsule
of brass or other metallic filter and covered with
rubber. These may be used in the same manner
as the ordinary radium capsule, lor the needles
may be placed side by side in a suitable flat me-
tallic container covered with rubber and used
whenever a flat plaque of standard construction
is indicated for the treatment of malignant dis-
ease.
be inserted, for example, through an endoscope
into the larynx between the cartilage and the
membrane with a minimum amount of trauma
to the tissues. The eye end of the needle is taper-
ing so that it may be withdrawn easily by means
of a braided silk thread after insertion below the
surface. The shorter 20 mm. needles are used in
delicate structures such as the eyelids, canthi,
larynx, etc., and the longer 30 mm. needles in
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THE PENNSYLVANIA MEDICAL JOURNAL
January, 1921
less delicate structures more extensively dis-
eased. The wall thickness is invariably 0.5 mm.,
as this seems to give the desired filtration. The
diameter at the widest point of the author's
needles is 2 mm. or 15 gauge measured by a
Stubs English wire gauge. The hollow needles
carried beneath the surface of the growth as
deeply as desired. A braided silk thread is al-
ways attached to the needle so that it may be
withdrawn easily from the tissue, and to obviate
the possibility of losing the needle with the sub-
sequent necessity of incising to find it. In dense,
ABC
Fig. II. — A. rodent ulcer of 15 years duration advancing rapidly at the time of consultation. Referred by Dr.
J. D. Morgan, Montreal. Canada. B. result of one electrocoagulation operation. Patient free from disease
two years. C, artiticial nose, lip and mustache by the sculpture method.
are so constructed that they are divided about
I mm. below the eye. After the needles are filled
with radium sulphate in the laboratory, the sec-
tions are screwed together, welded securely, and
polished, so that there will be no leakage of ra-
hard tissue a trocar or narrow blade scalpel is
first used to render the insertion of the needle
possible without force. Local anesthesia by 2%
novocaine and adrenalin is ordinarily used, al-
though when many needles are inserted at one
A ■ B
Fig. 12. — A. advanced basal cell epithelioma involving the cheek, parotid gland and osseous structures. Re*
ferred by Dr. Wm. Hamilton, Philadelphia. This case had resisted many forms of treatment and at the time
of consultation the patient was very toxic, emaciated, and in such a low state of vitality that death was immi-
nent. B, result of one electrocoagulation operation under ether anesthesia, which was entirely bloodless. Note
regeneration of tissue and slight scarring. No recurrence in three years. Patient gained over so pounds
and is in perfect health.
dium emanation and no possible focus of corro-
sion with resultant loss of radium. If the needle
wears through at the eye, the upper section may
be replaced without discarding the whole needle
or jeopardizing the radium.
These radium needles may be inserted directly
into soft tissues by means of a special applicator
or a small pointed hemostat, and they may be
time in very sensitive structures a general anes-
thetic may be employed to advantage.
Proper filtration is all important with any ra-
dium treatment, depending upon whether the
beta or gamma rays are to be utilized. The hard-
est of the gamma rays are very penetrating and
exert a more powerful action upon malignant
cells than the others, though the softer gamma
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January, 1921 MALIGNANT DISEASE AND RADIUM— CLARK
221
and the beta rays are utilized especially where
destruction of tissue is desired. Time will not
permit of a full discussion of the important fil-
tration question, the uses of the different radium
rays, and modifications of technic to suit various
types of cases. Essential information along this
line may be obtained from textbooks and cur-
sloughing near vital structures may jeopardize
the hfe of the patient. Clinical experience has
demonstrated the fallacy of this idea, if exposure
is not too long. It is true that, when a metal ap-
plicator containing radium is applied to the dry
skin for a sufficient period of time, a severe burn
of the third degree and sloughing of tissue will
■
T ^
1
I
^,f *■ 1
mli
i]
C D
Fig. 13. — A, result of electrocoagulation operation for extensive carcinoma involving the alveolus and inner
surface of the lip, also the antrum on both sides. ' B. deformity without dental plates, C, dental plates show-
ing posterior views. D, appearance of patient with plates in place.
rent medical literature dealing with radium
therapy.
It is still the opinion of some physicists and
radiumologists that radium needles are of little
practical utility, since it is thought that the sec-
ondary radiations from the metal in contact with
the tissues cause great irritation and objection-
able sloughs even with short exposures, and that
result; but, when radium needles, each contain-
ing 5 to 10 milligrams, or even more, of radium
element, are inserted into moist tissues such as
constitute malignant growths, the film of mois-
ture surrounding the needles may perhaps be
sufficient to absorb the secondary rays and the
destructive beta rays. The needles may remain in
place in some tissues as long as 24 hours, causing
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222
THE PENNSYLVANIA MEDICAL JOURNAL
January, 1921
cer.
retrogression and disappearance of malignant
growths but no destruction by sloughing. Tis-
sues of low vitality, or structures such as the
uvula, or soft tissues which are partly broken
down or devitalized will slough unless the radium
dosage is accurately estimated; hence the time
of exposure must depend
upon the density and vitality
of the tissues and the prox-
imity to vital' gtriictures, al-
though blood vessels such as
the carotid artery are surpris-
ingly resistant and no damage
has ever been noted, even
though the needles were close
to the artery as long as 24
hours. In some cases of very
advanced cancer of the cervix
the needles have been allowed
to remain in place 48 hours
without great sloughing and
with excellent results. Radium
needles are applicable in cases
of malignancy where tissue is
, • J f v 1 Fig- >4' — A, aeqaeatrum of exostosis of the
to be conserved tor vital or hard palate following devitalization of bone
^^^.^^i-:^ >;o„on»o ^^A i-Uair- hy the desiccation method. There is less
cosmetic reasons, and their dinger of entering the antrum by this method,
«rro-if irtiliio Viae Ko»n nrnvtv^ with careful technic, than if the chisel or other
g^eat value naS Oeen proved ^^^ instruments were used alone. B, seques-
in manv cases trum of alveolua following electrocoagulation
•' * treatment of carcinoma.
Radium needle treatment
should be administered in a hospital under
strictly sterile conditions with a trained nurse
in attendance. Every cases is a rule unto itself
and no absolutely definite guide can be given as
to the duration- of the application or the amount
of radium to be used. Generally speaking, the
treatment is usually all that is required. The
subsequent treatments may be given by capsule
from the outside.
Notwithstanding the potency of radium, it is
better not to temporize unnecessarily with can-
If the lesion is localized and can be con-
veniently immediately and en-
tirely destroyed by some
method, such as electrodesic-
cation or coagulation, it is rec-
ommended that it be employed
in preference to radium or
operative surgery as the pri-
mary agent, provided there is
a chance of eliminating the
disease at one operation;
otherwise the growth will be
stimulated. The author's per-
sonal preference is electro-
desiccation or coagulation,
since the destructive action
may be accurately confined
and the blood and lymph
channels sealed, rendering
local recurrence less likely.
This may be followed by
radium applied to the site of
the operation as an additional
safeguard, if this appears
necessary.
Operative surgery is of the greatest impor-
tance in cancer involving Inaccessible anatomical
structures to ligate blood vessels, if necessary,
and when there is extensive bone involvement;
but the use of electrothermic methods, radium or
Fig. 15. — A, sequestrum of lower jaw after electrocoagulation treatment of extensive carcinoma of the alveolus
with the view of conserving a shell of bone in the inferior position, thus avoiding^ the necessity of complete
resection. B, showing fracture of the jaw after sequestrum was removed. This united quickly and deformity
was avoided.
needles placed in sarcomatous tissue 20 milli-
meters apart should be withdrawn in 12 hours.
In the case of carcinoma the needles placed 25
millimeters apart should be withdrawn in from
18 to 24 hours. The treatment is repeated in
six weeks, if necessary, although one needle
both, directly applied immediately after opera-
tion, will reach malignant cells inaccessible to the
scalpel with results that can not possibly be ob-
tained by surgery alone. It is therefore con-
cluded in the light of experience that the greatest
success in the treatment of malignant disease in
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January, 1921 MALIGNANT DISEASE AND RADIUM— DISCUSSION
223
its various manifestations lies in the cotnple-
mentary action of surgery, electrothermic meth-
ods, radium and x-rays, judiciously selected or
combined to meet the particular requirements of
the individual case.
The accompanying photographs illustrate
equipment and some of the results obtained by
the methods under consideration.
Ft(. 16. — ^ppli
ne«dles m&y be
li. — .Applicators, trocar, forcepa,
les m&y be used singly, grouped
capsules, or placed side by side in flat brass containers as shown.
. containers, etc The
together in round brass
Fig. 17. — Radium needles. The three sets of needles above are as milli-
meters long, contain lo milligrams of radium each, and are attached to
braided silk thread. The single set below are ao millimeters long and
contain five milligrams of radium.
Fig. 18. — Five needles, each containing lo mg. of radium, were
placed upon an envelope containing a sensitized photographic
plate for two minutes. Note concentric radiations from needle
to needle. Radium rays are projected in the tissues in the same
manner.
DISCUSSION
Dr. Russell H. Boccs (Pittsburgh) : I have lis-
tened to Doctor Clark's excellent talk with a great
deal of interest and I am sure that every one was glad
to see his results as shown on the screen. I agree with
Dr. Clark in almost everything he has said. It is true
that excision or other treatment of a primary malig-
nant lesion and block dissection of metastatic glands is
not sufficient because the cancer cells have reached
glands which cannot be removed by the knife. All
cases should have at least one lethal dose of radium
preparatory to any other procedure for the purpose
of rendering benign the cancer cells in the ducts and
causing the glands to undergo a fibrous degeneration.
It is certainly folly to depend on cautery or surgery
in the treatment of cancer without ante- and post-
operative treatment. It is true that when the glands
are palpably enlarged, there are migratory cells in
lymphatic chains beyond.
It must be remembered that the lethal dose for
most types of cancer is from three to six times the
erythema dose. In many rodent ulcers slightly more
than an erythema dose will cure the lesion but if the
epithelioma is of the squamous type the
lethal dosage is from three to six times the
amount of the erythema dose.
Lip cancers are probably more success-
fully treated by applying radium to the lip
and treating the adjacent glands on both
sides of the neck with surface applications
of radium and the x-ray, than by the most
extensive surgical operation which cuts out
the center of the growth and only hastens
metastatsis. The most extensive glanduar
dissection is seldom ever successful.
William J. Mayo advocates anteoperative
radiation in the following words :
"Radiotherapy has justly achieved a
reputation in postoperative treatment of
cancer of the breast. It would appear,
however, to have its greatest field of use-
fulness in preparing a malignant area
against wound grafting during operation
and its ability at least temporarily to reduce
the vitality of the malignant cell. Radio-
therapy whether applied as radium, x-ray,
or heat, sickens malignant cells beyond the
area of destruction."
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THE PENNSYLVANIA MEDICAL JOURNAL
January, 1921
Lately I have been imbedding radium needles
throughout the breast, the glands in the axilla, and
the glands leading from the breast to the axilla with
good results. The cases treated in this manner were
far advanced. In conclusion we were very fortunate
in having Doctor Clark with us to-day.
Dr. G. Betton Massey (Philadelphia) : These pic-
tures were very interesting in spite of the poor show-
ing of the lantern, and welt worth seeing. I do not
share the apparent pessimism concerning the x-ray
treatment of cancer evidenced by some of our work-
ers turning to radium, but, nevertheless, call attention
to the fact that the radium pictures shown, of appar-
ently cured cases, do not indicate that the necessary
time has passed — the three-year period — before they
should be taken as conclusive evidence of cure. I do
not see how the radium rays are so much more effec-
tive than properly administered x-rays when the lat-
ter are properly applied.
It is possible that some of the bad odor of the x-ray
treatment of cancer is, as was brought out by Dr.
Clark, due to a lack of use of the proper remedy at
the proper time; that is, the lack of use of several
remedies, the association of remedies, the knife pos-
sibly in some cases, but more particularly the electro-
thermic method which is employed first to get rid of
the bulk of the accessible growth before the x-ray is
applied. It has appeared to me that a special field for
the x-ray is in the subdermic diffusions that are found
at times surrounding a healthy scar after operation.
But I have cases that are well at the end of seventeen
to twenty years from the electrothermic treatment
alone, or as it was then called, cataphoric destriKtton.
Many others failed of ultimate relief, before the dis-
covery of the x-ray, that are being cured now by post-
operative raying. I repeat that we are not yet at that
point of pessimism in regard to the proper application
of the local destruction method, combined with the lat-
ter use of the x-ray, that should lead us to give up
these methods for radium, a most expensive method,
and one that is necessarily limited. Of course, if it
is the only thing, we will have to use it. But let us
have the third year, the seventh year and the seven-
teenth year results before we are positive on that point.
Dr. John B. Roberts (Philadelphia) : I feel obliged
to state my disbelief in the author's statement that
excision of a part of a tumor to establish diagnosis by
histological study is dangerous and would lead to a
consequent rapid increase of the malignant growth.
I contend that experience does not support this view
and it is a dangerous teaching that might lead to un-
necessary operations of magnitude on nonmalignant
growths. My conception is that pathologic study and
opinions, like clinical study and opinions, are not in-
fallible, but must be considered together in obscure
or important problems in the treatment of malignant
disease. The author stated that at times he had a
pathologist examine a piece of suspicious growth by a
rapid microscopic technic just prior to operation by
electrothermic methods; and if the pathologist had
not enough faith in his own method and ability to give
a definite opinion as to the malignancy or nonmalig-
nancy of the tumor, "we get a pathologist who has."
This is an unwise attitude for an operator to assume
for a "cocksure" pathologist is as dangerous to the
patient as a "cocksure" surgeon.
Dr. Clark (in closing) : I wish to correct Dr. Rob-
ert's misunderstanding of my position in regard to the
taking of sections from malignant growths for patho-
logical study. While clinical diagnosis in most cases
is clear, there are times when pathological study is
imperative for differential diagnosis, and this has al-
ways been my practice in cases of doubt. Experience
has taught, however, that it is a reprehensible practice
to excise a section from a malignant growth and wait
even a few days for the pathologist's report. Blood
and lymph channels are opened and I have seen many
cases in which I am convinced the patient's interests
were jeopardized by so doing.
I am informed by competent pathologists that mod-
em methods of making frozen sections are quite as
satisfactory as the older methods which took several
days to prepare a specimen; and I prefer the modem
method since a pathologist's report may be returned
in from ten to fifteen minutes. I believe in the wis-
dom of the frozen section method with early return of
the report, so that whatever operation is contemplated
may be done without delay; and urge upon the medi-
cal profession the adoption of this method whenever
an examination of this kind is necessary. I have had
no reason to regret this policy, but I certainly have
had cause to regret incising malig^nant tissue and wait-
ing several days and sometimes weeks for a report.
HEALTH INSURANCE— A CHALLENGE
TO PHYSICIANS*
FREDERICK R. GREEN, A.M., M.D.
Secretary Council on Health and Public
Instruction, A. M. A.
Health insurance has now been under discus-
sion for nearly five years. The majority of
medical organizations that have considered this
question have adopted resolutions condemning it.
At the New Orleans meeting of the American
Medical Association, the House of Del^ates,
representing the fifty-four constituent associa-
tions which form the national body of our pro-
fession, adopted a resolution declaring its oppo-
sition to "any plan embodying the system of
compulsory, contributory insurance against ill-
ness, or any other plan of compulsory insurance
which provides for medical service to be ren-
dered contributors or their dependents, provided,
controlled or regulated by any state or the Fed-
eral Government."
In so far as any body has authority to speak
for the American medical profession, the adop-
tion of this resolution by the American Medical
Association definitely determines the attitude of
physicians on this question. It only remains for
•Read before the Public Meeting of the Medical Society of
the State of Pennsylvania, Pittsburgh Session, October 5, I9«-
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January, 1921
HEALTH INSURANCE— GREEN
225
us, as individuals and through the various units
of our organization, to mobilize the influence of
the profession and to mold public opinion so as
to make this policy effective.
In this attitude, in so far as it is opposed to
health insurance as proposed, I am in hearty ac-
cord. In a paper which I had the pleasure of
presenting recently before the Michigan and
Ohio State Medical Societies, I endeavored to
analyze the proposed plan and the arguments of
its advocates. I tried to show that the scheme
was not insurance, neither was it an effective
health measure, but that it was rather an eco-
nomic and industrial scheme for subsidizing a
comparatively small group of industrial em-
ployees at the expense of the public, either
through direct or indirect taxation ; that the plan
was not suited to this country or in harmony
with its institutions; that the burden of proof
rested on the advocates of the plan, and that in
order to establish their case, it would be neces-
sary for them to prove four fundamental propo-
sitions, viz:
1. That there is a disproportionate amount of
sickness among employed persons causing finan-
cial loss, incapacity and poverty, greater in pro-
portion than that sustained by the average per-
son and requiring special methods of relief.
Until this is proved, there is no justification for
special laws for employees.
2. That the financial burden caused by sick-
ness is heavier than the average employee is able
to bear. Until this is proved, there is no reason
to assume that he cannot carry his own burden.
3. That present methods of promoting public
health and controlling diseases are not adequate.
Until this is proved, there is no need of devising
any new plan.
4. That compulsory state supervised sickness
insurance is the best remedy for this condition.
Until this is proved, it is possible that some other
remedy may be better.
These four propositions have not as yet been
proved. I also endeavored to show that while
much interesting and valuable data on various
aspects of this question has been collected,
the evidence was as yet neither complete nor
convincing and that the only verdict which could
be rendered at present regarding the soundness
of the scheme itself or the advisability of its
adoption was the Scotch verdict of "not proven."
Assuming for the sake of the argument that
this reasoning is sound and that the medical pro-
fession is justified in the attitude which it has
taken, the question still remains whether the ren-
dering of such a verdict constitutes the whole
duty of physicians. Let us apply the same situa-
tion to the more familiar field of private prac-
tice. Suppose any one of us were called as a
consultant -in the case of an individual patient.
After as painstaking and exhaustive an exami-
nation of the patient as our knowledge and the
resources at our command will permit, we are
convinced that the diagnosis that has been made
is wrong and that the treatment that has been
prescribed is not effective. Is our full duty as a
consultant performed when we have stated these
conclusions to the patient or his friends ? Under
such circumstances, would we not immediately
be. asked to furnish the correct diagnosis in place
of the erroneous one that we had repudiated, and
to outline a proper method of treatme'nt in place
of the one we had criticized and condemned?
And would we not all admit that if we refused
to do so, there was no alternative remaining byt
to confess that the case was beyond our ability
and knowledge and to withdraw and give place
to a more capable diagnostician?
In the case under discussion, the patient is the
social body. That it is suffering from certain ills
is probably not questioned by any one. The ex-
act nature, extent and seriousness of these ills, in
other words, the diagnosis, is the question at
issue. Until an exact diagnosis is made, any
proposed method of treatment must necessarily
be empirical rather than scientific. We have
questioned the diagnosis of those who claim to
be competent and qualified to diagnose and pre-
scribe for our social ills. We have opposed the
treatment which they have prescribed as unscien-
tific and inadequate. Does not this situation con-
stitute a direct and unavoidable challenge to the
medical profession either to furnish a correct
diagnosis and to prescribe an adequate and effec-
tive remedy for such ills as may be demonstrated,
or to admit that the case lies outside of our prov-
ince and to withdraw in favor of a better quali-
fied authority?
I think we will all agree that both the making
of a diagnosis and the prescribing of the treat-
ment for the diseases of society are at present
beyond the ability and knowledge of any one
man, either physician or layman. We are at
present without the exact knowledge of social
conditions necessary for accurate diagnosis of
social ills, nor will such a diagnosis be possible
until we exert the same energy, ability, industry
and perseverance in the study of social ills that
the medical men of our own and previous gen-
erations have shown in investigating the diseases
of the individual. But the assumption of this
task is an assertion of our belief that the study
and treatment of social ills are just as much func-
tions of the modern physician as are the diag-
nosis and treatment of the ills of the individual.
Are we as a profession ready to assume the role
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THE PENNSYLVANIA MEDICAL JOURNAL
January, 1921
of social physicians? If so, what are our quali-
fications? If not, can we qualify for this task?
If we can, then it is obviously incumbent upon
us to do so. If we cannot or will not fit our-
selves for this duty, can we justly complain if
others assume a function which we refuse to
perform? These are pertinent questions of im-
mediate and pressing importance, which the
medical profession must answer frankly and
honestly if we expect to justify ourselves before
the American people and to retain the leadership
which we have assumed in directing and guid-
ing public health and public welfare.
If a physician is called to see a patient and
makes a diagnosis of typhoid fever, while he
will naturally do everything possible to promote
the comfort and recovery of the patient, yet the
determination of the source of the disease and
the prevention of the development of other cases
from the initial case as a focus, i. e., the social
aspects of the problem, are of as great; if not
greater importance than the treatment of the in-
dividual patient. This becomes increasingly true
as the disease increases in rarity and severity.
Suppose a single case of bubonic plague were
discovered to-morrow in New York City. The
correctness of the diagnosis in this single case
would affect directly or indirectly, every man,
woman and child of the millions in New York,
as well as the many millions in the eastern half
of the nation. A single case of yellow fever in
one of our seaports might easily change the cur-
rents of trade and affect millions of dollars of
capital and innumerable human beings. Modem
scientific medicine is to-day one of the most
vitally important and indispensable factors in
modem life, and we have as yet seen only the
beginning. In spite of the marvelous develop-
ment that has taken place in the fifty years since
Massachusetts established the first state depart-
ment of health in this country, we can not yet
begin to appreciate or realize the possible bene-
fits which our present and future knowledge of
diseases and their control will have on the well-
being and happiness of the human race.
But while for half a century our knowledge,
as Tennyson says, has "grown from more to
more," our professional habits have remained the
same. In this remarkable development of scien-
tific knowledge, physicians, both as individuals
and as a class, have been the leaders. So rapid
has been the growth of scientific knowledge that
it has been difficult even for the leading medical
schools to keep pace with its development. In
spite of the tremendous increase in equipment,
personnel and facilities for teaching, in spite of
the lengthening of the medical course from one
or two years of six months each to four years of
nine months each with two years of college work
as a preliminary qualification and a year of hos-
pital work for postgraduate training, our medi-
cal schools to-day find it impossible to include
even in this extensive period of instruction and
training all of the facts which should be taught
to the medical student. While the value of medi-
cal services to society is now equal to if not
greater than the value of medical services to the
individual, the medical profession is as individu-
alistic to-day as it was fifty years ago and as de-
voted to learning specific facts for application as
it has been for the last five hundred years. The
greater part of the time of medical students is
devoted to learning specific facts for application
to individual cases. In spite of the rapid devel-
opment of public health as a function of munici-
pal, state and national government and the con-
stantly increasing demand for properly trained
and qualified men to serve in official positions,
our medical graduates are still trained almost ex-
clusively for the treatment of individual patients.
Every medical student is given exactly the same
training, largely instruction in the examination,
diagnosis and treatment of individual patients.
Practically nothing is taught the student regard-
ing social medicine. If after graduation, he has
any opportunity to take up health work for the
community, he is forced to get his training at the
expense of the community after he has been ap-
pointed to office. He is taught nothing in medi-
cal school to prepare him for such work as a
recognized part of the activities of a physician.
It is only in the last few years that any differen-
tiation has been undertaken between the training
necessary for individual private practice and that
required of a man who desires to devote himself
to service to the community or the state.
What is true of our medical colleges is also
true of our medical societies. Papers on public
health questions or on social and economic prob-
lems are read to a handful of listeners, while the
majority of the members flock to some surgical
amphitheatre to see a surgeon operate on an in-
dividual gall bladder, or to listen eagerly to end-
less papers on the diagnosis and treatment of
individual patients. Questions of public policy
and legislation involving the welfare of an entire
state arouse little general interest. It is the uni-
versal experience of those interested in promot-
ing and securing health legislation of any sort
that the task of securing such laws, to say noth-
. ing of enforcing them, is invariably left to a
small group of public spirited physicians and
that it is generally impossible to obtain the co-
operation of a majority of the physicians of the
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January, 1921
HEALTH INSURANCE— GREEN
227
state. Our professional standards have been
based on the same methods of valuation. An in-
dividual's standing or success in the profession
is estimated largely by the number of patients
he has seen, the number of clinical cases he has
reported or the number of operations he has
performed. So long as the profession was lim-
ited entirely to individual services, these were
the natural standards. To-day with the social
value of modern medicine far outweighing its
individual value, these standards are obsolete and
need revision.
If it be argued that in the development of so-
cial medicine in so far as it has gone, the phy-
sician has contributed his full share of services,
often at considerable sacrifice to himself, it can
only be replied that this is perfectly true and
that as a health ofHcer or a member of a local
or state board of health at a ridiculously small
and inadequate salary or as an attending physi-
cian or surgeon to a public institution or free
clinic, the great majority of physicians give valu-
able services worth large sums of money ; but it
is at the same time equally true that these con-
tributions, magnificently generous as they are,
have been contributed by the physician as an in-
dividual rather than as a result of any well de-
fined professional program.
The explanation of this apparently paradoxi-
cal situation, of course, lies in the pertinent fact
that to-day, as for centuries past, the physician
makes his living by charging individual patients
for individual services, and so long as individual
services are the principal source of income of the
majority of physicians, there will his chief inter-
est naturally lie. Yet it is also true that the phy-
sician is to-day living on the least valuable part
of his knowledge and is giving away the most
valuable part of his services and that he will
probably continue to do so as long as present
methods continue.
This can be summarized by saying that, while
the development of scientific knowledge in the
last fifty years has produced an entirely different
conception of the relation of disease to society
and of the duty of society to the individual and
of the individual to society in the control and
prevention of disease, the attitude of physicians
both as individuals and as a body, is still prac-
tically the same individualistic attitude that it has
been for hundreds of years past. The medical
student of to-day still gives the greater part, if
not all, of his time to the study of disease as an
individual phenomenon, while the practicing
physician of to-day gives the bulk of his time
and practically all of his interest to the treatment
of individual patients; this in spite of the fact
that in the last fifty years the medical profession
of the world has developed and given to the hu-
man race for all time the most valuable contribu-
tion of knowledge and applied science that has
ever been produced since human history began,
and that its present and potential value to society
far outweighs its value to the individual. It is
absolutely essential that physicians recognize the
fact that diseases of the community are just as
much a function of the medical profession as are
diseases of the individual, and that they endeavor
to qualify for the same services in the social field
that they have so magnificently performed and
are now performing in the individual field. An
entirely new field has developed, that of social
medicine, as contrasted with individual medicine
which has been followed for centuries as the only
possible activity of physicians and is still fol-
lowed exclusively by the great majority of phy-
sicians.
Social medicine includes all practical applica-
tions of scientific knowledge regarding diseases
and their prevention and the promotion of health
and efficiency as applied to the community
rather than the individual. Less than fifty years
old in its development, it is naturally fragmen-
tary and incomplete. Its exact boundaries, limi-
tations and methods are still to be determined.
Resting as it does on scientific medicine as a
foundation, it has naturally been promoted so
far largely by men with medical training and a
professional point of view plus a social instinct
and vision. Yet it is a question still to be deter-
mined whether this field will be dominated by
medical or nonmedical men. It is only in the last
few years, comparatively speaking, that any
others than physicians have begun to take an ac-
tive part in its development. In two notable in-
stances is it becoming evident that nonmedical
workers may invade, even if they do not entirely
occupy this field. The creation of the degree of
Doctor of Public Health separate from the de-
gree of Doctor of Medicine, as well as the ap-
pointment of sanitary engineers, bacteriologists,
chemists and others to positions in public health
organizations have indicated the possibility in
the future of a large number of public health
workers being trained for public health and com-
munity functions alone, rather than for the treat-
ment of individual patients. The fact that so far
with very few exceptions, medical colleges have
shown no tendency to modify their methods of
instruction so as to produce any considerable
numbers of trained workers in the public health
field would indicate that unless there is a speedy
change in this particular, the public health men
of the future will not be medical men in the pres-
ent sense of the word. In fact, present methods
do not produce enough trained public health
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THE PENNSYLVANIA MEDICAL JOURNAL
January, 1921
workers to supply the demand. In Ohio last
winter when the state commissioner of health
undertook to administer the Hughes law which
provided for whole-time county health officers,
it was found impossible to secure enough trained
health officers to supply the eighty-eight counties
in that state. Yet we have been urging whole-
time county health officers for many years, not
only in Ohio, but in most of the larger states. If
there were not enough trained men to supply the
eighty-eight counties in Ohio, what is going to
happen when all of the states with an aggregate
of nearly 3,000 counties attempt to put in force
plans for whole-time county health officers in
every county in the United States. And when
every city of any size organizes a whole-time
health department, where are trained health offi-
cers to be secured ? Yet that this will eventually
occur, there is little doubt. Obviously, unless the
medical profession trains a sufficient number of
men for work in the field of social medicine, the
men are going to be drawn from outside the
medical profession.
The other instance in which this field has been
invaded by nonmedical men is the development
in the last few years of social welfare organiza-
tions and the social welfare workers. This class
consists almost entirely of men and women with-
out medical knowledge and in many cases with-
out any scientific training. Those active in this
field and especially the individuals conducting
the training courses for social workers which
have been established are drawn almost entirely
from philanthropic and charitable organizations.
While a sincere and painstaking effort has been
made on the part of liiany of the workers in this
field to put their theories and practice on a sound
scientific basis, the subject is as yet too new, the
data too incomplete and the workers as a rule
too little trained to entitle social welfare to rec-
ognition as a science. Yet it is from this class
very largely that the supporters and advocates of
so-called health insurance have been recruited
while the scheme itself is probably only the first
one of many plans which will be suggested as
remedies for conditions which increasing investi-
gation of the field of social medicine are re-
vealing.
It is most important that physicians should
understand clearly the significance of the pres-
ent agitation for health insurance. To regard
this movement as an isolated and single phe-
nomenon would be a serious error. On the con-
trary, it is the result of a long series of causes
which reach back to and spring from the same
source as the development of scientific medicine.
The medical profession itself, through its labors
and progress, is very largely responsible for the
present situation. We are also very lai^ely re-
sponsible for the fact that, while scientific knowl-
edge in the field of preventive medicine has
made tremendous strides in the last generation,
our personal and economic relations to the public
remain practically the same as they have been for
the last five hundred years. For fifty years past
we have been so busy extending our knowledge
of disease that we have had no time to adjust
our business methods to conform to changing
conditions. While we possess scientific knowl-
edge which enables us to render services to so-
ciety of greater value than any other professional
group can offer, we have continued to do busi-
ness on the old basis of so many dollars for so
many calls on the individual patient. Yet the
medical services which can be rendered and
which in the future must be rendered to the
community by physicians are of far greater value
than any services which we can render to the in-
dividual. Medical services have grown in value
and importance until under present methods,
modern up-to-date medical attention is beyond
the reach of the majority of persons unless they
secure it through charity. The proposed plan of
health insurance is only one of the schemes pro-
posed whereby adequate medical services can be
put within the reach of the average employee.
The fact that this particular plan is in our judg-
ment economically unsound and that it would
probably be ineffective in operation does not in
any way relieve us of the immediate necessity
of devising some method by which modem, up-
to-date medical services can be made available
for every individual needing them.
There are in my opinion two fatal defects in
the proposed plan of health insurance. The first
is that its proponents, instead of first studying the
situation in this country and devising a plan suit-
able to existing conditions, endeavored to trans-
plant entire, from Germany by way of England,
a plan unsuited to this country and out of har-
mony with our social institutions and economic
conditions. The other fatal objection is that so
far the advocates of health insurance have failed
to produce any conclusive and convincing tv\-
dence that the plan is sound or that it will do
what is claimed for it. But if we could tomor-
row defeat beyond any possibility of resuscia-
tion the establishment of health insurance in
every state in the Union, we would be no nearer
the solution of the problem than we were before.
There would still remain the need just as impera-
tive as ever of remodelling the economic meth-
ods of practice now existing in the medical pro-
fession by which professional services are ren-
dered almost exclusively to the individual, and of
substituting for the present method of individual
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January, 1921 ENDOCRINES IN GASTRIC DISEASE— SCHNABEL
229
services to individual patients some pljin whereby
each individual as a part of his social rights,
would secure every protection of his health and
well-being that modern medical knowledge could
give him. In the face of the fact that the dis-
coveries in medicine in the last fifty years have
been of greater value to the community than to
the individual, and that medical knowledge has
already a far greater social importance than it
has an individual value, it is idle to deny that the
medical profession in the near future must in-
evitably and unavoidably modify and readjust
its methods of service; The efforts for the adop-
tion of health insurance, therefore, instead of be-
ing regarded as a single, isolated movement which
will disappear with the defeat of the plan in the
various states, should rather be recognized as the
bq^inning of an effort to readjust professional
methods to social needs. If we prove that the
proposed plan is unwise and refuse to accept it,
there still remains the duty of devising, within
our own ranks, a better and a sounder method
by which the results desired can be secured.
In the discussion of this question there are,
as always, three distinct groups: first, the con-
servatives who desire only that things shall re-
main in the condition in which they always have
been so far as their experience and knowledge
goes; second, the radicals who look forward
with eager vision and often without accurate dis-
crimination toward what they hope will be better
conditions and who favor any proposed change
in the existing status; third, the mass of the
medical profession who have accepted conditions
as they found them and have made the best of
them, who are willing to adopt new methods if
their value can be demonstrated, who are neither
wedded to the past as are the conservatives nor
plunging rashly into the future as are the radi-
cals. I take it that 75 per cent, at least of this
audience belong to the third class. To you,
therefore, I wish to submit what is to my mind
the most important and fundamental question in
the whole discussion and to beg of you its most
careful and earnest consideration. Briefly stated
it is this: Is social medicine a function of the
medical profession ? This is the important ques-
tion for physicians to determine. Is the physi-
cian of the future going to restrict himself to the
treatment of individual patients as he has in the
past, or is he going to assume the responsibility
for the treatment of society and of humanity in
the mass as well as of the individual ? If he is,
then it is obviously necessary for him to qualify
himself for this work. If he is not, then he can-
not complain if others take up the functions and
the responsibilities which he declines and en-
deavor to the best of their ability to furnish the
services for society which he will not or cannot
give.
I assume that there is no difference of opinion
as to what the answer to this question should be.
The medical profession owes it to society just as
it does to the individual to render the best serv-
ices and do the best work of which it is capable.
It is inconceivable that the highest type of medi-
cal service, whether individual or social, shall be
rendered by any other than scientifically edu-
cated and trained medical men. But if physicians
are going to assume this responsibility, especially
if we are going to demand the control of this
field as we have of the treatment of individual
ills, then we must qualify for social services just
as thoroughly as we are now endeavoring to
qualify for individual services.
If the medical profession is to undertake the
responsibility for social service as a part of its
professional functions, then social medicine and
its problems must be more generally, frequently,
broadly and intelligently studied and discussed
in our medical organizations and medical publi-
cations thcin they have been in the past. If social
medicine is to be one of the functions of the
medical profession of the future, then the medi-
cal student must be given broad and adequate in-
struction regarding its problems. He must be
taught social anatomy, pathology, diagnosis and
treatment with at least the same thoroughness
that he is now taught the diagnosis and treatment
of individual diseases.
The issue is plainly before us. Shall we fol-
low the methods and practices of the past until
we are forced to abandon them, or shall we our-
selves recognize, as Lowell said, that
"New occasions teach new duties. Time makes
ancient good uncouth.
They must upward still and onward, who would
keep abreast of truth."
Shall we adhere to the limited field of our pro-
fessional forefathers or shall we broaden our
methods to keep pace with the ever widening
bounds of scientific knowledge? The question
is yours to answer, not only for your own day
and generation, but for the future of scientific
medicine.
THE ENDOCRINES IN GASTRIC
DISEASE*
TRUMAN G. SCHNABEL. M.D.
PHILADELPHIA
In a translation of Lobstein's Treatise on the
Structure, Functions and Diseases of the Human
'Read before the Section on Medicine of the Medical So-
ciety of tile State of Pennsylvania, Pittsburgh Session, Oc:ober
7, i9io.
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THE PENNSYLVANIA MEDICAL JOURNAL
January, 1921
Sympathetic Nerve,' Joseph Pancoast writes of
a patient on examination after death that "the
villous coat of the stomach appeared to be in-
flamed and thicker than usual, especially toward
the pylorus, and the semilunar ganglia were
found in a state of genuine inflammation." In
commenting on these findings and other similar
ones the trjmslation reads, "These marks of dis-
ease in the sympathetic nerve should not assur-
edly be despised nor the inflammation be lightly
thought of in which the vital forces are un-
doubtedly raised to the highest grade of inten-
sity and produce phenomena of a more or less
serious character." Although the original Latin
lines were written in 1823 there is very little to
be found in the literature for many years con-
cerning the relationship of what Langley styled
the autonomic nervous system and gastric dis-
ease whether functional or organic.
In 1910 Eppinger and Hess* presented their
classic study in vegetative neurology under the
title of "Vagotonia." In it is advanced the the-
ory of an equal and continuous tonic enervation
of the vagus and sympathetic nerves. Under
normal conditions these antagonistic systems are
maintained in a perfect state of equilibrium.
When, however, the tonus of either one or the
other becomes excessive, then the symptom com-
plex of vagotonia or sympathicotonia prevails.
The stimulant of the sympathetic system is
adrenalin and theorizing by analogy Eppinger
and Hess introduced the term "Autonomin" as
applying to a supposed stimulating substance of
the vagus. Most writers seem to be agreed with
these authors that vagal tonus is responsible for
gastric hypermotility, hyperperistalsis and hyper-
secretion and that the sympaticotonic has a
dilated stomach emptying with difficulty and
scanty in gastric secretion. Whether or not
there is agreement to all that is written in their
great monograph, Eppinger and Hess did the
medical profession a service in that they found
an excellent pathological peg upon which to hang
many neuroses diagnoses. They also called at-
tention to the controlling influence that internal
secretions may have in maintaining the balance
or creating an imbalance in the great autonomic
system and the viscera it supplies.
Since 1910 much investigation has been car-
ried on and much has been written concerning
the relation of ductless gland secretions and the
vegetative system. Just how the thyroid influ-
ences this nervous system is still uncertain.
Some insist that it acts only on the sympathetic
side, others believe it influences only the vagus,
while some attribute to thyroid secretion both a
vagotropic and a sympathicotropic function.
Cannon and his associates" showed that thyroid
secretion sensitizes the sympathetic nervous sys-
tem to the action of epinephrin; thus seeming
to give to the adrenals the role of maintaining
a hypertonic state in the gastrointestinal tract.
The work of Levy* tended to show the same end.
On the other hand Rogers and his coworkers'
believe that the effect of thyroid and parathyroid
secretion is a stimulating one upon the terminal
fllaments of the vagus, just as the effect of ad-
renalin is exerted in an inhibitive way upon simi-
lar structures in the sympathetic system.
As evidence of the influence that endocrine
dysfunction exerts upon ' gastric function we
find that Graves Disease is generally accom-
panied by a hypergastric activity. This is not
uniformly so, for there are instances when gas-
tric secretion, motility and peristalsis are dimin-
ished or normal in hyperthyroidism. In myxe-
dema the gastric secretion is reduced in amount
and the acidity is apt to be diminished.
The relationship of the parathyroids to tetany
is now well known to all. In some cases tetany
precedes, in others it follows gastric disturb-
ances. The first tjrpe is accompanied by hyper-
excitability on the administration of pilocarpin
with relaxation of stomach tonus, an increase in
gastric secretion and pronounced stasis leading
eventually to tenesmus and diarrhoea. Kussmaul
has called attention to a particular form of tetany
in which digestive disturbances exist for a long
time and are accompanied by most varied condi-
tions such as hour glass stomach and cicatricial
ulceration of the duodenum. Another type of
tetany was described by Barker' and Estes in
which both the stomach and duodenum are di-
lated and the condition of hematoporphyrinuria
is present.
In passing, mention need only be made of the
presence of abnormally long intestines in the
status thymico lymphaticus patients. The pitui-
tary seems to play a part in splanchomegaly. In
this condition enlargement of the walls of the
stomach and intestines is observed as well as an
increase in the size of the liver, spleen, and
pancreas.
The hypodermic use of pituitrin, in addition
to giving rise to intestinal hurry, also may be re-
sponsible for vomiting. The observations of
Beyer and Peter' in 1900, Bell* in 1909, and Pan-
coast® and Hopkins in 1917, on the influence of
pituitrin on the gastrointestinal tract are notable
contributions on the subject.
Adrenalin is a product of the chromaffin cells,
a part of the sympathetic system. In small doses
by the hypodermic route adrenalin inhibits gas-
trointestinal peristalis and stimulates the con-
traction of the sphincters. Hoskins and Mc-
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January, 1921 ENDOCRINES IN GASTRIC DISEASE— SCHNABEL
231
Clure'" have shown that smaller doses may in-
crease paristalsis.
Rogers" reports the successful use of espe-
cially prepared nucleo protein glandular products
in gastric disease. Thyroid and suprarenal ther-
apy is urged as a logical course of procedure in
such conditions. There are other reports in the
literature on the beneficial effects of organther-
apy in stomach diseases ; most of these are notes
on results in more or less isolated cases. On the
other hand Lehman" doubts that the vagus and
s>'mpathetic are antagonists and believes that a
disturbed function of the involuntary nervous
system is rare in ulcers of the stomach and there-
fore disbelieves the beneficial influence of glan-
dular therapy.
Cesaris Demel" was the first to call definite
attention to the presence of suprarenal pathology
in gastric ulcer patients. Finzi'* found ulcera-
tion in the gastric mucosa of animals in whom
a double adrenalectomy had been performed.
Friedman,"' Elliot,*' and Mann" all found gas-
tric ulcers after partial or total animal adrenal-
ectomy. After partial parathyroidectomy the
same findings were observed by Carlson** and
Jacobson.
Such reports as these together with other ex-
periments led Friedman*' to advocate the endo-
crine origin of gastric and duodenal ulcers al-
though he does not deny the possible factor of
hydrochloric acid in the further development of
ulcers, nor does he deny the influence of the cen-
tral nervous system on the v^etative system and
consequently upon gastric secretion. He begins
by assuming some mucosal lesion accomplished
by interference in local blood supply either of
an ischmeic or stasis type. An imbalance in the
v^etative system is held as being responsible for
either constriction or dilation of the blood ves-
sels and contraction or relaxation of the mus-
cles. This allows for a break in surface con-
tinuity followed by the possibility of an infective
process. Assuming then that the autonomic sys-
tem is under endocrine control he attributes gas-
tric and duodenal ulcer to an internal secretory
origin. Such an origin may be found in real
endocrine pathology or may be of the ductless
gland neurosis type; in which latter event one
may have all the phenomena of a dysfunction
disease without gland pathology. Excision of a
gland does not relieve such a glandular neurosis.
Bauer*" and later Hemmeter'* called attention to
cases of exophthalmic goiter in which all the phe-
nomena of the disease are present but in which
no relief follows a thyroidectomy and parts of
the excised thyroid are normal. It is believed by
some workers that exophthalmic goiter begins
with a neurosis leading up to real changes in
the glandular structure. The work of Cannon-*
on the influence of emotion upon adrenal output
tends to support such a theory.
Rogers*' believes that fatigue behaves just as
the emotions do. It being responsible for an un-
usual outpouring of adrenalin. This product
stimulates the sympathetic to a point of fatigue
and eventually to paralysis. With the sympa-
thetic out of commission an unbridled influence
is exerted by its antagonist the vagus. Thus in
fatigue we find evidence of vagal tonicity in the
presence of hypermotility and pylorus spasm,
well known events in the exhausted and tired.
Eventually fatigue may involve all the ductless
glands so that h)rperfunction, hypofunction and
afunction may be the sequence of events.
There is then some basis for assuming an
endocrine relationship in gastric disease, as evi-
denced by literature. There are, however, many
conflicting theories and much questionable evi-
dence in the matter.
An analysis of three hundred and fifty cases
as they presented themselves to a gastrointestinal
outpatient department* shows some interesting
findings on the question of this relationship. In
sixty of these patients the diagnosis of gastric
neurosis was made. It appeared that the major
portion of these neurosis cases as far as this
could be determined were individuals who re-
spond to stimuli with unusual rapidity and ex-
penditure of energy and that many were tired,
overworked and often ' undernourished. In a
number of these cases, commercial preparations
of thyroid, adrenal and corpus leteum were used.
In keeping with the work of Rogers, supra-
renalin was prescribed in the hyperfunctioning
and thyroid in the hypofunctionation cases. In
common with most members of the profession
we only had at our disposal commercial prepara-
tions of these glands while Rogers** and his co-
workers, it must be noted, used especially pre-
pared ones. Less improvement was attained by
such glandular therapy than was obtained in con-
trolled cases by other methods of treatment. The
exhibition of thyroid alone did not relieve the
achylia gastrica cases and it seemed to make
some of them worse. Only three per cent, of
the hjrpersecretory cases improved on exclusive
suprarenal therapy. The combination of organo-
therapy with other therapeutic procedures in-
cluding diet, seemed to enhance the effect of the
latter, although it must be evident that such a
conclusion cannot be drawn with any reasonable
degree of accuracy.
Evidences of internal secretory derangement
in the entire group were found in eight cases
*Ga8tro Intestinal Clinic — Medical Outpatient Department of
the Hospital of the University of Pennsylvania.
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THE PENNSYLVANIA MEDICAL JOURNAL
January, 1921
with hyperthyroid findings. The secretory curves
in these cases were variable. In addition to
these hyperthyroid patients, seventeen had en-
larged thyroids. Two cases were myxedematous
after a thyroidectomy; six cases were past the
menopause and two had had a double oopho-
rectomy. One case showed adrenalin insuffi-
ciency as manifested by excessive pigmentation,
achylia gastrica, asthenia and a low blood pres-
sure. This case is taking an extract of adrenalin
gland with no . appreciable effect upon gastric
function.
Among the three hundred and fifty cases there
were one hundred and fifteen cases in whom a
non-gastrointestinal diagnosis was made although
their chief complaint seemed to be in this tract.
In this group there were none who showed evi-
dences of endocrine disease.
In conclusion it is fair to say that : ( i ) With
dysfunction of the ductless glands there is some-
times found dysfunction and pathology in the
stomach. (2) The relationship of the ductless
glands to the stomach by way of the anatomic
system has some evidence in its favor from an
experimental and clinical standpoint. Perhaps
internal secretions influence the stomach directly.
(3) The influence of some center in the central
nervous system as a regulator of the vegetative
system is still to be considered. (4) Fatigue
seems to be a factor in gastric disease. (5) A
relatively small percentage of stomach cases show
endocrine disturbances as found in those coming
to a gastrointestinal clinic over a period of time.
(6) Organotherapy should be tried, either alone
or in combination with other agencies, in gastric
disease especially of a. functional type ; it may be
followed by some success in a small number of
cases.
REFERENCES
I. Lobstein: Great Sympathetic Nerve; translated from the
Latin, 1 83 1.
J. Epping^ and Hess: Die Vagotonie; Hirschwald, 1910.
3. Cannon and Cattell: Am. J. Physiol. 41, 58-73, 1916.
4. Levy: Am. J. Physiol. 41, 492-511; i9i6'
5. Rogers et al: Am. J. Physiol, m, iS4, 1915.
6. Barker and Estes: J. A. M. A. Lix. 718, 191 a.
7. Beyer and Peter: Barker quoted proceedings Am. Gas-
troentrolog. Soc., 191 8.
8. Bell: Ibid.
9. Pancoast and Hopkins; N. Y. Med. J. iaS'389-a9S, 19 17.
10. Hoskins and McClure: Barker quoted proceedmgs A.
Gastroentrolog. Soc. 1918.
II. Rogers: Archives of Int. Med. 23, 4, 498, 1918.
12. Lehman: Berlin klin. Wchscbr. 1919, 56, 772.
13. Quoted by Finzi (footnote 19).
14. Finzi: Virchows Arch. f. path. anat. 1913, 214, 413.
15. Friedman: Jour. Med. Research, 1918, 38, 69.
16. Elliot: Am. J. Physiol. 1915, 49, 38.
17. Mann: J. Expcr. Med. 1916. 23, 203.
18. Carlson and Jacobson: Am. J. Physiol. 1911, 28, 133.
19. Friedman: J. A. M. A. 71, 19, 1543.
20. Bauer: Deutsch. Arch. f. klin. med., 1912, 107, 39.
21. Hemmeter: N. Y. Med. Jour. 1914, 99, loi.
22. Cannon and de la Pax: Am. J. Physiol. 1911, 28, 64.
23. Rogers: loc. cit.
24. Rogers: Am. J. Physiol. 48, 79, 1919.
DISCUSSION
Db. John A. Lichty (Pittsburgh) : Dr. Schnabel
has opened a very large question here, which we might
discuss all afternoon, but I doubt whether we would
get any more information than we have obtained from
his very valuable paper, in which he sums up the opin-
ions of those who are authorities on this question. I
am glad to see or to notice the very guarded conclu-
sions which the writer gives to his work. He has ob-
served a number of cases and has made honest obser-
vations, and has not been carried away by what he
has seen, but has given definitely what he has seen,
without theories.
The one point I wish to discuss is the relation of
fatigue to gastrointestinal dysfunctions, gastric ulcer
or whatever may occur. We speak of these quite fre-
quently, and it is possible that the fatigue of which
we speak is more frequently a fatigue which comes,
not from brdinary physical tiredness, from long walks
or overworking physically, but rather more fatigue
which comes through the nervous system and the ap-
plication in the patient's work where the work is irri-
tating, where the surroimdings are difficult, and where
there is considerable worry. So there is a very con-
siderable difference between nervous and physical
fatigue. I should say it is more frequently due to
nervous fatigue, and it is possible that this nervous
fatigue evidences itself more usually through the
endocrine system than in any other way. It may be we
are on the right track when we are looking toward the
endocrine system in digestive disturbances.
While I was reading this paper which Dr. Schnabel
was kind enough to send to me before the meeting,
there occurred to me a Case which I had seen in 1908
where a diagnosis of peptic ulcer was considered. In
seeing the patient, however, I noticed marked exoph-
thalmos, a rapid pulse, and had a typical picture of
exophthalmic goitre. Nausea and vomiting were the
points that led to the diagnosis of gastric ulcer. This
patient was treated from the standpoint of exoph-
thalmic goitre, and recovered in a reasonable time.
The pulse reduced to 130, and in six months the pa-
tient was apparently well. In 1910 I saw the patient
again for an attack of acute indigestion, and ttiis was
described as being one of many attacks, with nausea
and vomiting — in fact it is what I am sure would be
called an acute abdomen. I didn't find symptoms of
exophthalmic goitre at that time, but did find very
definite evidence of pyloric obstruction. It then oc-
curred to me that after all, probably she had an ulcer,
or probably there was a relation between it and the
goitre. Dr. R. W. Stewart operated on this patient,
and fotmd carcinoma in the pylorus. The patient died
two years later.
Now of course it would be a very nice confirmation
of a theory to think that probably the thyroid dis-
turbance in 1908 led to a peptic ulcer and say "Here
is something which confirms Dr. Schnabel's impres-
sions in what he points out in his paper," but unfor-
tunately it leads us too far, for it would follow that
probably exopthalmic goitre is also the cause of
carcinoma of the stomach.
The paper is a most excellent one, and it sums up
in a most definite way our present knowledge of the
endocrine system in gastrointestinal disease.
DiL John J. GiiABise (Philadelphia) : I am very
much interested in this excellent paper of Dr. Schna-
bel's. I have records in my office of the study of the
functions of the stomach in twenty-four cases of
hyperthyroidism, and in looking over those records,
there is not anything in the gastric analysis of these
cases that is suggestive of any uniform gastric find-
ings in hyperthyroidism. Some patients have a nor-
mal gastric secretion, etc., and other patients show
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January, 1921
CHRONIC GASTRITIS— REHFUSS
233
altered secretions, or there may also be a disturbance
of the motility of the stomach combined with secre-
tory changes.
I also many years ago made a study of the function .
of the stomach in a few cases of diabetes. (J. A. M.
A., 1911.) However, I found in these cases, five in all,
a reduction of pepsin which is in accord with a reduc-
tion of other ferments in diabetes.
ANALYSIS OF CHRONIC GASTRITIS*
MARTIN E. REHFUSS, M.D.
PHILADELPHIA
Chronic gastritis is a chronic inflammation of
the stomach. By universal acceptance and be-
cause in most instances this inflammation in-
volves the mucosa and infrequently, although not
inevitably, other layers of the stomach wall, all
the phenomena connected with chronic gastritis
are associated with "mucosal activity." Inas-
much as the causes inducing chronic changes in
the gastric mucous membrane are legion, I have
attempted in a recent article to present an etio-
logical classiflcation of the causes of chronic
gastritis, emphasizing the fact that diseases of
nearly all the visceral organs are accompanied
directly or indirectly by alterations of the gas-
tric mucous membrane or its resulting work,
which we might call "mucosal activity."
An etiological classiflcation is of value inas-
much as a study of the determining causes is
after all the essentia! key to silccessful thera-
peutics. It is nevertheless a diagnosis based on
association and subject to a wide range of errors.
There can be no difficulty in associating chronic
inflammations of the stomach with pulmonary
tuberculosis, hepatic cirrhosis, advanced renal or
cardiac disease or, in an altogether different way,
the unquestioned chronic gastritis associated
with and relieved by the removal of focal infec-
tion such as diseased tonsils or teeth ; but cause
and effect while obviously associated have so
many factors intervening that a clean cut picture
cannot be drawn, and we can argue only from
the clearing up of pathological data that a given
set of gastritic symptoms have been due to a spe-
cific etiological cause.
On the other hand throughout French litera-
. ture, and German as well, we are struck with the
fact that the underlying basis for the classifica-
tion of chronic gastritis is a pathological one and
we see on opposite ends of the pole the gross
pathological types inducted into our own system
— chronic "atrophic" and "hypertrophic" types,
and on the other the elaborate histopathological
•Read before the Section on Medicine of the Medical Society
of the State of Pennsylvania, Pittsburgh Session, October 6,
I9».
classification offered by Hayem based on sections
of the mucosa.
The former is open to criticism in that it
covers some 200 different etiological causes,
without offering any further light on the practi-
cal study of this disease in the patient, and the
latter, the histo-pathological classification of
Hayem, is open to identically the same criticism
— namely, that it is a thing of the postmortem
room and the laboratory, and not a classification
likely ever to be reached before the gastric
mucous membrane is bottled up and the patient
is dead and gone. Our studies on gastric func-
tion, and particularly those relating to the
psychic secretion, show how impossible it is to
predicate a given "mucosal type" from gastric
analysis, facts which were unknown when
Hayem elaborated his classification.
What we need to-day is not a postmortem
classification, nor even a gross classification, but
some practical classification which will enable
us to know more regarding what form of gastric
disease we are dealing with, and that which is
equally essential, what is most likely to improve
the condition, once it is finally determined.
Before discussing the forms of gastritis which
I have encountered I want simply to make a few
remarks about the disease which, to my mind are
pertinent. Sometime ago I collected some 212
definite causes of chronic inflammation of the
stomach. These causes ranged all the way from
the multitude of direct causes, including dietary
indiscretions and food infections, to the second-
ary forms of gastritis, secondary to disease of
nearly all the visceral organs as well as focal in-
fection in various parts of the body. From this
study it was apparent that many different causes,
acting by totally different mechanisms, whether
through direct ingestion, blood or lymphatic
channels, could eventually induce evidence of
chronic inflammation of the gastric mucosa. I
believe in my work I have seen every form of
gastritis from the severe irremediable chronic in-
flammation, to the subtle insidious types asso-
ciated with focal infection, and only one thing is
possible from a study of etiological data ; that is,
that certain definite etiological data are asso-
ciated with certain but not necessarily specific
forms of gastritis. In other words an etiological
cause is only of value from a therapeutic stand-
point, and not because it produces a specific form
of gastritis.
Gastritis forms a convenient cloak for every
gastric condition not directly associated with
demonstrable organic diseases and alteration in
position or contour of the stomach. Physicians
diagnose chronic gastritis without realizing that
the diagnosis "chronic gastritis" is only the first
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THE PENNSYLVANIA MEDICAL JOURNAL
January, 1921
step in a searching analysis to determine the
cause. Only after a complete study of the pa-
tient is it possible to throw light on the nature
of the disease. The old conception of the clin-
ical formula for the diagnosis of chronic gas-
tritis was negative x-ray findings, gastric mucous
in the gastric contents and generally a depression
in the secretory output. I am strongly inclined
to alter this conception because it does not agree
with all the facts of the case. I should say un-
doubtedly that negative x-ray findings, that is
to say, negative as to contour, position, motility
and general appearance of the gastric image are
important, but the general conception of chronic
gastritis is, that it is a disease accompanied by
mucous in the gastric contents, which is open to
the gravest criticism.
In the first place, I have pointed out elsewhere
the differentiation between swallowed and gas-
tric mucous. There are two reasons why mu-
cous should not be the sole determining feature
of chronic gastritis. In the first place the pres-
ence of mucous simply indicates an irritation of
the superficial layer of goblet cells covering the
mucosa. There is no evidence to believe that
mucous is formed below that point and in many
of the chronic inflammations involving the whole
mucosa and, due to involvement of the whole
secretory structure from circulating toxins and
secondary to disease elsewhere, little or no mu-
cous is present, so that some of the most persist-
ent forms of chronic gastritis can exist without
mucous. On the other hand the large group of
chronic cases due to the ingestion of irritants,
dietary, medicinal and others, are particularly
those in which the mucous element is predomi-
nant and in which that layer of the mucosa is
particularly affected. In the second place, total
atrophy of the mucous membrane or atrophic
gastritis shows little or no mucous in the gastric
content, owing to an atrophy of the goblet cells.
To my mind the sole determinant in the diag-
nosis of chronic gastritis is a measure of mucosal
function and by that I mean secretory work.
Motor work may or may not be impaired, but
from the earliest time, chronic gastritis has been
taken to mean chronic mucosal gastritis, while
abnormality in muscular action has been placed
in another category. Therefore an inflammation
of whatever type is almost certain to result in
alteration in the secretory or mucosal function
of the stomach. This alteration is almost always
toward a diminution in output or depression in
function. Although it is probable that a hyper-
acid gastritis exists, and not simply a hyper ex-
citation which is purely functional, nevertheless
it is true that the greater number of cases show
secretory depression.
From a study of many cases of this disease I
am inclined to believe that the most constant
^ finding of chronic gastritis is a general persistent
depression in gastric secretory activity, involving
particularly the later or chemical portion of the
secretory curve. Furthermore, during the inter-
digestive period, or the empty stomach period,
there is apt to be a lessening of the secretion
rather than an increase, which is seen in so many
of the functional conditions. There may or may
not be mucous, depending on whether or not the
superficial layer of the mucosa is involved, but
of one thing I am convinced and this is, that the
presence or absence of mucous is not the essen-
tial point. If it were we would only diagnose
the irritation type, or primary type, due to in-
gestion of irritants and miss the great number of
equally important cases in which mucous plays a
comparatively small role. We diagnose renal
disease not by urinary albumen any longer but
by mensuration of function, and it is in pre-
cisely the same way that I would propose to
measure gastric function — namely, by determin-
ing the function. A diseased organ does not
functionate like a normal organ and the proof of
this conclusion is that a return to health is ac-
companied by a return of normal function.
CONCLUSIONS FROM OUR STUDIES
1. The normal response is rarely, if ever, sub-
acid, anacid or achylous.
2. Chronic gastritis is essentially a mucosal
disease and finds its expression in alterations in
mucosal or secretory activity. Its motor altera-
tions are practically negligible as well as are the
roentgen findings.
3. A persistent subacid or anacid curve in-
volving every portion of the digestive phase in
the presence of negative roentgen findings is
from our studies, an expression of altered mu-
cosal activity and to us, most probably a form
of chronic gastritis.
4. The essential point in the determination of
chronic gastritis, is the determination of a per-
sistent alteration in the secretory output and
nearly always eventually downward in trend.
5. While it is permissible to believe that hy-
pertrophy with an exaggerated gout, represents
one phase or form of chronic gastritis, the great
majority are represented by the depressive type.
6. It is differentiated from the purely func-
tional types by ( I ) the constancy of the findings,
(2) the entire gastric output is affected, and (3)
the association of etiological data likely to result
in such a change.
7. Mucus is certainly not essential to the pic-
ture of inflammations of the gastric mucous
membrane of the chronic type. It indicates an
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CHRONIC GASTRITIS— DISCUSSION
235
involvement of the superficial portion of the
mucosa, and as such is most frequently found in
the dietary types and those due to the ingestion
of irritants, medicinal, alcoholic and so forth.
8. A reduction in the gastric curve can come
about in one of four ways : ( i ) a lack of build-
ing material in the blood in certain blood dys-
crasias, (2) by neutralization due to the regur-
gitation of pancreatic secretion, (3) a lack of
formation due to alteration in the gastric cell it-
self, and finally (4) its neutralization by patho-
logic elements, pus, blood, and mucus. The last
two belong to true forms of gastritis and are
usually readily differentiated from the first two
forms.
9. The following are secretory forms en-
countered, subacidity, anacidity, achylia, and
finally a frequent form, namely, delayed gastric
digestion.
10. In my studies I have encountered this
form of ciarve apart from the forms of dietetic
gastritis most commonly associated with focal
infections and the result of acute infections.
There can be no doubt that this form of curve
with the typical clinical picture of chronic gas-
tritis, is completely relieved by removal of ob-
vious focal infections. I have a series of cases
to be published, in which the only explanation
for altered secretory activity was the presence of
focal infections, not alone of the teeth, tonsils,
nasopharynx, but of parts of the digestive and
urinary tract as well. It is probable that certain
bacteria have a selective inhibitory effect on gas-
tric secretory function.
11. With the exception of the primary irri-
tative forms due to ingestion of irritants, local
treatment can scarcely effect any improvement.
Our whole effort should be devoted to etiology.
This is possible in associated renal, cardiac, pul-
monary, dietetic conditions ; it is difficult and fre-
quently impossible in those cases following acute
infections. I confess my complete inability to
throw light on the way influenza, for example,
has produced gastric changes, extremely persis-
tent at times, and yet there is no doubt in my
mind that at times active mucosal changes occur.
12. I have a series of cases in which vaccina-
tion by means of autogenous vaccines, resulted
in a return of the secretion.
13. We must teach chronic gastritis as a group
syndrome which, for the purpose of convenience,
are most readily divided into the following types :
A. Gastritis due to dietary indiscretion: In-
gestion of irritants, excessive ingestion of food,
irregular eating, unbalanced dietary.
B. Gastritis due to medicaments: Purges,
salines and drastic salicylates, iodides, mercury
opiates, iron, copaiba, santal wood oil, etc.
C. Gastritis due to organic disease elsewhere:
(a) Cardiac incompensation. (b) Pulmonary,
t. b., bronchitis, bronchiectasis, (c) Nephritis,
nitrogenous and salt retention, (d) Hepatic,
cirrhosis with portal hypertenstion. (e) Intes-
tinal infections, reversed peristalsis, inflamma-
tion, (f ) Blood anemias, chlorosis systemic dis-
ease.
D. Gastritis due to direct infection of the
stomach wall: (a) Direct ingestion, (b) Hema-
togenous.
E. Gastritis due to specific irritants : Alcohol,
tobacco.
F. Gastritis due to or accompanying organic
disease of the stomach : (a) Cancer, 'syphilis.
14. It is absurd to expect an inflammation of
the stomach due to the swallowing of ingested
muco-pus and bacteria to clear up under a bland
diet; it is equally absurd to expect the chronic
gastritis associated with cardiorenal disease to
clear up under local treatment, and finally it is
likewise absurd to expect gastric treatment to
produce results in the presence of manifest focal
infection elsewhere in the body.
15. It was with the hope of pointing out the
presence of many cases of this disease, which I
firmly believe belong to this group, secondly the
essentially mucosal character of the disease, and
finally the necessity of a searching analysis of
etiological factors, that this paper is written.
DISCUSSION
Dr. Joseph Sailer (Philadelphia) : I want to ex-
press my very cordial agreement with the statement
that chronic gastritis is not a diagnosis. I think the
term could be entirely discarded in clinical medicine
with considerable advantage.
In the second place I think that we possibly make
a mistake in classifying our forms upon an anatomical
basis. The stimulus given to research by the cellular
theory of Virchow led to a tremendous amount of
work; it added very greatly to our knowledge, but I
don't believe that it has added very much to our under-
standing of disease. After we have seen changes in
the cell, it may help us perhaps to a diagnosis, but it
doesn't teach us much about the disturbance of physi-
ology. When we come to the endocrine factor in the
question of gastric conditions I think we are treading
on somewhat delicate grounds.
The paper of Eppinger and Hess to which Dr.
Schnabel referred is most stimulating but these inves-
tigators were entirely carried away by the discovery
of vagotonia and we know that they sought to find a
relation to the so-called vegetative nervous system in
everything. I think there has been a general failure
to substantiate a majority of their claims, nevertheless
there have been many interesting observations as a
result of them.
Dr. Rehfuss did not speak of the factor of enzyme
secretion in gastric disorders. It is not necessary to
assume that it is wholly of nervous origin. There are
certain factors of interest in regard to this which I
think have some influence in showing that in perhaps
a majority of these cases of hypochlorhydria, of
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THE PENNSYLVANIA MEDICAL JOURNAL
January, 1921
which Dr. Rehfuss has considered one of the impor-
tant forms, this is due partly to hormones. Some years
ago Jaworski stated that in cases of achylia it was
possible, by the introduction of a hydrochloric acid
test meal, to secure a gastric juice which contained
pepsin in appreciable amounts. I tested this and found
the statement entirely correct, and in a considerable
number of cases that I tried, I never failed to find
pepsin. It was possible, even in advanced cases of car-
cinoma to produce a moderate secretion of pepsin.
It seems reasonably certain that this is due to hormone
action. We must always remember one thing, and
that is that no matter what the underlying pathology
of the subject may be, as long as the patient is alive,
the disturbance of the physiological function of the
tract is the important factor in the disease, with the
exception of these disttu-bances which led to mechan-
ical obstruction.
A BRIEF OF ONE THOUSAND
HYSTERECTOMIES*
H. J. DONALDSON, M.D.
WILLIAMSPORT, PA.
Historical. — According to Noble^ the first hys-
terectomy was made by Clay, an Englishman, in
1843, when the abdomen was opened under a
diagnosis of ovarian tumor. The patient did not
live. Many operators then tried the operation of
removing fibroid tumors, but all patients died of
peritonitis, until Burnham, in 1853, made the
first successful hysterectomy with the abdomen
open under a mistaken diagnosis. Kimball, of
Lowell, Massachusetts, in 1855, made the first
successful hysteromyomectomy after previously
making a correct diagnosis, and his technique
was the beginning of the supravaginal method in
practice to-day.
During the succeeding years many methods
were tried. Especially worth mentioning is the
Tait extra peritonial treatment of the stump. But
finally the method of the present, that of ligating
the four arteries and covering the dropped stump
by peritoneum, was adopted, and during the past
twenty years very little improvement has been
made over the methods perfected by those mas-
ters of gynecology, Baldy, Noble, Kelley, Pryor,
Montgomery and Penrose.
All of the earlier work was done with solid
tumors, and hysterectomy was not applied to the
treatment of pelvic inflammatory diseases until
1890-1-2 and 3, when Baldy, followed by Polk,
recommended its use. It was then taken up by
the gynecologists, and after a stormy difference
of opinion was adopted as a routine operation by
the leading and bolder surgeons.
In 1894 Pryor applied the vaginal hysterec-
tomy to cases of small fibroid uteri and to cases
•Read by title before the Section on Surgery, of the Medical
Society of the State of Pennsylvania, Pittsburgh session. Oc-
tober 7, 19Z0.
of pelvic inflammation, and introduced his oper-
ations of turning the uterus, by which it was pos-
sible to eliminate the danger of tying or clamp-
ing the ureters, to such a degree of certainty that
the operation was adopted by many of the
younger surgeons and was found by lliose who
possessed some skill in finger dissection to be not
only far easier but a much more rapid operation,
accompanied by a shorter convalescence, and
capable of being applied to subjects in whom the
longer abdominal route was contraindicated.
In this series of one thousand cases made un-
der varied conditions of private house, coimtry
practice and finally the later, better environment
of a well-equipped operating room, it will be
noted that not such a great reduction of mor-
tality was achieved as might be supposed, but as
is to be expected of the later cases the end re-
sults were much better, and while hysterectomy
may be done in private homes, it is not to be
recommended. This is especially true of vaginal
hysterectomy, which I have never undertaken
outside of the hospital.
Brief of Cases. — Abdominal hysterectomy was
made in 640 cases, or 64 per cent.
Vaginal hysterectomy in 360 cases, or 36 per
cent.
Hysterectomy for cancer alone, 156 cases.
For disease with one to four complications, in
128 cases.
For pelvic inflammation, in 264 cases.
In fibroid disease, 386 cases.
For ovarian cyst, tuberculosis, uterine pro-
lapse, ectopic pregnancy, chronic metritis, hem-
orrhage uteri and ovarian sarcoma, in 194
cases.
The percentage of death in the first one hun-
dred cases was six; in the last one hundred,
three.
In the first and last hundred five died from
embolism, or two and one-half per cent.
The average age of the patient was forty-four
years.
The complications were lacerated perineum,
salpingitis, chronic appendicitis, gallstones, ova-
rian abscess, tubal infections, intestinal adhe-
sions, tubercular disease, tumor with twisted
pedicle, ulcer of the stomach, myocarditis, ne-
phritis, goitre and toxic goitre, dead fcetus with
cancer, hemorrhagic uteri with cardiovascular
disease and Cancer of the rectum.
Of fibroids with which malignancy occurred I
cannot state accurately, for the reason that many
specimens were not submitted to a laboratory
examination, but I find a record of 5 7/10 per
cent, in which carcinoma was determined by
both gross and microscopical examinations. The
malignant degeneration did not seem to occur in
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HYSTERECTOMIES— DONALDSON
237
the tumor proper, but usually in the tissues ad-
jacent to it, and more often in the hard, fibrous
cervix of the uterus containing fibroids. It was
not found more frequently in cases accompanied
by pelvic inflammation, rather more often in
uteri showing no such evidence, and therefore it
is fair to presume that it occurs coincidentally,
or the presence of the tumors furnish sufficient
irritation to cause malignancy to occur. It is
worthy of note that in two cases of impacted
adneo-fibroma there was found carcinoma of the
recttun at the position subjected to pressure by
the tumor, and in these two cases the patient's
attention was attracted by the bowel condition
and not by the tumor. In all caseg of carcinoma
of the cervix it was found that the cervix had
been years before subjected to traumatism by
cervical dilatation from instruments, child birth,
or what not.
Cancer of the fundus occurred almost entirely
in nulliperus women, but was accompanied by
evidence of pelvic peritonitis.
Of the three hundred and eighty-six cases of
fibroids it could only be determined definitely
that sarcomatous degeneration occurred eight
times, or two per cent., but in these cases the de-
generation actually occurred in the tumor tis-
sues, wholly imlike the occurrence of carcinoma.
Fibroids occurred in company with pyosalpinx
salpingitis and hsematosalpinx in 88 cases, and
with large ovarian cysts in 28 cases. In these
cases the fibroid development seemed excessive.
There were, of course, intestinal adhesions and a
greatly increased vascularity, which might ac-
count for the oedema, which produced much
above the average sized fibroid.
Pelvic Inflammation. — Pelvic inflammatory
disease was operated by hysterectomy in 264
cases, and many of these were done by the vagi-
nal route. This group was made up of large
ovarian abscesses, double pyosalpinx and hydro-
salpinx, always with a permanently disabled
uterus, greatly enlarged by prolonged, chronic
metritis.
The question of hysterectomy in this class of
cases was made because our experience has
tai^ht us the lesson that in 85 per cent, of cases
the infection is from without, deposited in the
vaginal canal, finding its way through the uterine
canal, infecting the uterine tissues and some-
times the broad ligaments, before reaching' the
fallopian tubes and ovaries, and that to remove
the abscesses and leave a primarily diseased
uterus was to invite a continuation of the symp-
toms and suffering, and leave a thankless patient
who would put in her spare time discouraging
other women from seeking relief from an opera-
tion which failed to relieve her.
If the inflammatory action has not been too
severe and it is possible to save a healthy tube
and ovary, then we save the uterus. Again, if
the patient is very young, we save organs, if
possible, but always explain to the patient the
necessity of saving them, and the fact that in
saving them we also save her some painful and
troublesome days, and so warn her against ex-
pecting the complete relief which is so greatly
sought.
General Remarks. — Vaginal hysterectomy is
employed, when possible ; in large, stout women
with a reasonably roomy vaginal outlet, because
it is easier, shorter and does not leave an inci-
sional hernia.
In all cases of cervical carcinoma, because
thirty per cent, of all recurrences occur at the
cervico-vaginal junction, bladder and broad liga-
ment, and there are no metastatis. (Murphy.)*
However, in late cases, we use, in addition, the
treatment recommended by Percy, and believe
vaginal hysterectomy with the cautery is as good
as any method yet recommended.
In all cases of bleeding, fibroids, of small or
medium size, in a patient with myocarditis, ne-
phritis and grave anaemia, because it can be done
in from twelve to twenty minutes under light
anesthesia and with a greatly lessened mortality.
In all cases of pelvic inflammatory disease
with abscesses where drainage is a necessity.
In cases of pelvic prolapse where it is neces-
sary to sacrifice the organ, though here we pre-
fer, in women past the climacteric and with
healthy organs, to do the interposition operation.
Pelvic drainage by lo-inch iodoform gauze has
supplanted the abdominal drain, and in severe
cases of pelvic inflammatory disease precedes and
follows hysterectomy when a two stage operation
is indicated.
In our earlier work we used the Mikulicz
drain many times, which of course was followed
by adhesions.
Many cases were operated under spinal anes-
thesia and I consider it an ideal anesthetic. But
one must work rapidly, for it lasts only forty or
fifty minutes. Local anesthesia enabled us to
save several cases of large ovarian colloid cysts
filling the abdomen and adherent to parietal peri-
toneum. These cases occurred in elderly women
and were malignant.
In some of our earlier cases of large left
ovarian abscesses, where laceration of sigmoid
occurred during the operation, the uterus was
saved and used to fill the defect and with some
success, but in recent years axial anastomasis
over a rubber tube was found to be a much bet-
ter procedure.
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THE PENNSYLVANIA MEDICAL JOURNAL
Januaky, 1921
Preparaiion of Patients Then and Now. —
Preparatory treatment formerly was most dras-
tic, carried out in a routine manner, leaving the
patient weak and exhausted. To-day our aim is
to support the strength of the patient, to smooth
away her fears, and to learn, if possible, the mar-
gin of safety, so that we can, the better, direct
our operative procedure.
To this end we must consider the condition of
heart, lungs, kidneys, acidosis, blood pressure
and picture and treatment of any complicating
diseases, all a subject too great to deal with at
this time.
In conclusion the margin of safety in hyster-
ectomy is greatly increased by
1. A rapid, well thought-out technique, adapted
to the individual case.
2. A patient in a contented frame of mind,
not exhausted, or frightened by overpreparation.
3. A carefully given anesthesia, be it local,
spinal or general.
4. A nurse who is unafraid of surgery, un-
afraid of work, and one who specials the patient,
not the office or resident.
5. A surgeon who possesses the ability to in-
still confidence by being the most confident in the
presence of grave emergencies.
106 E. Fourth Street.
1. Kelley and Noble. Abdominal Surgery, page 666.
2. Murphy's Clinics, December, 1915, page 1145.
THE VALUE OF SUBTOTAL HYSTER-
ECTOMY IN THE TREATMENT
OF FIBROMYOMATA OF
THE UTERUS*
F. HURST MAIER, M.D.
PHUADELPHIA
In recent years there has been a tendency on
the part of some of the gynecic surgeons to ad-
vocate the performance of total instead of sub-
total hysterectomy in the treatment of fibro-
myomata of the uterus. Their contentions are
based on two apparently good reasons : first, that
fibromyomata are associated with a high per-
centage of malignant disease; and second, that
total hysterectomy is not attended with any more
danger to the patient than the subtotal operation.
Were these claims entirely borne out in fact,
the subject would admit of no further discus-
sion, and total hysterectomy would perforce be-
come the operation of choice. A review of the
literature on this subject cannot fail to impress
one with the fact that there is a relatively high
'Read before tbe section on Surgery of the Medical Society
of the state of Pennsylvania, Pittsburgh session, October 7,
1920.
laboratory percentage of malignant disease m as-
sociation with these growths.
In considering the frequency of sarcomatous
changes, we find that Baum, in 590 myomata re-
moved by total hysterectomy, discovered the dis-
ease in 74 or 12.8 per cent. ; while Fehling,
quoted by Cullen, only observed it 8 times in 505
cases ; and Martin, in 205 cases, noted the changf
in 4 instances. In Kelly and CuUen's series ol
1,428 cases, sarcoma was found 17 times, and i;
other cases were suspects. Cullen is of the opin-
ion that this percentage of 1.21 does not reprt
sent the proper proportion, as only such area-
were examined as presented suspicious foci u
the naked eye. Cullen's percentage is very simi
lar to that of other observers. Noble saw it oc
cur in 1.8 per cent., and Treacy gives 1.5 pei
cent.
In associated malignant disease of the uteriiK
mucosa, Bumm, reported by Fehnin, found, ir
590 cases of fibroids, that cancer occurred in th(
cervix in 3.8 per cent.; while Cullen, in 1,4a
cases, discovered carcinoma of the body in 21
or 1.7 per cent., and carcinoma of the cervix ir
18, or 1.27 per cent. Treacy in 3,561 coUectd
cases reported corporeal cancer in 1.7 per cent.,
and cancer of the cervix in .7 per cent.; and
Brown, in 1,760 consecutive cases, discovered that
25 had malignant disease of the fundus, but none
in the cervix. Pequand, quoted by Bland-Sutton,
found cancer of the body associated with my-
omata in 15 out of r,ooo cases; and Bland-
Sutton's own percentage is 1.6, and in every in-
stance the patient was over fifty years of age.
Lockyer, in 210 major operations for myomata,
.saw carcinoma of the body in 2 cases and car-
cinoma of the cervix also in 2 cases. The latest
contribution to this subject is probably that of
Polak, who in a paper read before the last meet-
ing of the American Medical Association, states
that in his cases serial sections showed 2 per cent.
of ephitheloma, in the cervices of completely re-
covered uteri for fibroids in which malignancy
was unsuspected, and quotes Schottlsender,
Spencer and Noble as having demonstrated by
routine serial sections of the uteri removed in
more than 900 total hysterectomies, that car-
cinoma of the cervix actually exists in more than
2 per cent, of all fibroid tumors of the uterus.
From these statistics we must assume that 5
per cent, of all uterine myomata are associated
with malignant disease and that in at least 2 per
cent, of cases cancer of the cervix occurs. For-
tunately however, for the woman developing a
fibroid of the uterus, the actual findings of ma-
lignancy discovered by the laboratory investiga-
tor are not entirely borne out by the observations
of the clinical worker, ais otherwise, out of every
\
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January, 1921
SUBTOTAL HYSTERECTOMY— MAIER
239
series of lOO partial hysterectomies such as are
usually practiced by American and English sur-
geons, a definite occurrence of -malignant dis-
ease of the cervical stump should be encountered.
Clark states that in more than 1,000 hyster-
ectomies performed in the gynecological depart-
ment of the University Hospital, such a sequel
has been observed but once; and Giles asserts
that the fate of the cervical stump after a supra-
vaginal hysterectomy need cause no apprehen-
sion. In his investigation of the after results of
181 cases of fibroids and fibrosis uteri, there was
not one that showed any sign of malignancy.
The patients concerned in this inquiry had been
operated upon at least a year before, and with
many of them a long time had intervened, up to
sixteen years. Similar views are entertained by
Graves and Bland-Sutton. Polak, on the other
hand, reports a collection of 256 cases of cancer
in the conserved stumps, that occurred from one
to twenty years after the primary operation (in
America). He furthermore states that 40 other
cases were reported in the discussion of his
paper. Herbert R. Spencer, who has become a
strong advocate for the abandonment of the am-
putation method, collected 28 cases from various
Continental and English sources.
The apparent discrepancy that exists between
the percentage of malignancy that is found in the
laboratory and the number of cases of cervical
stump cancers reported by the clinical observers,
can in part be explained: first, by errors of
laboratory diagnosis that undoubtedly account
for the high percentage of sarcoma reported by
many of these investigators, for it is difficult to
distinguish between leiomyomata and spindle cell
sarcoma; second, as a rule sarcoma and adeno-
carcinoma of the body develop late in life, and
in the early stages of the disease tend to remain
localized (often the area examined is the only
focus of malignant disease present, and with the
removal of the body containing the neoplasm,
further danger of recurrence of the growth is
largely eliminated) ; third, in a percentage of
the cases, the malignant complication is micro-
scopically so evident that elimination of the en-
tire organ is imperative; and fourth, the grow-
ing practice of the hysterectomyst to have every
uterus that he removes by the subtotal method,
immediately examined by some one not taking
part in the operation, frequently uncovers the
presence of unsuspected malignant disease, with
the result that the cervix is also extirpated. To-
tal removal is also advisable if the case presents
a complicating gonorrheal infection or a badly
diseased cervix, providing its performance can
ie enacted without increased risk to the patient.
In determining the respective value of total
and subtotal hysterectomy in the treatment of
fibromyomata, we cannot ignore the fact that
carcinoma of the cervix is present in at least 2
per cent, of the cases, and that there is a defi-
nite, if unknown, percentage of malignant dis-
ease associated with the cervices retained after
the supravaginal procedure. Despite this for-
midable incidence of malignancy, however, we
are of the belief that with our present knowl-
edge, the personal equation of the operator must
be the dominating factor in deciding the choice
of the operation. When we remember that the
mortality of hysterectomy in the hands of the
operator skilled in pelvic surgery is not appre-
ciably higher than 2 per cent., we are convinced
that for this group of surgeons, panhysterectomy
should be the method of election.
Myomata of the uterus, however, are the com-
monest tumors to be found in any part of the
human body. Furthermore, their removal is not
confined alone to any one class of operators;
rather, they occur in the practice of all surgeons,
many of whom are not especially trained or
skilled in pelvic work. In a personal canvas of
quite a number of men who do their own hys-
terectomies for fibroids, I ascertained that
whereas their mortality for the subtotal opera-
tion is in the neighborhood of 2 per cent., it is
never less than 5 per cent, for the total extirpa-
tion of the organ. This is quite obvious, when
we consider that the partial operation is a rela-
tively simple technical procedure in comparison
to the complete removal of the uterus. It is only
when the cervix is removed that we meet with
anatomical conditions and technical difficulties
which increase the risk of the operation.
A large proportion of the deaths from hyster-
ectomy are due to sepsis. The comparative free-
dom of the uterus from pathogenic organisms
explains part of the great success of the subtotal
operation. Fatal pulmonary embolism occurs in
at least i per cent, of the patients that have hys-
terectomies performed for fibroids. This tragic
mode of death is much more frequent after the
complete removal of the organ. As a rule the
illiac veins are the carriers of the fatal clot. It
is more or less definitely determined that injury
to the vein and infection are the cause of this
sequel. Apropos of this, McCann claims that
since he has abandoned transfixion and ligation
of the broad ligaments en masse, and operates
anatomically, picking up vessels cleanly and liga-
turing them without encompassing masses of tis-
sue, that he has never had another case of post-
operative embolism or thrombosis, either in his
private or his hospital practice.
Total hysterectomy not only requires a longer
time- for its accomplishment, but it is also accom-
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240
THE PENNSYLVANIA MEDICAL JOURNAL
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panied by a greater loss of blood. These factors
tend to lower tissue resistance, increase the sus-
ceptibility to infection, and at times provoke fatal
shock. Injuries to the bladder and ureters are
liable to happen in both operations, but the ma-
jority occur when the neck of the uterus is re-
moved. It is also easier to correct a complicat-
ing prolapse of the pelvic contents by utilizing
the stump of the cervix as a support.
Finally, in summing up the advantages and
disadvantages of the two operations, it is safe
to assume, if total hysterectomy were to be per-
formed as a routine procedure in the removal of
fibromyomata, that the primary operative mor-
tality, not to mention the morbidity, would be
mudi greater than the incidence of malignancy
that occurs in connection with the retained cer-
vical stump.
We are therefore convinced that, for the aver-
age operator, subtotal hysterectomy is the more
valuable procedure in the treatment of these
growths.
2019 Walnut Street
Giles, Arthur A., London, Bailliere, Zyndall & Cox, 1910.
Oark, J. G., J. A. M. A. VoL 73, No. 13, Sept. a?, 1919.
Broun, LeRoy, A. J. of Obst. 78, 410, 1918.
Cullen, Am. J. of Obst., 78, 477, 1918.
Kelly & Cullen, Mjromata of the Uterus.
Bland-Sutton, ■919.
McCann, Frederick, Brit. Med. J., March, 1918.
Spencer, Herbert, Froc. Roy. Soc. Med., I<ondon, 1916, 191 7.
Treacy.
Polak, John Osborne, J. A. M. A., Vol. LXXV., No. 9, Aug.
>8, i9ao.
Noble, Charles.
Lockyer i Eden's System of Gynecology.
Fehim, Arch. f. Gyn., Berlin, 59, 347-357.
Broun, Am. J. Obst., 79, £75.
Kelly & Noble, Gynecology and Abdominal Surgery.
DISCUSSION
Dr. Herbert B. Gibby (Wilkes-Barre) : Dr. Maier
has opened up a question which is of extreme import-
ance. End results are really what the surgeon is after
. and he who has a very high mortality in his operations
certainly does not get good end results. He has given
us a very fair presentation of the incidence of malig-
nant disease in the cervices associated with fibroid
uteri; the question is, are his conclusions correct?
Until recently I was very much inclined to do as Dr.
Maier suggested, leave the cervix behind. About 18
months ago I had a case in which there was appar-
ently no disease whatever of the cervix. I removed
the uterus by the supravaginal method and within a
year had a malignant condition of the cervix and
stump. This I referred to Dr. John G. Clark, of
Philadelphia, for radium exposures, and up to the pres-
ent time the patient has been doing very nicely on that
line of treatment. Since that operation I have only
performed one hysterectomy in which I have left the
cervix behind. The possibilities of radium treatment
as mentioned yesterday by Dr. Sistrunk, apparently
will prove of great value in the future. One of the
men who is using radium a great deal tells me that
practically 50% of his cases of fibroid can t>e treated
by radium alone, and that he is able to shrink the
growth to such an extent that operation is not ad-
visable. In that case it seems to me that it would be
wise, where it is feasible, to treat all of these fibroid
cases by radium and then remove the uterus, doing
a complete hysterectomy in those cases which cannot
be property treated by the radium alone. Dr. Sis-
trunk says the operation is an extremely easy one after
radium has been used. A certain procedure in the
technic also makes the operation very much easier.
This was brought to the attention of the profession by
Dr. J. Rilus Eastman it the New Orleans session of
the American Medical Association. After opening the
vagina, the cervix is grasped with a double tenaculum
and drawn sharply up' into the abdominal cavity. This
puts the vaginal fornix on the stretch and it is a com-
paratively simple matter to take blunt pointed scissors
and cut around the attachments of the vaginal wall to
the cervix. It makes the operation much easier, les-
sens the time consumed, and makes the operation ap-
plicable in some cases in which otherwise one would
hesitate to do it In conclusion, I think as Dr. Maier
says, that the personal equation of the surgeon should
determine the kind of operation, and I think also, that
the personal equation of the patient plays an important
role. There are some patients in whom the operation
is not attended with any great difficulties. In those
cases where there is but little risk of hemorrhage I
think we should remove the cervix wherever possible,
that is, if the operator himself is stifiiciently skilled in
its technic. In the cases where there is a great deal of
difficulty and where it will add a great deal of time
to the operation and where the patient's condition is
poor, I agree with Dr. Maier that supravaginal hys-
terectomy is the operation of choice.
Dr. Edwakd a. Weiss (Pittsburgh) : Total hyster-
ectomy should not give a much higher mortality than
subtotal, when performed by a competent surgeon, but
statistics show that there is a somewhat higher mor-
tality with panhysterectomy than in subtotal. The
former requires greater technical skill, and the opera-
tion is performed with attendant risks such as pro-
longed anesthesia, increased bleeding and the greater
possibility of infection. Some recent articles and dis-
cussions on the subject would lead us to believe that
the cervix is an entirely useless organ. Personally, I
have always felt that the cervix had a very distinct
function to perform. I always teach that the cervix is
to pelvic contents what a cork is to the contents of an
inverted bottle. It acts as a distinct plug for the
pelvic contents and I believe the preservation of the
healthy cervix is of decided benefit The type of
operation depends upon two considerations: first,
where the pathological condition is suc)i that panhys-
terectomy is clearly indicated, as in carcinoma; sec-
ond, when laceration, erosion or so-called cystic de-
generation of the cervix is present. Here it is ques-
tionable whether the cervix should be removed or not
I believe amputation may be performed which will
preserve at least a portion of the cervix. This type of
operation is purely elective, and it is questionable
whether it should be done as a routine procedure. The
possibility of malignancy developing in the remaining
stump is open to a great deal of discussion. The re-
ports from some clinics would give the idea that the
percentage is very high. In my own practice I have
seen cancer develop in the remaining stump but once.
Possibly there may have been other cases which went
to other surgeons. I have likewise seen it three times
in the service of Dr. Werdner who had a very ex-
tended experience. So that the possibility of malig-
nancy developing in the remaining stump should be
rather a negligible factor and should be weighed
against the increased morbidity attending panhyster-
ectomy. The latter is not a simple procedure, but the
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MENTAL DISEASES— PIKE
241
illustrations of Polak would lead us to believe that it
is. In the main I agree with Dr. Maier in saying that
panhysterectomy should be done only in those cases
where radical removal is clearly indicated. When we
have only mild pathology preserve the cervix because
it has a distinct function.
Dk. Edwabd a. Schumann (Philadelphia) : I sim-
ply wish to add a word in support of the conclusions
of Dr. Maier and Dr. Weiss. I believe that the choice
between subtotal and complete hysterectomy depends
largely upon the character of the case. In a multipa-
rous woman, whose vagina has been separated from
its attachments by confinements and in whom the tis-
sues are distensible and elastic, the complete hyster-
ectomy offers but little difficulty. In a virginal woman
with a thick abdominal wall and short, tense vagina,
I believe the operation is very difficult. In regard to
the occurrence of carcinoma in the remaining stump,
I believe our statistics are grossly exaggerated. We
have certainly rim well over 2,000,000 supravaginal
hysterectomies in the literature of the world and we
learn that there have been 269 carcinomata found in
the remaining stump. Personally, I have never seen
such an occurrence among my own patients. To put
the matter briefly and succinctly, I should say that
my own surgical opinion is that the operation of total
hysterectomy as compared to that of subtotal would be ,
characterized as being bloody, difficult and dangerous.
GENERAL SYMPTOMATOLOGY OF
MENTAL DISEASES*
HORACE V. PIKE, M.D.
Assistant Phjrtician, State Hospital for the Insane.
DANVILtB
In presenting this paper it is with no claim of
adding a contribution to the study of either
psychology or psychiatry. The objective signs
and subjective symptoms of mental disorders
are dealt with at a great length by many writers,
and to those especially interested in the subject
1 would recommend the handbooks of De-
Fursac or White as reliable working guides. I
shall attempt however, to cull from the maze of
confusing psychiatric terms, the cardinal symp-
toms of mental diseases and place them before
you in a simple and rather didactic way.
In order to appreciate at their full value the
operations of the abnormal mind it is essential
that we have some accurate understanding of
the faculties and functions of the normal intel-
lect.
The brain as the organ of consciousness or
mind is possessed of three faculties: feeling,
thinking and acting. Through the medium of
the senses, impressions made upon the organs of
sense are transmitted to the various brain cen-
ters as sensations and thus the individual
"Read before the Montour County Medical Society at the
State Hospital for the Insane, Danville; one of a series of
papers arranged for physicians, dealing with indications for
commitment, methods of procedure, diagnosis, intra- and extra-
mural treatment and mental hygiene.
derives knowledge of his own body, which de-
velops the personality, and the knowledge of the
external world or his environment, to which he
is enabled by the domination of these three
faculties to adjust himself.
In order that these faculties may function to-
gether harmoniously, certain separate and dis-
tinct operations must take place. . The various
sensations or stimuli received by the nerve cen-
ters of the brain are of themselves unproduc-
tive. The external causes of a given sensation
must be consciously recognized, hence we have
added to sensation — consciousness with the re-
sult— perception. The various percepts or im-
pressions must, once acquired, be stored for
future use, and memory now comes into action
hoarding the perceptions received from the
outer world and likewise from the body, and
then grouping the myriads of percepts together
into ideas or concepts with a resultant appre-
ciation or conception of environment and de-
velopment of personality.
The process of the relation of percept to
ideas, and the association of ideas one with an-
other, or in general terms the process of as-
similation and rearrangement of the materials
of knowledge furnished by the senses, with the
materials already present in consciousness is
the process of thinking. When from the asso-
ciation of two or more ideas there issues forth
a new and different idea, the process which pro-
duces this result is the process of reasoning and
the new idea is termed a judgment.
Having obtained knowledge of the environ-
ment and the personality, having assimilated the
various percepts, reasoned regarding them and
reached certain judgments, the next logical step
is the release of appropriate actions. If the
reasoning is at all complicated, there are usually
several judgments formed, each of which may
tend to express itself in an appropriate action,
the strongest one finally, however, succeeding in
expressing itself. This conflict of tendencies
has been described by Ziehen as the "Battle of
Motives," which he illustrated as follows: "I
see a rose in a strange garden. A long series of
ideas is aroused by the stimulus and the visual
sensation of the flower. The memory of the
rose's fragrance comes to my mind, I think how
well it would look in my room, that it is the
property of another, that plucking it would be
punishable and so on. Only after the whole
series of presentations has passed before my
mind does action follow, and whether I pluck
the flower or go on my way without it, will de-
pend upon the strength and intensity of the con-
quering idea."
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The conscious realization in action of the
strongest motive is the process of volition and is
accompanied by a feeling of freedom to choose
which motive shall dominate, and the sum total
of the actions of the individual are known as
conduct.
All of the mental processes of which I have
spoken are accompanied by certain general con-
ditions of consciousness known as affects, which
are pleasant or unpleasant, pleasurable or pain-
ful, agreeable or disagreeable, and like sensa-
tions are elemental constituents of conscious-
ness. These pleasurable or painful states are
the result of the interaction between the indi-
vidual and the environment and are known as
feelings when the interaction is relatively sim-
ple and direct. For instance, a shrill whistle
may be accompanied by a feeling that is dis-
agreeable to the point of being actually painful.
Whep the interaction is relatively more complex
and indirect there may result the state of con-
sciousness known as an emotion — the sudden
sharp whistle of a locomotive accompanied by
the hiss of an airbrake is heard coupled with
screams and cries of pain — the mind at once
pictures to itself an accident and the emotion
of fear arises in consciousness. If the interac-
tions are still more complex and indirect, the
resultant phenomena are termed sentiments and
we have honor, patriotism, etc.
From this brief summary it will be seen that
while these mental processes are each in them-
selves distinct actions, they are nevertheless
most intimately connected, forming parts of the
great whole, and in considering the symptoms
of mental disorders we therefore start with the
general understanding that insanity is a pro-
longed departure from an individual's normal
standard of thinking, feeling and acting and this
departure will necessarily be manifested in dis-
orders of the various operations which contrib-
ute to mental upbuilding, namely disorders of
perception, consciousness, memory, conception
and judgment, emotions and volition.
DISORDERS OF PERCEPTION
These comprise illusions, hallucinations and
insufficiency of perception.
Illusions.'— An illusion is an inexact or inac-
curate perception. The information conveyed
to the mind by the sense organs is misinter-
preted, and the qualities of the object perceived
are presented to the consciousness in a form
other than its real one. In a normal individual
illusions are not uncommon. How often have
each one of us mistaken at night a tree along
the road for a human being ? The normal mind,
however, recc^izes the abnormal character of
the image, whereas by the insane the illusion is
recognized as an exact perception. A strap ly-
ing on the floor may be perceived as a snake;
patterns in the wallpaper, as horrible insects;
nurses may be mistaken for and persistently
called by names of old friends; the sighing of
the wind may be mistaken for human voices ; a
bad taste in the mouth for poison arid so on
throughout the different sensory realms. The
distinguishing thing about an illusion is, that an
actual something in the environment is per-
ceived, but the perception is not a correct one
and conveys false information to the mind.
Hallucinations. — An hallucination on the other
hand, is a perception without an object. A
snake is seen on the floor where there is nothing
that can be mistaken for a snake, the floor is
bare ; human voices are heard where there are
actually no sounds in the environment which
could be interpreted as such; poison is tasted
where there has been nothing in the mouth or
food, which has given origin to the taste. The
distinguishing feature of an hallucination then,
is, a perception without the presence of anything
in the environment to perceive. Hallucinations
may involve any or all of the special senses, and
hence we have auditory, visual hallucinations,
etc.
Auditory hallucinations are divided into two
classes: elementary which are largely sensory
in character with few associations (these con-
sist of simple sounds, such as buzzing, crackling,
ringing and the like, and are spoken of as
"akoasms") ; and more complicated, which are
conceived by the patient to be, "Voices." These
are spoken of as verbal auditory hallucinations
or phonemes. The voices say pledsant or un-
pleasant things, but usually the character of the
remarks are consistent throughout and in har-
mony with the general mental condition of the
patient. These voices may be heard in both
ears or only in one ; the patient may recognize
and call by name the persons speaking, or the
sounds may be simply heard as voices of un-
known persons. In some cases different voices
are heard speaking in the two ears, the devil in
one and Christ in the other. Again, these voices
may be heard coming from different parts of
the body. One of my patients built upon such
an hallucination the delusion that she carried in
her stomach a living personality to which she
gave the name of "Sammy," and she would per-
sistently tell of things that "Sammy" wanted to
eat, that "Sammy" wanted to do, and of con-
versations that "Sammy" had had with her
during the night. This type of auditory hallu-
cination is spoken of as the "Epigastric Voice."
In some obscure conditions the patient be-
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MENTAL DISEASES— PIKE
243
lieves that his own thoughts become audible and
that he can hear his thoughts before he can
speak them. Personally I believe that this type
of auditory hallucination may be more common
than is generally supposed, and that the retarda-
tion of thought seen in cases of depression
where answers to questions come slowly and de-
liberately may be in some cases due to this type
of hallucination ; the patient waiting to hear his
thought before giving utterance to it. In the
consideration of auditory hallucinations, espe-
cially of the elementary type, one should always
bear in mind the possibility of the presence of
ear diseases. As a matter of fact it is not an
tuicommon thing to see auditory hallucinations
develop with a progressing deafness.
Visual Hallucinations. — These like the hallu-
cinations of hearing may be elementary and
occur as flashes of light, sparks, colors, etc.,
which are known as photomata, or they may be
more complicated even to the extent of the pro-
duction of complex visions. These may be
pleasaYit or on the other hand terrifying. It is
not uncommon to find auditory and visual hal-
lucinations associated in the same patient. I
have at the present time imder observation two
cases of psychosis with epilepsy. Each of these
patients are subject to periods of marked con-
fusion and clouding of consciousness following
epileptic convulsion. One of these invariably
hears the voice of the devil and sees upon the
wall shapes that he calls tuberculosis bugs. He
will stare in horror at these creatures and point
them out; suddenly he will scream in terror,
put his fingers in his ears and beg God to take
the devil away. The other patient will be found
gazing in rapture at the ceiling and repeating
over and over, "Oh, it is beautiful, it is heaven,
I hear the music and the birds and I see my
Saviour."
Hallucinations of Taste and Smell. — These
as a rule are of a disagreeable nature. Patients
will complain that they smell and taste human
blood, noxious and poisonous vapors surround
them and poison is tasted in the food.
Other Hallucinations. — In addition to the
above we find haptic hallucinations which are
referable to the special senses located in the
skin as touch, pain, heat and cold. Hallucina-
tions of the organic sensations in which pecul-
iar and indescribable sensations coming from
the internal organs give rise to such beliefs as
the bones are broken, the brain dried up, etc.
In the realm of sexual sensation, these halluci-
nations lead to the belief in women that they
are violated while they sleep, and in men that
their organs are abused and their semen drawn
off.
Inadequacy or Insufficiency of Perception. —
In addition to these inaccurate and imaginary
perceptions there is a condition in which sensory
stimuli are not adequately recognized. The
mind is so preoccupied with hallucinations and
delusions that the attention cannot be fixed upon
what takes place in the environment, and we
liave as a result insufficient or inadequate per-
ception, which is closely associated with dis-
orders of consciousness.
Disorders of Consciousness. — Consciousness
may be lost, a condition which we know as un-
consciousness; it may be weakened, when we
speak of it as clouded; or it may be exag-
gerated, when we call it hyper-consciousness.
Unconsciousness exists normally during sleep
and pathologically in conditions of coma and
complete stupor. Clouding of consciousness is
always associated with more or less complete
disorientation, which implies a lack of appre-
hension of time, person and place. The patient
who is unable to tell correctly the year, month
or the day of the week, suffers with temporal
disorientation; if he has no knowledge of the
city in which he lives, the street on which his
home is located, has no conception of where he
is or the character of his surroundings, he shows
spatial disorientation or disorientation for
place ; while he who is unable to tell the names
of people, with whom he has been associated
in his daily life or has forgotten his own name
is disoriented for person.
Between the stages of disorientation and
complete unconsciousness there are many grades
and phases of confusion and clouding.
Closely associated with disorders of percep-
tion and consciousness are those of memory.
Disorders of Memory. — An act of memory
comprises three distinct operations : the fixation
of a perception, its conservation, its revival or
reproduction in the field of consciousness.
Loss of memory or amnesia is therefore of
two types :
1. Amnesia of fixation or anterograde amne-
sia, which is a loss of memory for recent events.
In this form of amnesia perceptions are either
vague and uncertain or if clear and distinct do
not fix themselves upon the mind. The patient
will have forgotten what he had for dinner,
what he did yesterday, etc.
2. Retrograde amnesia or loss of memory for
remote events. This may be due to either faulty
conservation or faulty reproduction. In the
former and more serious form, ideas though
fixed in memory under the influence of some
pathological condition are destroyed and can-
not be regained. In the latter, or amnesia by
default of reproduction, the ideas have been re-
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THE PENNSYLVANIA MEDICAL JOURNAL
January, 1921
ceived, fixed and retained, but the power of re-
production is suspended. An amnesia which is
prc^ressive follows a definite logical course. It
descends progressively from the unstable to the
stable. In senile dementia this law is most per-
fectly demonstrated ; the impressions of old age,
the events of yesterday, a week or a month ago,
are the first to disappear, while those of child-
hood and early life are retained until the last.
Hence, the senile dement lives in the past. An-
other disorder of memory is that known as
paramnesia, which is a condition in which
events are remembered that never happened.
These false memories are often projected into
the past and form the fabrications often met
with in paranoia and senile dementia. The old
person whose memory is fast becoming a blank
will sit for hours telling of imaginary events in
his life and each time he tells the story the hap-
penings will be different.
Disorders of Personality. — Closely associated
with the memory is the personality, for the in-
dividual, in addition to the knowledge of his
environment has a consciousness of self ; a self
that maintains its own individual identity
throughout and which the individual calls "I."
As a result of hallucinations of the organic
sensations the feeling of personal identity may
become disrupted, the personality disorganized,
and as a result we have the condition, known as,
depersonalization, the patient claiming that he
has no head, no arms, no legs, that his eyes are
not his own, but cat's eyes, etc. ; or there may
be complete transformation of personality in
which, John Smith, the patient becomes Wood-
row Wilson the President, and he will ape the
individual whose personality he assumes. An
interesting condition occasionally seen is that of
multiple personality, in which the patient passes
through various transformations in each bi
which the personality is different and usually
separated from each other by complete amnesia,
so that one personality does not know of the
existence of the other. These cases of double
consciousness 'are similar to the famed char-
acter of fiction, Dr. Jekyl and Mr. Hyde.
Disorders of Conception and Judgment. —
Following the disorders of perception and mem-
ory, it is but a step to .disorders of conception
and judgment. Among these disorders delu-
sions play a major role. A delusion is a false
belief, but as such is not necessarily evidence
of a psychosis. A man may believe that to-day
is Thursday when in fact it is Friday. That is
a false belief while it lasts, but has only the
significance of a mistake. Delusions from the
pathological standpoint are false beliefs pre-
senting as a rule three main characteristics.
1. They are not true to facts, highly improba-
ble even manifestly impossible often to the ex-
tent of being bizarre. Such for instance are
the delusions of great wealth, royal lineage, etc.
2. They cannot be corrected by any appeal to
reason ; not originating in experience, they can-
not be corrected by appeal to experience.
3. They are out of harmony with the indi-
vidual's education and surroundings. A mem-
ber of a savage tribe lying upon his back and
crying for his soul to come back to him, is but
voicing the belief of his race that sickness is due
to the soul leaving the body. If we should find
however, a man educated in and living in the
United States acting in such a manner, we
should be justified in asserting that he suffered
from a. delusion. Delusions are classed as fixed
or changeable, systematized or unsystematized.
The terms fixed and changeable are of them-
selves explanatory. An unsystematized delu-
sion is one that seems to exercise no special con-
trol over the patient's conduct, he seems to rest
with its statement alone, unable to substantiate
his position by cogent argument or example. A
person who believes that all the bones of his
body are broken but nevertheless goes about his
affairs as usual has an imsystematized delusion.
A systematized delusion, on the other hand,
is supported by reasons, by arguments, and by
appeals to experience; it is acted on as if it
were an actual fact, and finally may so reach
out its influence that the whole life of the pa-
tient is centered about and becomes secondary
to it. The patient with a systematized delusion
of persecution regulates his whole life in order
to avoid his persecutors, his food is often tasted
for poison and perhaps discarded, the bed he
sleeps in must be insulated to prevent electric
currents being applied to him while he sleeps,
the key-hole stopped up so that poisonous
vapors cannot be injected through it, etc. If the
patient is asked for an explanation of his con-
duct he is ready with reasons and appeals to
experience, while his arguments are woven to-
gether with no little logic. His delusions are
systematized.
The sum of a patient's delusions constitute a
delusional system. Such a system may consist
of purely imaginary ideas, or of ideas based
upon actual facts improperly interpreted. Al-
most always the delusions are multiple and
while there may be seemingly a single fixed delu-
sion, as a rule careful examination will reveal a
number of false conceptions that are secondar>'
to it, or in some cases a number of delusions
may exist without any apparent connection be-
tween them.
Delusions whether fixed or changeable, sys-
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SELECTIONS
245
tematized or unsystematized, present as a rule
one of three types of ideas or combinations of
these types. These are melancholy ideas, ideas
of persecution, ideas of grandeur.
Melancholy Ideas. — These are generally ex-
pressed by the patient as ideas of ruin and pov-
erty in which he believes himself bereft of
everything; ideas of self-accusation, in which
he considers himself responsible for the various
misfortunes of others, that he has committed an
luipardonable sin and must of necessity be pun-
ished; ideas of negation, in which he believes
that the universe has ceased to exist, that the
earth is nothing but a shadow, and that his own
body has become unreal and its various organs
destroyed; hypochondriacal ideas, which are
often dependent upon a real physical condition
but which are falsely interpreted by the patient.
He believes himslf to be suffering from various
incurable diseases, etc.
Ideas of Persecution. — These are spoken of
as paranoid delusions, and like melancholy ideas
are of a painful nature. But while the melan-
choliac considers himself a culpable victim, and
submits beforehand to the chastisements which
he believes he has merited, the subject of per-
secution is convinced of his innocence and pro-
tects and defends himself. These delusions are
of necessity varied in their character and pre-
sent all phases of development from ideas of
reference in which the patient interprets every-
thing that occurs about him as having some
relation to himself, feeling that people act differ-
ently than usual to him, that people on the street
avoid him, people conversing together are talk-
ing about him, to a perfect delusional system in
which he narrates precisely his persecutions,
displays an exact knowledge of his persecutors,
their object and the means employed by them,
and formulates plans of defense against them.
Delusions of this type may or may not be ac-
companied by hallucinations and they are the
hardest to eradicate and render their victim a
dangerous person to be at large.
Ideas of Grandeur. — These are generally of
an absurd nature and bear the marks of mental
enfeeblement. The patients are rich, all power-
ful, popes, emperors, creators of the universe.
While found in some of the acute functional
psychoses, they occur chiefly in demented states
and are often part of the mental picture of
paresis.
Disorders of Affectivity, — As the emotions
play a great part in the normal mental life, it is
to be expected that they would share in mental
disorders. As a matter of fact, pathological
changes of affectivity are encountered in all the
psychoses ; they appear early and often are the
first symptoms noticed. Relatives of patients
will invariably date the beginning of abnormal-
ity from the time when a change in disposition
was observed. These symptoms run the entire
gamut of the emotions from indiflFerence to
deep depression, from irritability to morbid
anger and passion, from a sense of satisfaction
and a vague sense of well-being to euphoria and
ecstasy.
I have tried briefly to outline the more com-
mon symptoms seen in the various psychoses.
As a result of disorders in the spheres of feel-
ing and thinking there naturally follow disor-
ders of volition and conduct, which as a rule
speak for themselves. Other symptomatology
as disorders of reactions, disorders of the train
of thought, including flight of ideas, retarda-
tion, incoherence, etc., have been previously
considered, ( i ) and it is hoped that these sum-
maries may prove of practical value to the busy
general practitioner in the examination of pa-
tients concerning whom he may be called upon
to pass judgment as to the advisability of treat-
ment at home or commitment to a state hospital
for the insane.
I. Etiological Factora and Differential Diagnosis in Mental
Disease — Pike — Pennsylvania Medical Journal. September,
1920.
SELECTIONS
MEDICAL PRACTICE AND MEDICAL
EDUCATION IN ITS RELATION-
SHIP TO COMPULSORY
HEALTH INSURANCE*
CLARENCE BARTLETT, M.D.
Professor of Medicine in the Hahnemann Medical College of
Philadelphia
PHII,ADEU>HIA
This meeting has been called, as I understand
it, to elicit facts from the medical profession
concerning compulsory health insurance, with
the idea of giving the commission information
as to its practicability, and as to the best means
of drafting an act should compulsory health in-
surance be regarded as a wise step. Our chair-
man has requested me to address you concerning
medical education and the practice of medicine
in its relationship to the subject under review.
First, permit me to discuss with you the course
of practical medicine as followed at Hahnemann
Medical College, of which I have the honor
to be in charge. We start our students in the
first year of their career with a study of the his-
tory of medicine which enables them to correlate
'Read before the Health Insurance Commission Conference
at the Bellerue-Stratford Hotel, Philadelphia, December 3,
1920.
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THE PENNSYLVANIA MEDICAL JOURNAL
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the practices of the past and those of the present.
In their second year, they are put through a
rigid training of practical work in the study of
the normal man, in order that they may better
hereafter appreciate the abnormal. Sixty-four
hours are devoted to this subject, and students
are rigorously trained in inspection, palpation,
percussion and auscultation. Even this early in
his career the medical student is forced to real-
ize that patients cannot be examined hurriedly.
In the third year, students are given three more
lines of practical work as follows : the taking of
case histories, the study of physical diagnosis in
its relation to the sick, and the training of the
eye in the visualization of disease. At the same
time didactic work in general diagnosis and prac-
tice of medicine is required, and they attend clin-
ical lectures, the total curriculum being two hun-
dred or more hours. In the fourth year, they are
assigned to hospital and dispensary service,
where they receive instruction, attend didactic
and clinical lectures, comprising probably two
hundred hours at least. In all of their work,
they are made to appreciate the following apho-
risms : first, that more mistakes are made by not
looking than by not knowing; second, that all
statements of patients must be accepted cum
grano soli until such statements are proved to be
correct. Misstatements of fact are common
sources of error in medical work. Third, that
many patients are not sick, but are worried or
subsist in an unfortunate environment; fourth,
that it is just as important to know the patient
as it is to know his disease, in fact there are many
instances where knowing the patient is the im-
portant factor in the conduct of his illness.
When the teaching is put into actual practice,
it will be found that first-class medical work, and
there really should not be any other kind, re-
quires a large amount of time. The situation is
very different from what it was forty or more
years ago, when it was a not uncommon practice
for physicians to write 10,000 prescriptions in
the course of a year. That, you can easily see,
means *an average of thirty patients daily, which
also means that doctors saw anywhere from ten
to seventy-five people in the course of a day.
Satisfactory though these so-called busy practi-
tioners may be to the people, they cannot do the
best work of which they are capable under pres-
ent auspices. Years ago such practice was the
best obtainable; to-day it is archaic. It is not
necessary for you of the commission to depend
upon my statements as to the importance of the
above aissertions. Dr. Jackson of the Mayo
Hospital at Rochester, Minn., has stated that the
limit of best work on the part of a physician is
nine patients daily, that any larger number re-
sults in a loss of quality as to the work. The
State Board of Licensure of Pennsylanvia has de-
creed that unless a hospital maintains an interne
for every twenty-five beds that hospital cannot
go on the approved list, which means in fact that
such hospitals cannot be regarded as class A in-
stitutions, and merit appropriations from the
legislature for the care of the citizens of Penn-
sylvania. When this board says "one physician
for twenty-five beds," it does not mean one phy-
sician for twenty-five patients. It means that
twenty-five patients is the maximum. When you
come to consider, you find that of the patients in
the medical wards (and I speak of the medical
wards because it is of them that I have the most
knowledge), not more than half, if that many,
are seriously ill at one time. A very large pro-
portion of the sick in our hospitals are convales-
cents, who require but comparatively little of the
physician's time.
It may be objected to that when bringing be-
fore you the question of hospital illness I am
utilizing a class composed of seriously sick peo-
ple. Please remember, gentlemen of the Com-
mission, that all people may be seriou-sly sick;
that each person is as sick as he thinks he is, until
after thorough examination he has been officially
informed of his correct condition. Please bear
in mind that there never was a serious illness that
did not have a mild or innocent-appearing com-
mencement. Even that terrible disease, cancer,
starts as a mere pimple. Tuberculosis has as its
initial lesion a deposit scarcely greater than a
grain of sand. If we were to recognize disease
in its curable stages, we must diagnose while it
is still young and still curable. In reality, the
trivial illnesses are the important ones and de-
mand deliberate and careful attention. The ex-
cuse that an illness is insignificant is never a rea-
son why it should be neglected. Many a patient
has died of tuberculosis because he and his doc-
tor thought at the onset that it was a cold ; the
patient did not take care of himself properly, and
the doctor did not properly examine.
Gentlemen of the Commission, the world is
filled with horror over the 34,000 American
youths killed and a quarter of a million maimed
in the World War ; a bomb in Wall Street, killing
some thirty or forty people and destroying prop-
erty is impressive, and demands numerous col-
umns in the daily press ; a flood in China, a fam-
ine in India or typhus in Servia awakens world-
wide interest and sympathy. Indeed, gentlemen,
I might multiply horrors of this kind which are
indelibly fastened upon the minds of the Ameri-
can people, and yet I know that the lives lost,
the health ruined, by these calamities are but a
pittance in comparison to the lives lost, the healA
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247
ruined by quantity production in medical work.
Quality production should be the cry, for remem-
ber that the prevailing folly of the medical pro-
fession is not ignorance, but it is not looking, be-
cause the doctor, like the engineer asleep at the
throttle, fails to observe the danger signals ahead.
Overwork, and not ignorance, is the prevailing
barrier to good medical service.
Next comes the question of economics. Ordi-
narily when it is said that a physician has a prac-
tice of three, five or ten thousand a year, these
figures are intended to convey that that is his in-
come. As a matter of fact, the conduct of a
medical practice demands overhead and carrying
charges such as are incidental to any other busi-
ness. These include office rent, automobile, tele-
phone, library, medical society dues, light, heat,
assistants, etc., as overheads, while his carrying
charges include medicines, surgical instruments,
special supplies, to say nothing of numerous
other items. These in the aggregate count up
very heavily so that it is pretty safe to say that
but few physicians get off with less than thirty
per cent., many put out more than forty per cent.,
and in certain small practices the overhead is so
high in relation to the income that the physician
is lucky if he gets forty per cent, for himself.
I might add what may be called the medical
turnover to correspond with the labor turn-
over. The manufacturer knows that it costs him
money to discharge and break in labor. One of
the problems of the factories to-day is that of
making labor contented so that the cost of labor
turnover may be reduced. The housekeeper to-
day knows all about labor turnover as she recog-
nizes the fact that in the numerous changes inci-
dental to household help there are many expenses
which add to the burden of keeping servants. I
recognize, for example, that it costs from fifty
dollars to seventy-five dollars to change chauf-
feurs. Medical practice has its turnover as time
and expense are incidental to each new case of
illness coming under one card. Many physicians
recognize this fact by exacting larger fees for
first examinations.
Let me mention as modest overhead charges
for a physician: office rent, $600; automobile,
$1,000; telephone, $35 ; heat and light, $50; li-
brary and journals, $100 ; society dues, $25 ; the
total being $1,810, and you will agree with me
that this would represent a very modest outlay
and would probably mean a gross income or busi-
ness of $4,000 or $4,500 per annum. Present
day medical practice demands equipment the ab-
sence of which most assuredly interferes with a
man's efficiency. The above estimate for ex-
penses does not provide for this to any extent.
I have not seen any figures relating to the re-
turns to the physician in health insurance work
that could begin to compensate him for his busi-
ness expenses, much less afford him a means of
decent support for his family and himself. Re-
member that above expenses are the same irre-
spective of the fee received. It costs the same to
travel two miles to receive one dollar as it does
to travel two miles to receive five dollars. I
would submit the question that medical work
under the reduced fee schedule of compulsory
health insurance would place the physician in the
position of. using his diploma as a mere excuse
for getting less returns from operating his auto-
mobile than are given to the chauffeur driver.
Another economic question is that of hours.
Labor unions have for several years contended
for the eight-hour day. Physicians, to their
honor let it be said, have always been willing to
work, no matter how long nor how inconvenient
the time, and despite weather conditions. When
human life and health are at stake they respond,
and cheerfully as a rule. If they growl that
growl does not count, they go just the same.
When one analyzes the activities of physicians
in medical legislation one will appreciate that
every movement in which they have been active
has been for the public good. Laws for health
and for medical education alike stand as monu-
ments to their strict altruism. I believe that
compulsory health insurance is a bad thing
as tending to the neglect of quality production
and the encouragement of quantity work. It
means that physicians must work long hours
daily in order to make sufficient money to sup-
port a family. It means that the profession will
be robbed of its altruism and will be forced into
commercialism. The time given to work will be
greatly increased because of the incidental paper
work on medical cases for the guidance of the
central bodies.
So far as medical work is concerned there
seems to be a decided lack of appreciation as to
its relative position in human affairs. It is only
three years since the Kansas legislature made
certain appropriations as follows : for sick babies,
$3,000; for sick bees, $5,000; for sick hogs,.
$50,000. Now, gentlemen, you may think that
this is a joke. It is not; it is serious. I know
of an instance where, one week, a man whose
income that year was $100,000 or over, paid
$500 for a prize bull dog, and the next week
raised the deuce over a bill of $50 for attendance
upon his sick wife. As 'twixt his love for his
dog and his wife he may have stated his relative
appreciation, and I may have done him an in-
justice; still, we all have our opinions. One of
our popular novelists makes one of her charac-
ters say that a man will pay cheerfully to a lawyer
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$10,000 for keeping him out of jail for six
months, and then will complain of a doctor's bill
of $100 for saving his life and perhaps keeping
him out of hell forever.
From what I have said in the opening sections
of this address, you will appreciate that it takes
special preliminary education and long years of
preparation before one can become a graduated
physician. While men who enter medical prac-
tice do so of course as a means of making an
honest living, they are not actuated entirely by
monetary motives. If they were they, would seek
some other calling. Medicine properly practiced,
made an art, a pleasure and a science, is fascin-
ating in the extreme to its votaries. Part of their
reward comes from the pleasure obtained and
the honorable position of physicians in the com-
munity. Compulsory he^th insurance will so
surely remove from the practice of medicine its
aspects of art and science that I fear truly that
but few young men of proper mental calibre will
take it up. Just what the beneficiaries of this
law will think of it I do not know. My impres-
sion, however, is that after they have tried it out
they will take but little interest in it. Last Sat-
urday, November the 27th, I filled out a certifi-
cate for sick benefits for one of my patients, a
shop foreman in a large industrial plant in this
city. I proceeded to sound him on compulsory
health insurance. He sidestepped my question
entirely by stating facts that existed in his fac-
tory. His corporation maintains three physicians
on salary whose services are given to the entire
personnel of the employed at the works. My in-
formant assured me that no more than ten per
cent, of the men employed took the company
doctors, but preferred, physicians of their own
choosing and to pay their own bills.
During the late war it was not uncommon
among the enlisted men to voice serious objec-
tions to the military or naval doctor. I know
this personally because one of my pleasures was
to entertain at my home a large number of the
boys, and I could hear their jokes about "mag.
sulph.," "dope" and other things to indicate that
.they looked upon medical practice in the army
and navy as of a decided machine-like order. I
know their criticisms were not fair because our
army and navy doctors did good work. Unfor-
tunately the environment that existed forced a
kind of medical service to which the men were
not accustomed. They were deprived of the lib-
erty of choosing a medical man in whom they
had confidence. They wanted a medical man
who knew them personally. In other words they
craved the human factor. Unless a physician's
presence and personality gives to the sick a cer-
tain amount of assuredness of return to health,
the patient loses, we will say, twenty per cent,
(certainly he loses something) of his chances of
recovery. Will this be given to the sick in com-
pulsory health insurance with its quantity pro-
duction ?
Gentlemen of the Commission, if in your wis-
dom you see fit to formulate and recommend a
compulsory health insurance bill, may I ask you
to provide that such bill shall give to the helpless
sick who entrust themselves to your care and
who no longer have the privilege of choosing
their own medical advisors an opportunity for
the best medical advice. Assuredly the best is
none too good for labor. The best is the cheap-
est in the long run. Do not take away from the
sick the human factor without which illness has
no factors other than those found in the practice
of veterinary medicine.
SUMMARY OF THE REASONS WHY
THE MEDICAL PROFESSION IS
OPPOSED TO COMPULSORY
HEALTH INSURANCE*
FRANK C. HAMMOND, M.D.
PHILADELPHIA
The medical profession of the state is anxious
to help all constructive legislation, and to oppose
any legislation inimical to the best interests and
health of the people of the commonwealth.
The following is submitted as a summary of
some of the reasons why the medical profession
is opposed to compulsory health insurance.
1. Most sickness is traceable to ignorance of,
or wilful violation of well recognized laws of
health or hygiene on the part of the individual
employee or his dependents.
2. If the employer is not responsible for the
illness developing among his employees and their
dependents, or does not benefit from the insur-
ance against the losses occasioned thereby, he
should not be forced to contribute to such relief
— many employers do continue the wages of em-
ployees during time of illness. All true occupa-
tional diseases should be compensated by the in-
dustry involved.
3. Health insurance will compel the employer
to pay a high premium on his employees, and no
doubt in excess per ratio over the charges now
being made for industrial accident insurance.
This increase in the overhead, with surtax on
profits from production, will increase the retail
price on commodities.
4. The class-making features, dividing work-
ers into those forced to insure and those consid-
*Read before the Health Insurance Commission ConfeRoce
at the Bellevue-Stratford Hotel, Philadelphia, December 3.
1930.
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SELECTIONS
249
ered capable of caring for themselves, are un-
American.
5. Adequate wages and better working condi-
tions, without forced insurance contribution by
employer, avoid any appearance of charity and
permit advantages of privately managed volun-
tary forms of insurance, with free choice of phy-
sician, dentist, etc.
6. It will mean that either the employer must
pay for preexisting diseases, or discharge bad
risks (for example employees who have chronic
diseases but who at present are self-supporting,
and a help to the community).
7. The taxpayer now supports financially all
well established state agencies for the prevention
and control of contagious diseases, the treatment
through dispensaries and sanitoria of tubercu-
losis and venereal diseases, the treatment of de-
pendent sick individuals through state aided dis-
pensaries and hospitals, and the complete care of
the indigent, disabled and insane.
8. State supervision of workmen's compen-
sation insurance costs the taxpayers of Pennsyl-
vania several hundred thousands of dollars an-
nually. State supervision of health insurance,
covering the insured regular employees plus their
million dependents, will cost the taxpayers con-
siderably more than does \Yorkmen's compensa-
tion insurance.
9. The taxpayer, who is an employer, will find
his total contribution more than the 50 per cent,
which may be pro rated to him by the plan.
10. Complusory health insurance as a scheme
of insurance is unsound if a flat rate of contribu-
tion is required, because it assumes an equality
of risk which does not exist ; the lower incidence
of sickness in rural districts making it in effect
a tax on rural industries and occupations for the
benefit of town dwellers.
11. The various cities, towns, etc., of the state
have employees eligible under the proposed plan.
Will such employees during illness be paid 100%
of w^es, and will the management of "locals"
pay all sick benefits? If so, the taxpayer will
pay 100% wage to the city employee while ill,
as well as 50% of his insurance benefits.
12. The enormous cost in money will be out
of all proportion to the promised benefits.
13. Where tried, the plan has not influenced
favorably the incidence of sickness prevention,
nor reduced the death rate, nor lowered infant
mortality. In fact most practices and laws re-
sulting in the prevention of disease, and the re-
duction of sickness have their origin in the ef-
forts of individual or grouped physicians. Wit-
ness the magnificent results obtained in the pre-
vention of smallpox, t)rphoid fever, malarial and
yellow fevers, and the treatment of diphtheria
and cerebrospinal fever. Physicians led the way
toward improved infant mortality, improved
school and industrial hygiene, and they form the
nucleus of the organizations endeavoring to re-
duce tuberculosis, insanity and venereal diseases.
Such trained and experienced men should be
trusted to develop, in a careful and orderly
process, proper plans to meet economically the
existing widespread improvements in preventing
and treating sickness. This should suggest to
thinking individuals, an improvement over the
proposed plan for compulsion of contract medi-
cal practice.
14. We are told that in Germany and England
health insurance has demoralized the medical pro-
fession by removal of incentive to individual ad-
vancement, and has discouraged research work.
15. A state bureau of laymen in control of
sickness and treatment may be created.
16. The successful treatment of sickness is en-
tirely a question of confidential, individual and
personal relation, between physician or dentist
and patient.
17. The compulsion features are distasteful to
employer, employee, physician, dentist and bene-
ficiary alike — compulsion to attend certain pa-
tients ; compulsion to accept attention of certain
physicians or dentists.
18. All plans proposed to date will result in
the evils of contract medical practice in its most
obnoxious form — maximum of demands by
beneficiary, minimum of service by physicians.
19. The various county societies, the Medical
Society of the State of Pennsylvania, the State
Homeopathic Society, the State Electric Soci-
ety, the American Medical Association, various
other medical societies, the Pennsylvania State
Chamber of Commerce and numerous other
bodies, have passed resolutions opposing the ne-
cessity for any legislation on health insurance.
20. It would substitute for the medical care
and treatment now received by the wage earning
class, medical care and treatment of an inferior
character, thereby doing positive injury to that
class.
21. It would compel citizens to invest their
savings in a certain way, and it would fix the
remuneration of a class of special workers
(physicians, dentists, druggists and nurses)
without their consent.
22. It would impose on the wage earning
class the annoyance of extensive inquisition into
their private affairs by government officers and
agents.
23. It is opposed to sound public policy in a
democracy, in fostering objectionable class dis-
tinctions and a dangerous encroachment on pub-
lic rights and privileges, including the most per-
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THE PENNSYLVANIA MEDICAL JOURNAL
January. 1921
sonal concerns of the individuals, and the super-
vision, control and direction of the person in
matters of health and welfare.
24. It is a danger to democracy, in that the
promises made are impossible of fulfilment, and
on this ground will ultimately create an unwhole-
some industrial unrest.
25. Such demand for compulsory health in-
surance as exists has been created artificially by
a skillful propaganda.
26. It does not promote the health of the in-
dividual, but rather fosters a tendency toward
malingering and an undue prolongation of minor
ailments for the purpose of wrongful gain.
27. Experience in other countries shows that
medical treatment under its rules results in a
standardized method of mediocre practice. The
doctor who gives his whole time to the service
reduces his profession to a mere trade ; the doc-
tor who gives only part of his time to the prac-
tice is bound to give it indifferent attention.
28. It would make the profession of medicine
less attractive, would drive many now practicing
it into other occupations, and would discourage
many from taking it up.
colored girl, heart, lungs and kidneys normal.
Wasserman negative, but anemic from constant
loss of blood. A panhysterectomy was done and
the upper zone of the vagina removed. The
growth microscopically showed all the evidences
of carcinoma and originated from the posterior
lip of the cervix. It had destroyed the mucosa
but had not yet invaded the deeply lying uterine
muscle.
The patient reacted well from the operation
and the next day was hungry for food and
wanted to know when she was going home. She
stated that she did not have much pain and felt
like she could sit up. Unfortunately that same
night she was suddenly seized with a pulmonary
embolism and died before the intern could get
down stairs to her so that we could never know
what the possibilities of recurrence would have
been. In most of the carcinoma cases reported
in the young, recurrence has been early and the
course has been rapidly downward.
The pathologists report was adeno carcinoma.
The case again accentuates the extreme impor-
tance of examining every woman who presents
herself with unusual or irregular menstrual
bleeding, no matter at what age.
CAULIFLOWER CANCER OF THE CER-
VIX IN A WOMAN OF TWENTY
WM. EDGAR DARNALL, A.M.. M.D., F.A.C.S.
ATLANTIC CITY, N. J.
This case is reported because of the extreme
rarity of carcinoma in a woman so young. It is
true that there have occasionally been reported
cases of carcinoma in young women, one in a
girl of twelve years of age, but it is well known
that such growths appear rarely before the age
of forty. In a series of 262 hysterectomies for
cancer of the uterus, including Wartheim's, ordi-
nary panhysterectomies and a few vaginal, my
next youngest case was 32 years of age. The
malignancy of carcinoma in the young seems to
be of a more virulent order. It is necessary for
us not to be too positive that a patient does not
have malignant disease simply because of her
age.
Lottie J., colored, age 20, came to the hospital
because of a more or less constant flow and a
feeling of fullness in the vagina. She was un-
married and there was no history of pregnancy
or miscarriage. Her personal and family his-
tory were negative. She began to menstruate at
14. On examination the vagina was completely
filled with a perfect cauliflower growth as large
as a man's fist. She was a well developed dark
YELLOW FEVER VACCINE TO MAKE TRAV-
ELERS IMMUNE IN SOUTHERN
COUNTRIES
The discovery by Dr. Hideyo Noguchi, at the Rocke-
feller Institute for Medical Research, of a vaccine for
ydlow fever, introduces a new factor in yellow fever
control through the possibility of making persons im-
mune to yellow fever by vaccination.
Heretofore, work in yellow fever control has been
entirely that of prevention of infection by controlling
breeding places of the mosquito which carried the yel-
low fever germ. The isolation of the yellow fever or-
ganism, however, has made it possible for Dr. Noguchi
to develop a serum which it is believed will reduce the
mortality from yellow fever and a vaccine which gives
promise of protecting the nonimmunes against con-
tracting the disease.
Already vaccination against yellow fever of people
going to tropical countries is being made in New York.
This work is being done at the Broad Street Hospital
with vaccine furnished by the Rockefeller Institute.
The first shipment of vaccine for yellow fever from
the Rockefeller Institute to tropical coimtries was
made a year ago when three hundred bottles were sent
to Mexico. Other shipments have been made since
then, the latest on November loth. All vaccine sup-
plied to Mexico is sent to the Mexican Department of
Health which arranges for its distribution.
The Central American countries are so well con-
vinced of the efficacy of Dr. Noguchi's vaccine that
they are permitting travel without quarantine deten-
tion of those who have been successfully vaccinated.
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MEDICAL COLLEGES OF PENNSYLVANIA
251
THE MEDICAL COLLEGES OF
PENNSYLVANIA
UNIVERSITY OF PENNSYLVANIA
THE SCHOOL OF MEDICINE
The School of Medicine of the University of
Pennsylvania has enrolled this year 432 students
divided as follows among the four classes :
1st year 99 3d year 1 19
2d year 94 4th year 120
The first year class is composed entirely of
new students without a single so-called "re-
peater." In previous years students who failed
in one or more subjects were permitted to repeat
the year's work but an investigation of the rec-
ords of such students during the past ten years
showed conclusively that they did not make good
later. Only half of those who repeated their
first year ever graduated, and those who even-
tually did graduate without a single exception
were in the lower half of their class, with low
averages for each year. As a limit of 100 has
been placed on the size of the entering class it
seemed, therefore, unwise to keep out a new and
presumably good student to make room for one
who, having failed once, might from experience
be expected in 50% of cases to fail to graduate,
or at most to graduate with a low general
average.
The third year class includes this year forty
students admitted on advanced standing from
other medical schools. It is felt that at the Uni-
versity of Pennsylvania, although 100 seems to
be the proper limit in size for the first and sec-
ond-year classes, that about 125 can be taught in
the tliird and fourth years. There is no trouble
in filling the class up to such a figure as each year
there are a great many applications for admission
to the third-year class. There are now eleven
class "A" medical schools giving only the first
two years of instruction, and last year these
eleven schools had a total enrollment of 565 in
their two classes. This means that annually at
present nearly 300, or about half of the total en-
rollment must seek admittance to other schools
in order to complete their medical education. In
addition applications are received from students
in schools which give the whole four-year course.
In the past nine years 212 students have been
admitted to the thirchyear class of the Univer-
sity of Pennsylvania School of Medicine on ad-
vanced standing. One hundred and seventy of
these came from these so-called "two-year
schools" and 42 from "four-year schools." As
it is possible to ascertain how all these students
have succeeded in their medical studies and to
choose only the very best students, a very satis-
factory addition, scholastically, is annually made
to the school. Only one student so admitted has
failed and been forced to repeat a year .
On account of the large number of applica-
tions for admission to the first-year class and the
limit of 100, a very careful selection is made and
a class chosen which presumably contains few, if
any, poorly prepared or stupid students. It is
confidendy believed that by means of this care-
ful selection a reduction can be made in the
heavy "mortality" that has existed in the past.
For some years the classes have been losing be-
fore the beginning of the third year an average
of 22% on account of scholastic failures. Eight
years ago a certiiin class lost during its first two
years 34% of its enrollment through failures.
Repetition of such a high mortality should be
prevented. High standards, careful selection and
insurance against overcrowding makes a strong
appeal to the intelligent student wishing to ob-
tain satisfactory instruction in medicine to-day.
William Pepper, Dean.
JEFFERSON MEDICAL COLLEGE
JEFFERSON'S WAR PARTICIPATION
A memorial tablet to the graduates of Jeffer-
son Medical College who died in service during
the World War, was dedicated with appropriate
special ceremonies, on October 7, 1920. The
tablet, which was presented by the Alumni As-
sociation, is of statuary bronze, bas-relief, five
feet high by five feet wide. An allegorical figure
of victory points with inverted torch to the
names of the men who "gave the last full meas-
ure of devotion." These, so far as known, are
twenty-seven in number. The list follows:
Class
W. E. Purviance, 1889
John J. HJslop, 1892
Harry M. Lavelle, 1900
Robert L. Hull, 1902
T. B. Ferguson, 1906
Richard L. Jett, 1907
B. B. Cox, 1907
Lindsay C. Whiteside, 1907
Carl E. Holmberg, 1908
C C. Wood, 1910
Joseph E. Dudenhofer, 191 1
JohnH.Burkartmaier, 191 1
F. A. Henderson, 191 1
Perry S. Gaston, 1912
The tablet has been placed just inside the main
entrance to the college building at Tenth and
Walnut' Streets. It was procured, and subscrip-
tions obtained, by a committee consisting of Dr.
S. MacCuen Smith, chairman ; Dr. Fielding. O.
Lewis, Dr. William M. Sweet, and Dr. P.
Burgess A. Gibson,
Abner P. H. Sage,
Russell G. Parson,
Francis R. Hoyt,
James W. Phillips,
Grady R. Roberts,
Frank H. Gardner,
Reese Davis,
Gustaf L. Norstedt,
Francis F. Hanbidge, 1916
Casper J. Middlekauff, 1917
Frederick G. Carow, 1917
J. A. McCarthy, 1918
Class
1913
1913
X914
1915
191S
1916
1916
1916
1916
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THE PENNSYLVANIA MEDICAL JOURNAL
January, 1921
Brooke Bland; the first contribution coming
from the Northeastern Pennsylvania Chapter of
the Alumni.
The dedicatory exercises were held in the hos-
pital amphitheatre, before an audience which
overflowed the hall. Members of the teaching
corps, who were in military service, appeared in
the uniform of their rank. The invocation was
made by the Reverend John H. Chapman, rector
of St. Paul's Episcopal Church, Chestnut Hill,
who served overseas as chaplain to the Jefferson
Base Hospital (No. 38) . After a brief introduc-
tory address, in the course of which the audi-
ence rose and stood while he read the names of
the honored dead, Dr. S. Solis Cohen, President
of the Alumni Association, introduced the Hon-
orable William Potter, President of the Board
of Trustees, as the presiding officer of the eve-
ning. Following Mr. Potter's brief remarks, the
presentation address was delivered by Dr. J.
Chalmers DaCosta, the Samuel D. Gross Profes-
sor of Surgery ; and the speech of acceptance, on
behalf of the trustees, by Owen J. Roberts, Esq.,
a recent valued addition to that board. The
ceremonies concluded with the benediction, pro-
nounced by the Reverend Mr. Chapman.
While the data are still incomplete, the record
of service of Jefferson graduates in the World
War, as thus far compiled and verified by com-
parison with the official records at Washington,
appears to be second to none. The tabulated
record so far shows that 1,468 graduates served
in the medical departments of the army and
navy, most of them as volunteers, but quite a
number, in virtue of their commissions, in the
regular or reserve establishments. They held
rank in the army from major general (Merritte
W. Ireland, surgeon-general), down through
colonel, lieutenant colonel, major, captain and
lieutenant. In the navy, the list embraced com-
manders, lieutenant commanders, captains and
lieutenants. Many of the higher grades in both
services were attained through promotion for
merit. The records of the marine corps and
public health service have not yet been made
up. They will, doubtless, give many additional
names. As it stands, more than one in four of
the living graduates of Jefferson Medical Col-
lege are officially listed as participants in the ac-
tive work of the medical corps of the armed
forces of the United States, making up, it is
said, more than five per cent, of the total enroll-
ment of medical officers. They represented
every section and every state of the Union, in-
cluding the island possessions. They received
every military decoration, including the Congres-
sional Medal of Honor, awarded to a member of
the teaching corps, and nearly every decoration
awarded by foreign governments.
The classes represented were 1862 (Major W.
W. Keen, Emeritus Professor of Surgery), 1870,
1871, 1872, and then continuously from 1874 to
1918, inclusive — every class for an unbroken pe-
riod of forty-four years. Sixty-five per cent, of
the graduates from 1913 to 1918 served, includ-
ing 103 of the class of 1916 ; 94 of the class of
1917, and 91 of the class of 1918. In the Jeffer-
son Hospital Unit (No. 38), an expenditure of
$210,000 was made for equipment, and the per-
sonnel was composed of 34 physicians and sur-
geons, 200 enlisted men, 5 civilians and 100
nurses. There were 431 undergraduates in the
Student Army Training Corps, of whom about
nine-tenths were enrolled in the army, and one-
tenth in the navy.
The Secretary of the Alumni Association, Dr.
E. J. Klopp, Philadelphia, requests that any one
who may know of a Jefferson Alumnus not in-
cluded in the published list, who died in service
during the war, whether by casualty of battle,
or by disease contracted in the course of duty,
will be good enough to notify him, so that the
name may be added to the tablet.
Ross V. Patterson, Dean.
PITTSBURGH ACADEMY OF
MEDICINE
Abstracts of Papers Read Before the
Academy
THE CLINICAL SIGNIFICANCE OF
NYSTAGMUS
DR. E. A. WEISSER'
Clinically speaking, nystagmus is any abnor-
mal movement of the eyeball. As there are sev-
eral forms of nystagmus, such as pseudonyst^-
mus in ataxia, searching nystagmus of the blind,
or in cases where central vision has been de-
stroyed and several other varieties of more or
less value, such as reflex nystagmus, it will be
necessary to describe just what a true nystagmus
movement is. We describe it as a short, rythmic,
involuntary, more or less jerky tremor. It is
usually biocular, ranging from i to 4 movements
per second and from i to 5 m.m. in width. Ac-
cording to the direction of the motion we speak
of a horizontal, vertical, lateral or rotary nys-
tagmus. Occasionally we see a mixture of the
lateral and rotatory movements.
The early cases usually exist from infancy and
depend upon the diminution of vision — in other
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PITTSBURGH ACADEMY OF MEDICINE
253
words amblyopia as the result of opacities of the
cornea or the media, and diseases of the fundi.
The principal cause of nystagmus from scar-
ring of cornea is ophthalmia-neonatorium, where
opacity of the lens is present from congenital
cataract. The principal diseases of the fundi
causing nystagmus are retinitis, pigmentosa, cen-
tral choroditis and coloboma of the optic nerve
or choroid.
The nystagmus of adolescence and adult life
we group into three subdivisions, nystagmus
from diseases of nervous system, occupational
nystagmus and otitic nystagmus.
1st. Nystagmus of the Nervous System. — In
this class, multiple sclerosis is the principal cause
according to various writers. Nystagmus is
present in 12 to 50% of cases according to
these authors. In my experience in seeing cases
and reviewing case histories at the hospital I
found it present in 25% of cases. In all these
cases of multiple sclerosis the pupils were more
or less sluggish in reaction. The fundi were
normal or nearly so. Where fields were taken
they were irregularly contracted. Wassermans
were negative.
2d. Occupational Nystagmus. — Under occu-
pational nystagmus I have notes on two cases.
One of short standing and one of long standing.
The one of long standing has quite an error of
refraction making the etiology of the nystagmus
a trifle difficult. Both these cases were pickers
in a coal mine, whose eyes were strained working
in an unusual position of their eyes. The prog-
nosis of miners nystagmus is favorable provided
they change their occupation. An occasional
case of occupational nystagmus has been re-
ported in bookkepeers and compositors.
3d. Otitic Nystagmus. — The nystagmus of
otitic origin has been described in certain dis-
eases of the middle and inner ear, but must be
differentiated from brain abscess and sinus
thrombosis following suppurtation of the mid-
dle ear.
CHRONIC CYSTIC MASTITIS AND
TREATMENT
DR. OTTO C. GAUB
Chronic cystic mastitis is a precarious lesion of
the breast, and it is extremely difficult to deter-
mine whether a given case requires an operation
or not. In the final analysis a surgeon must rely
upon the microscopic examination of a section of
the tissue to answer the above question. If a pa-
tient has pain extending down the arm, pain in
the breast and a discharge from the nipple, it is
probably a simple mastitis not requiring an
operation. On the other hand, if the breast tis-
sue is nodular, the overlying skin attached and
somewhat puckered, there is possibly or even
probably a cancerous change taking place, and
the patient should be treated by operation. Many
names have been used to describe the various
•lesions of the breast, but all the terms used in
describing the various stages are of the same
pathological process.
Four out of twenty cases studied sometime
ago by Gaub and Dearth showed cancerous
changes. Murphy of Chicago thought that all
true cancers of the breast died in eighteen to
twenty-four, months. This is probably too
gloomy a view to take and is not true if patients
with the breast lesion are seen sufficiently early
to receive the appropriate surgical operation in
the precancerous period.
Etiology. — All cases of chronic cystic mastitis
are the result of an irritation occurring in most
instances near the menopause, and have been
thought by some to be due to absorption from
the gastrointestinal tract. There appears at first
a small lump in the breast, the true nature of
which is impossible to determine by examination
alone.
Treatment. — Having made an examination of
such a breast, a pressure bandage should be put
on and the breast watched for a period of four
to eight weeks. During this time the bowels
should be kept open, the patient advised to drink
an abundance of water, and a thorough examina-
tion of the pelvic organs made to ascertain if
there may possibly be a cancerous lesion there.
If there is no improvement at the end of the
stated period of observation, the breast should
be dissected from below upward, a section of
tissue removed and examined at once by frozen
section by a pathologist. If the cancer exists the
usual radical breast amputation should be done.
If the acini are filled with cells but there is no
breaking through of the basement membrane,
and no suspected cancerous arrangement at the
time, an amputation of the breast without the
muscles should be performed. If on the other
hand the acini and ducts are nearly normal with-
out being filled with cells, the incision made may
be closed without any amputation being per-
formed.
POSTOPERATIVE PAROTITIS
DR. W. B. McKENNA
During the past year I have had two cases de-
velop parotitis after operation. The first case
was operated upon for carcinoma of the stom-
ach. A posterior gastroenterostomy was done.
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THE PENNSYLVANIA MEDICAL JOURNAL
January, 1921
It was my intention to do a partial gastrectomy
at a later date, within two weeks, if possible, but
unfortunately the patient developed a bilateral
parotitis two days atfer operation and died on the
second day following the onset of the parotitis,
four days after operation. The onset of the paro-
titis was very acute, both glands involved from
the start. Marked constitutional symptoms were
present. Temperature went to 105 and pulse to
150. Patient became very delirious. The urine
was normal at all times. Death occurred before
any evidence of suppuration occurred in either
gland. A partial autopsy was performed, only
the abdomen being opened. The anastomosis
was intact and no evidence of infection could
be found within the abdomen.
The second case developed on the third day
following an operation for removal of a large
stone from the pelvis of the right kidney. In
this case the parotitis was confined to the left
parotid gland. Pain w£is complained of in the
region of the left ear; the swelling developed
within two hours after the onset of pain and ex-
tended from the gland up beyond the middle of
the forehead closing the left eye, and down over
the left side of the left shoulder and upper left
chest. This patient had marked symptoms for
three days but on the fourth day the swelling
was less, the general condition better. From
then on convalescence was normal and recovery
complete without any evidence of suppuration in
the gland. Parotitis, following operations, was
first regarded as a primary inflammation, or
"mumps." It was, however, very soon discov-
ered that the former was secondary, prone to
lead to suppuration, while "mumps" was a pri-
mary disease, and as a rule never formed pus.
Consequently, secondary parotitis must have a
separate pathology of its own, and as a result
five different theories were advanced by various
writers on the subject to explain its origin. ( i )
Pyemic or embolic theory. (2) Heat degenera-
tion theory. (3) Toxic excretion theory. (4)
Sympathetic theory. (5) Duct infection theory.
While all of the theories are based more or less
on theoretic ground, I feel certain that, after
presenting the foundations upon which they rest,
it will be very plain that the last named theory
of duct infection has a more scientific basis for
its explanation, and is the only one that offers
any reasonable hope for a rational prevention
and treatment of this complication.
Duct Infection Theory. — In 1889 Hanau and
Pilliet were the first to suggest secondary paro-
titis to be due to direct infection of Stenson's
duct with microorganisms from the mouth. They
found, on microscopic examination of sections of
parotids secondarily infected, that the ducts were
choked with debris containing microorganisms;
that inflammatory processes invariably began
around the duct in the center of each lobule and
spread later to its periphery and perilobular con-
nective tissue where the blood vessels are situ-
ated. These findings made them conclude that
secondary parotitis could not be of embolic
origin, or else the inflammation would begin
around the vessels; furthermore, the fact that
the inflammation began simultaneously in the
center of many lobules at once, pointed to an
ascending infection. This conclusion was fur-
ther borne out by the bacteriological studies of
Girode, who found, on taking cultures from the
gland, the orifices of Stenson's ducts and the oral
cavity, that the organisms from each growth
were invariably identical, and that the bacteria
giving rise to secondary parotitis were not the
same as that of the primary diseeise. In embolic
parotitis, due to pyemia, the germs in the parotid
are identical with those of the primary disease,
and abscesses in other parts of the body usually
precede the parotid infection.
Claise and Duplay have shown, from clinical
experiments and observations on animals, that
secondary infection of the parotid can only occur
in the presence of certain abnormal predisposing
conditions ; ( i ) microorganisms introduced must
be excessive in number and be very vindent;
(2) general vitality of animal must be depressed
by starvation or other methods; (3) the normal
secretion of parotid altered in quantity and in
quality.
The following conclusions can be made re-
garding postoperative or secondary parotitis:
1. That it is highly probable that secondary
parotitis is due to an ascending infection of Sten-
son's duct.
2. Secondary parotitis may complicate cases
of gastric ulcer treated medically by oral starva-
tion.
3. That it occurs ten and a half times more
frequently in such cases of gastric ulcer than in
cases allowed fluid by the mouth.
4. That it is an outcome of the dry condition
of the mouth and that mouth washes do not pre-
vent its recurrence.
5. That it is more often unilateral than bi-
lateral.
6. That suppuration occurs in about one-
fourth of the cases and that this constitutes a
grave complication.
7. That the onset of this complication may be
prevented by attending to the following details:
(a) mouth carefully cleansed before and after
operation; (b) everything used for the anes-
thetic should be sterile; (c) the anesthetizer
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PITTSBURGH ACADEMY OF MEDICINE
255
should avoid pressure on the gland while at-
tempting to elevate the jaws during anesthesia.
8. Postoperative parotitis is more apt to occur
after abdominal operations than operations on
any part of the body.
9. In patients whose abdominal condition
makes it necessary to withhold food and drink
from the mouth and stomach for a time, prophy-
lactic treatment should be instituted.
10. The mouth should be kept clean and moist
by its own secretions and the body should be
abundantly supplied with water.
11. A good way to excite the secretions of the
mouth and to keep a current of saliva flowing
down Stenson's duct is to allow the patient to
suck on a stick of lemon candy after operation
or chew chewing gum.
12. If thfe prophylactic treatment fails and
parotitis develops and the inflammation is in-
creasing, or is no better by the third or fourth
day, the gland should be uncovered by a free
incision and punctured in several places with
blunt forceps and the incision packed with wet
sterile gauze.
THE BLOOD PICTURE IN SEVERAL
TYPES OF ANEMIA BEFORE AND
AFTER SPLENECTOMY
DR. C. C. HARTMAN
Having been able to study a number of pa-
tients with splenomegaly and anaemia whose
blood was followed somewhat closely and in
whom removal of the spleen was done, I thought
it worth while to report some of the observations
made on several patients exhibiting different
types of anaemia who were observed before and
after splenectomy, one for more than two years.
The first patient was a white schoolgirl, 11
years of age, complaining of jaundice and en-
larged spleen. The family history was unim-
portant. Her past history showed the usual dis-
eases of childhood, and an acute febrile condition
in 1907 with early and complete recovery (diag-
nosed meningitis by her physician). The pres-
ent illness dated probably from birth. She was
always of waxen color and the yellowish appear-
ance gradually increased to a certain stage where
it remained almost constant. She was generally
weak and did not care for play. The enlarge-
ment of the spleen was first noticed by a physi-
cian about 1907 and had varied somewhat in size
since. About 1907 or 8, Dr. Park of Buffalo
x-rayed the spleen every day for two weeks.
Physical examination on November 26, 191 3,
showed a small frail girl, 63 pounds in weight,
with lemon yellow color of skin and conjunctiva.
pale mucous membrane, large ragged tonsils, a
few enlarged cervical and submaxillary glands,
normal thyroid, clear lungs, a somewhat en-
larged, overacting heart with a slight blowing
systolic murmur at apex, transmitted to the left.
Pulse 112. Distended abdomen, with the liver
one-half inch below the costal border. Spleen
enlarged and extending to within one-half inch
of the midline and to the umbilicus. R. B. C.
3,776,000; W. B. C. 10,000; Hb. 68%. Stools
negative. Urine normal. On December 6, 191 3,
R. B. C. 3,560,000; W. B. C. 11,200; Hb. 48%
(N. S.). Differential showed P. M. N. 78%,
Lymphs. 17%, L. Monos. 15%, Eosinophiles
4%. The R. B. C. showed definite variation in'
size, shape and hemoglobin content. No poly-
chromatophilia. No stippling. No Howell-JoUy
bodies. One nucleated R. B. C. was seen. Blood
platelets relatively scarce. Fragility tests of the
R. B. C. December 13 and 16, 1913, showed
beginning hemolysis at 0.650 and complete
hemolysis at 0.375. On February 16, 1914,
the urine showed many W. B. C, few R. B. C,
faint trace of urobilin and urobilinogen, bile
negative. On June. 2, 1914, splenectomy done
by Dr. F. F. Simpson. Convalescence was un-
eventful until June 12. Her jaundice had com-
pletely disappeared by June 6th. About June
I2th, the patient developed a pneumonia from
which she recovered. On July 21, she began to
bleed from the incision. About July 22, she de-
veloped severe hemorrhage. On July 24th, was
opened up and bleeding point Hgated, but patient
died a few hours after. Spleen weight 695
grams. A smear of splenic blood showed the
same characters of the R. B. C. as the R. B. C.
of the peripheral blood, but the P. M. N. and
lymphocyte percentages were practically re-
versed.
In comparing the blood of this patient before
and after splenectomy, there was very marked
change. The number of the R. B. C. and the
amount of hemoglobin returned to normal.
There was some improvement in the character-
istics of the R. B. C. though they did not return
to normal. Nucleation and polychromatophilia
disappeared. The fragility of the R. B. C. was
less (0.650 to 0.550). The blood platelets in-
creased greatly in number. Some Howell- Jolly
bodies were noted after operation. In the W. B.
C, the striking change was the great increase in
large, uneven cells having irregular, rather ve-
sicular nuclei, abundant, pale-blue staining cyto-
plasm (some with a pinkish tinge) and having
the appearance of containing numerous fine,
neutrophilic grandules and one or more vacuoles.
(Endothelial cells, large monon.). Subsequent
examination of the blood smears revealed the
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THE PENNSYLVANIA MEDICAL JOURNAL
January, 1921
presence of normoblasts with multilobulated
nuclei, which, being one of the signs of abnormal
regeneration, removes the condition from the
single secondary ansemies and places it in the
toxic or myelopathic ansemies.
Diagnosis : Congenital hemolytic jaundice.
The second patient was a white adult married
woman, 53 years of age. She complained of ex-
haustion. Her family history was unimportant.
Past history unimportant except for scarlet fever
at i6. Her present illness dated from the spring
of 1914, which began as a tired feeling and weak-
ness. After an attack of "ptomaine" poisoning
in October, 1914 (from oysters), she noticed a
tingling sensation in the fingers and had attacks
of vomiting ; there was no loss of weight ; a
change of complexion was noticed by her friends.
The physical examination showed a sub-icteroid
tint to the skin, pale mucous membrane, and poor
nutrition. Spleen just palpable at the costal bor-
der. Urine showed a few hyaline and granular
casts. On January 14, 1915, the R. B. C. were
1,376,000; W. B. C. 5,200; Hb. 55^0. The R.
B. C. showed very great variation in size, shape
and hemoglocin content. Macrocytes and poiki-
locytes were numerous. Differential : P. M. N.
72.6%, Lymphs. 21.0%, L. Mono. 4.6%, Eosino-
philes 0.6%, Mastz. o. Wasserman, positive.
Fragility test of R. B. C. on Sept. 21, 1915,
showed beginning hemolysis at 0.400 and com-
plete at 0.325%. Salvarsan was given February
18, 1915, and six doses given. On account of
the presence of a positive Wasserman, it was
thought the blood picture might be due to a
sjrphilitic condition and that the administration
of salvarsan might remove it. Splenectomy was
finally decided upon and was carried out by Dr.
Gaub, January 26, 1916. The spleen weighed
140 gms.
Convalescence was uneventful until March 2d,
when an acute diffuse bronchitis began with per-
haps an area of pneumonia in the right lower
lobe. She recovered incompletely. After going
home, the patient became gradually weaker, lost
the use of her lower extremities, developed in-
continence of urine and feces, and a large bed
sore (Decubitus ulcer) and finally died about
May, 1916.
In comparing the blood before and after
splenectomy several things must be considered.
She had a positive Wasserman. The striking
rise in the cell count and hemoglobin estimation
under or coincident with the administration of
salvarsan is interesting. We were at first elated
and concluded we had to deal with an anemia of
pernicious characteristics but of syphilitic origin.
It soon became evident, however, that we had as-
sumed too much. Despite treatment, the count
and hemoglobin began to fall and, since the char-
acterhtics of the R. B. C. never were much al-
tered, it is probable that we were fooled by a re-
mission in the course of a pernicious anemia.
The R. B. C. before operation showed very great
variation in size, shape, hemoglobin content,
multilobulated nuclei, polychromatophilia, hyper-
chromia, etc. The blood platelets were in fair
number during remission, but fell during the re-
lapse. The fragility of the R. B. C. showed be-
ginning hemolysis at 0.400 and complete at 0.325.
The nucleated R. B. C. were never nimierous
before splenectomy but many appeared after-
ward and a great increase in Howell- Jolly bodies
occurred. Reticulated R. B. C. were fairly nu-
merous before operation, but few after. There
was no increase in blood platelets. There was
comparatively little fluctuation in the W. B. C.
There was not the increase in L. Monon. noted
in the other bloods, although many of the cells
classified as lymphocytes were rather on the
borderline.
A smear of the splenic blood showed prac-
tically the same characteristics of the R. B. C.
as the periphereal blood but the differential
showed about the reverse percentage of P. M. N.
and lymphs (15-78%). Diagnosis: pernicious
anxmia.
The third patient was a white male, Italian,
aged 26 years. Admitted to the hospital October
15, 191 5, complaining of pain in region of the
spleen. His family history was unimportant.
Past history showed he was never healthy as a
child ; was yellow at times. The present illness
began at least in early childhood. The yellow
color of the skin had been noticed since 5 years
of age. It usually deepened in the summer and
cleared in the winter. There had been no as-
sociated symptoms with the jaundice, no symp-
toms of purpura or hemophilia. He was re-
fused for the Italian army in 1908 on account of
''malarial anaemia." The physical examination
showed jaundice of the skin and sclera, spleno-
megaly— the edge reaching to the umbilicus.
R. B. C. 4,000,000 ; W. B. C. 7,600 ; Hb. 45fe.
Fresh blood showed very marked variation in
size, shape and color of the R. B. C. Though
many of the cells were quite large, they were
generally pale. Cresyl blue — reticulated cells
very numerous, blood platelets few. Differen-
tial— P. M. N. 64%, lymphs 22.6%, L. Mono.
5.6%, eosino. 1.0%, mastz. 0.8%. The above
characters of the R. B. C. were verified and ad-
ditionally showed very marked polychromato-
philia, a few strippled cells and ten nucleated
R. B. C. Wasserman negative. Fragility test
showed beginning hemolysis at 0.350, complete
at 0.250. The serum showed no hemolytic power
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ABSTRACTS FROM STATE JOURNALS
257
against normal R. B. C. nor normal serum
against his R. B. C. The stool examination
showed some ova of trichocephalus trichiurae.
Splenectomy was advised and carried out by Dr.
Gaub on December 6, 1915. Spleen weight,
547 grams. The jaudice promptly disappeared.
Some enlargement of the lymph glands was
noted. One from the inguinal region being ex-
cised and cultured. No growth appeared. Fra-
gility test December 15, 1915, showed banning
hemolysis at 0.300 and complete hemolysis at
0.200. Diagnosis: Chroic hemolytic jaundice
(?). The blood picture in this patient was a
most interesting one to follow. It was that prin-
cipally of a secondary ansemia. No signs of ab-
normal regeneration were noted, which argued
against a toxic or myelopathic ansemia. The
fragility of the R. B. C. was not increased.
There was some nucleated R. B. C. present.
Blood platelets were below normal. Reticulated
R. B. C. were few to fairly numerous. No ab-
normality was noted in the W. B. C. The R. B.
C. showed very marked variation in size, shape
and hemoglobin content, polychromatophilia and
a few stippled cells. After operation the R. B.
C. count ascended to practically 7,000,000 per
cm. Hb. from 55% to 70%. The characteris-
tics of the R. B. C. changed little immediately,
although there was a tendency to become much
more abnormal as time went on. There was a
great rise in the number of nucleated R. B. C.
which showed wide variations. Reticulated cells
were comparatively few immediately after opera-
tion, but increased until most of the R. B. C.
were reticulated. The nucleated cells were small
and large, regular arid irregular, orthochromatic
and polychromatic, stippled and unstippled, con-
taining single and multilobulated nuclei. Howell-
Jolly bodies were for a time extremely numer-
ous. Fragility was not apparently influenced. A
most striking change was the great increase in
blood platelets. They became so numerous as
to make the drawing of smears difHcult, and giv-
ing to the smears a frosted appearance. There
was great increase in the number of W. B. C.
The partition showing the greatest change to be
in the P. M. N. and the L. Mono, these cells be-
ing the same as described under the first patient.
Frederick B. Utley, M.D., Secretary.
ABSTRACTS FROM STATE MEDICAL
JOURNALS
Moke Misbranded Nostrums. — The following prod-
ucts have been the subject of prosecution by the fed-
eral authorities: Dr. Clifton's Brazilian Herbs (Clif-
ton Drug Co.), sold under therapeutic claims which
were false and fraudulent. Her-Vo (Her-Vo Mfg.
Co.), sold with therai>eutic claims which were false
and fraudulent. Acetylo-Salicylic Acid Tablets
(James and Annis), containing acetanilid but no
acetylsalicylic acid. — {Jour. A. M. A., Nov. 13, 1920, p.
I3S9)
FRANK P. D. RECKORD. M.D.
Assistant Editor
A METHOD FOR PREVENTION OF COLIC IN
THE NURSING INFANT
By E. H. Current, M.D.
Spokane, Washing^ton
During the past five years the author has worked
out and followed a method which, after constant ap-
plication in cases of colic of varied severity, has
proved very successful in preventing the colicky at-
tacks. Knowing that colic is caused by decomposition
of food in the bowel, it was conceived that, by ad-
ministering a food vehicle which would be antagon-
istic to decomposing intestinal medium and which
would render an intestinal digestive flora less liable to
decomposing changes, this trouble could be prevented
in the greater number of instances. The method con-
sists in the giving of from one-half to one ounce of
from 3 per cent, to 4.5 per cent, of a warm cereal
gruel immediately before each nursing except the night
nursing, and before each and every nursing if neces-
sary. The results obtained have been excellent. This
technic has been used in all cases of colic, and reqtiires
no alterations except the amount of the starch mixture
required for a certain infant, and the strength of the
starch mixture according to the digestive ability and
tolerance of a certain infant for a starch food. Very
few infants of whatever age have any perceptible diffi-
culty in digesting a 3 per cent, starch mixture. The
reports of Sauer and of Porter on the starch feeding
of infants are sufficiently convincing. There is no
doubt that starch' as a food is better borne and better
tolerated by the infant than we have been not long
since led to believe. By administering cereal gruel in
cases of colic, the decomposing culture-field is removed
and a less favorable culture medium is established
for the development of the intestinal bacteria.
That the diastatic and amyloytic ferments are pres-
ent in the digestive tract of the greater percentage of
infants of all ages has been proved by Moro, Hess and
others. Starch is, no doubt, well tolerated during in-
fancy and there are no by-products formed to produce
an intestinal toxemia. Oatmeal gruel, wheat gruel and
barley gruel comprise the different cereal gruels used.
Oatmeal gruel is indicated where there is inactivity
of the bowel, as it favors the formation of the volatile
fatty acids and for this reason gives a decidedly laxa-
tive action. Wheat gruel has very little effect upon
peristalsis. Barley gruel has a qtiieting effect upon the
paristaltic action and is indicated in instances where the
bowel is overactive. — From Northwest Medicine for
October, 1920.
THE TREATMENT OF UTERINE FIBROID AND
UTERINE HEMORRHAGE BY MEANS
OF RADIUM AND X-RAYS
By George E. Pfahler, M.D.
Philadelphia, Pennsylvania
Types op Hemorrhagic Cases to be Treated by Ra-
dium.— I cannot do better than refer to the classifica-
tion given by C. Jeff Miller (Radium in the Treatment
of Certain Types of Uterine Hemorrhage and Uterine
Fibroids. Surgery, Gyn. and Obs., May, 1918, p. 495) :
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258
THE PENNSYLVANIA MEDICAL JOURNAL
January, 1921
"Group I. Myopathia Hemorrhagica (hemorrhage
of the menopause)." These are especially responsive
to radiation when not due to malignancy, and even
wjien due to cardnoma of the cervix the results ap-
pear to be better than those obtained from surgery,
according to the observations of Janeway, Adler,
Bailey, Kelly, Burnham and others, when properly and
thoroughly applied.
"Group II. Chronic metritis, polypoid edometritis,
hyperplasia, fibrosis, etc." All of these cases may be
expected to recover promptly.
"Group. III. Myomata. For small or medium sized
growths and those presenting contra-indications to
operations, radium is the ideal remedial agent." In all
this group of cases either radium or roentgen radia-
tion will produce good results and the combined ra-
diation may be expected to produce more prompt re-
sults than either agent alone.
"Group IV. Uterine Bleeding in Young Girls." Ra-
diation may be expected to control hemorrhage in this
class, but great care should be exercised in diagnosis
and also in the application of the radium or roentgen
rays. It is better to use small doses and repeat, if nec-
essary, imtil the desired result is produced. Some of
these cases are especially sensitive to radiation and a
permanent amenorrhea may be produced unexpectedly.
Therefore, if small doses are used and care exercised,
good results can be produced.
Advantages of Radiation. — i. The treatment is
painless when the roentgen rays alone are used, and
when radium is used it is only painful in so far as
dilatation of the uterus is painful.
2. There is no mortality. While operative mortality
is low, it still exists.
3. It preserves, to a certain extent, we believe, the
internal secretions, which are lost in a complete
oophorectomy.
4. It does not interrupt the usual habits where the
roentgen rays are used alone, and only interrupts for
a few days when radium is used.
5. Prolonged confinement in the hospital is avoided.
6. In skilled hands it is without risk.
7. The menopause is brought on gradually when de-
sirable.
8. The amount of treatment can be graded to the
needs of the patient.
9. In certain cases treated by the roentgen rays in
which the fibroids involve the body of the uterus the
ovaries can be protected whereby sterility is avoided
and the patient remains capable of bearing children. —
From New York State Journal of Medicine for Octo-
ber, 1920.
INTESTINAL STASIS AND CONSTIPATION:
ITS CAUSES AND TREATMENT FROM
A NONSURGICAL STANDPOINT
Bv Katherine B. Luzader, M.D.
Greenville, Illinois
The first thought in every instance is to find out *id
correct the dietetic errors as nearly as possible. Out-
line the foods to be taken, also kind of exercise, hours
of rest, etc.
Have the patient bring the outline along each time
for any changes necessary.
Give specific directions about the food combinations,
what to avoid, especially acid fruits and sweet milk
combinations.
If constipation is in evidence, direct patient to take a
glass of buttermilk on retiring and a glass of water on
rising, and two drams agar-agar, with breakfast food \
instruct patient to use water plentifully between meals.
Occasionally she will get good results with some form
of mineral oil taken three times a day.
If the case is obstinate, electricity may render valu-
able service in several ways. Here I find the sinusoidal
current gives excellent service. Stimulation of the in-
testinal nerves is the object sought for. My method is
to fix one electrode over the sacrum and the other over
the spines of the first three lumbar vertebra. The
strong rapid sinusoidal current for fifteen minutes
daily usually brings good results within ten days, from
then on the treatments are continued less frequently.
While the patient is lying on the table face downward,
I frequently give an additional stimulus to the intes-
tinal nerves by means of concussion over the dumping
centre which extends from the eleventh dorsal to the
fourth lumbar vertebrae.
Another excellent plan is to put a rectal electrode
in the rectum a wet pad over the lumbar region.
This treatment has served me very well in many most
di£Bcult cases of constipation. The 2,000 candle power
lamp serves to relax these patients if the heat is di-
rected immediately over the spine during these treat-
ments.
For a prolasped colon, and catarrh of the sigmoid,
I direct treatment immediately to these parts by means
of a sigmoidoscope. The mucous lining is treated
with iodine solution. Krameria is also a valuable
remedy, as it acts as an astringent. For home treat-
ment I direct the patient to put one dram iodine tinc-
ture in three pints warm water, this is used as an
enema every other day. This treatment has also
proved invaluable where there is an ulcerated condi-
tion of the rectum and sigmoid.
Her attention was first directed about two years ago
to this line of treatment of stasis. One remarkable
feature was that many cases of hemorrhoids cleared
up promptly after using this method. Another con-
sideration for both patients and doctor is that many
operations for removal of pelvic organs can thus be
prevented, and the doctor enjoys the everlasting grati-
tude and confidence of the patient cured. — From the
Illinois Medical-Journal for October, 1920.
AN ANALYSIS OF THE END RESULTS OF
TREATED CHRONIC SEPTIC MYOSITIS,
NEURITIS AND ARTHRITIS CASES
Bv Noble Wiley Jones, M.D.
Portland, Oregon
It may be noted, in the table of cultured myositis
and neuritis cases, that in all the animals only non-
hemolytic streptococci were obtained from the lesions.
No deductions were made from this, because of the
small number of cases studied and because in the
arthritis cases we were able to find no relationship be-
tween the type of lesion in the human or in the ani-
mals and the strain of streptococci found. One might
assume from Pemberton's recent report of his work
with arthritis in the army that a streptococcus hemo-
lyticus was looked upon as possibly specific in the 21
of his 34 cases studied serologically, or else other
strains of streptococci happened to be absent. In the
44 cases of this series studied serologically, 33 gave
for the most part pure cultures of nonhemolytic
streptococci, 12 a hemolytic streptococcus, 5 a non-
hemolytic streptococcus viridans and 2 a hemolytic
streptococcus viridains. In the arthritis group of 38
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ABSTRACTS FROM STATE JOURNALS
259
cases apparently the same type of lesions were found,
both in the human and in the animals, from these dif-
ferent strains. A marked elective action on the part
of the organisms is to be noted in this series. Seventy-
one per cent, positive muscle and joint lesions were
foimd in the arthritis group, and lOO per cent, positive
muscle and tendon sheath lesions in the myositis-
neuritis group. Strangely we found no nerve lesions in
the animals, as has been repeatedly found by Rosenow,
although diligent search was made for them. With
this one exception, our work has been strongly cor-
roborative of Rosenow's work.
In the treatment of all the cases the principles have
been divided into, first, the radical removal of all foci
of infection, and, second, the subsidiary measures.
The subsidiary measures of treatment which we
have employed in our cases to a more or less degree
are: (i) Mechanical and hydrotherapeutic, (2) auto-
genous vaccines, (3) stock vaccines, (4) foreign pro-
teins, (s) radium, (6) dietetic, and (7) climatic.
In conclusion, the question is asked as to whether
this detailed, time-consuming, and often expensive
work is worth while from the patient's standpoint. In
the myositis-neuritis group there can be no debate, as
the smaller cultured series gave much relief in 100 per
cent, and the larger noncultured series in 78 per cent.
Many factors enter into the same question as regards
the arthritic group. Many arthritic patients receive
temporary relief with no treatment, many arc hope-
lessly incurable in the face of the most painstaking
treatment, and seemingly there is no chance to study
such patients in control series. In view, however, of
the experimental evidence in favor of a specific
ettologic relationship between some strains of strep-
tococci and the joint lesions of chronic septic rheuma-
tism and because we were able seemingly to obtain by
these methods of treatment reasonably good results
in 48 per cent, of the cultured series and 64 per cent,
in the noncultured series, we personally have learned
to believe in these principles. The author believes
firmly in the radical removal of all suspicious surgical
foci, and he entertains no regrets in these cases when
a suspicious focus is found to be innocent after its
removal. — From Northwest Medicine for November,
1920.
HEADACHES: WITH SPECIAL REFERENCE
TO THOSE OF NASAL ORIGIN
By Robert Sonnenschein, M.D.
Chicago
Headaches arising from nasal conditions are divided
into two great classes: the suppurative and the non-
suppurative.
The suppurative form constitutes probably by far
the majority of the cases, and consists of the acute
and chronic accessory sinusitis. Only the most funda-
mental facts can be here enumerated as the subject
of infection of the nasal sinuses is very extensive. In
making a diagnosis of sinuses, transillumination of
the maxillary and frontal sinuses is often of consid-
erable aid, but has little value with reference to the
other accessory cavities. Better than this measure is
the use of the x-ray picture, but most important is the
history of the case, and the finding of pus on exami-
nation with or without the use of suction after shrink-
ing the mucosa. Pus issuing from the middle meatus
comes from one or more cells of the anterior group of
sinuses, namely, the frontal, anterior ethmoidal cells
or maxillary sinus ; pus in the superior meatus or in
the spheTioethmoidal recess, arises from one or other
of the posterior set of sinuses, posterior ethmoidal
cells or the sphenoid cells.
As Hajek has said : "The most definite thing about
the pains in sinusitis is the uncertain localization
thereof." There is no characteristic localization of
the pain or tenderness in involvement of any particular
sinus but generally speaking it is fairly true that with
maxillary antrum disease the pain is mainly in the
upper teeth, the cheek and floor of the orbit; with
frontal sinusitis usually in the forehead ; with anterior
ethmoiditis between the eyes and in the temporal and
parietal regions; and with posterior ethmoiditis or
sphenoiditis in the occipital regions. But all manner
of variations from this statement may occur, such as
occipital pains with frontal sinusitis, vice versa, eta
The sinus pain occurs with considerable periodicity at
certain times of the day, and then may after some
hours entirely disappear, to recur again the next day,
or after several days, weeks or even months. Particu-
larly with frontal sinusitis (and sometimes also with
maxillary antrum and other involvements), do we find
that a patient awakes feeling well, later in the morning
notices pain which increases in severity toward noon
or early afternoon, then again subsides, so that by
evening there is complete freedom from pain. The in-
dividual sleeps well and awakes, as above mentioned,
feeling fine, only to repeat the cycle. The cause for
this peculiar periodicity has never been explained.
It is important to remember that a slight leukocytosis
and a moderate rise in temperature often accompany
the acute or chronic sinusitis. There is usually tender-
ness on pressure or percussion, but this is not defi-
nitely localized in all cases for the particular sinus in-
volved.
The nonsuppurative nasal conditions producing
headaches comprise two groups, the first of which is
the so-called hyperplastic form, especially the ethmoid-
itis and sphenoiditis. Here there is a thickening of
the mucosal lining of the sinuses involved, or even a
polypoidal degeneration thereof. The headaches are
those described under the suppurative form, but there
is, of course, absence of pus, leukocytosis or fever. —
From Illinois Medical Journal for October, 1920.
THE ROENTGEN DIAGNOSIS AND LOCALI-
ZATION OF PEPTIC ULCER
By R. D. Carman, M.D.
Section on Roentgenology, Mayo Clinic
Rochester, Minn.
The statistics compiled by the Mayo Clinic show
that 95 per cent, of the chronic peptic ulcers are demon-
strable by the roentgen ray. It is the trend of opinion
that many ulcers are probably potential cancers ; hence
the advantage of an exact diagnosis of gastric ulcer
afforded by the roentgen ray'is apparent.
Four types of gastric ulcers may be distinguished at
operation :
1. Small mucous erosions and minute, slit-like ulcers.
2. Penetrating, or perforating ulcers with relatively
deep craters.
3. Perforated ulcers, with or without the produc-
tion of accessory pockets.
4. Carcinomatous ulcers.
The first type of ulcer, the small mucous erosion,
offers the greatest difficulty to roentgenologic detec-
tion. It is either a superficial denudation, or a mere
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THE PENNSYLVANIA MEDICAL JOURNAL
January. . ^
slit in the mucosa incapable of holding enough barium
to make a visible projection from the gastric lumen.
The penetrating or perforating ulcer which has bur-
rowed more or less deeply into the gastric wall, but
does not penetrate the peritoneal coat of the stomach,
produces a definite crater jutting from the lumen of
the stomach. The degree of facility with which this
crater can be seen by the roentgen ray depends more
on the location than on the size of the crater.
The perforated ulcer which has excavated through
the peritoneal coat of the stomach may, at the time
of perforation, become covered by gastrophepatic
omentum, or, if the perforation is chronic, it may be
protected by adhesions. In either case the roentgeno-
logic signs are the same as in the penetrating or per-
forating ulcer before perforation takes place. The
only condition indicating perforation, therefore, is the
depth of the crater. Perforation of an ulcer with a
continuation of the destructive process into adjacent
tissue results in the formation of an accessory pocket
outside the stomach.
Carcinomatous ulcers are not as a rule, distinguish-
able from nonmalignant ulcers; their roentgenologic
signs are very much the same as those of penetrating
and perforated ulcer.
The roentgen ray signs of gastric ulcer may be di-
vided into three groups :
1. Direct signs (pathognomonic).
a. The niche.
b. The accessory pocket.
2. Indirect signs (but diagnostic).
a. Organic hour-glass stomach.
b. Spastic manifestations.
1. Spasmodic hour-glass stomach.
2. Gastrospasm.
3. Corroborative signs (not diagnostic).
a. Retention from the six-hour meal.
b. Gastric hypotonus.
c. Alterations of peristalsis.
The niche is a bud-like projection from the barium-
filled stomach wholly within the gastric wall, and is an
index either of a penetrating or of 0 perforated ulcer
which has not excavated an adjacent organ. The ac-
cessory pocket, sometimes loosely spoken of as a
"diverticulum," is a pouchlike excavation resulting
from extension of a perforated ulcer into nearby tis-
sues, usually the pancreas or liver, less often the lesser
omentum, abdominal wall, or spleen. An accessory
pocket ranges in diameter from i to 5 or 6 cm. and
may appear like a miniature stomach with successive
layers of gas, fluid, and barium ; it may retain barium
after the stomach is empty. An accessory pocket in
the liver moves with respiration, while a pocket in the
pancreas does not. The latter also has a more pos-
terior situation, as shown by the oblique view, and a
wider excursion when the patient is rotated.
Both the niche and the pocket are obviously signs
of advanced ulcer, but ulcers not sufficiently extensive
to produce an excavation that can be visualized on the
screen or plate are rarely found at operation ; they are
mere mucous erosions or small crevices, and their diag-
nosis can be made only on less definite signs such as
spasmodic hour-glass stomach.
Indirect signs (but diagnostic) :
1. Organic hour-glass stomach.
2. Spastic manifestations.
a. Spasmodic hour-glass stomach.
b. Gastrospasm,
For the differentiation of intrinsic and extrinsic
spastic deformity tincture of belladonna is prescribed,
starting with twenty drops and increasing the doa.. trc-
quently until the physiologic effects, such as dryness
of the throat, and pupillary dilatation occur; the pa-
tient is then reexamined. It is true that belladonna or
atropin will not differentiate spasmodic and organic
forms of hour-glass stomach, but they will differen-
tiate intrinsic and extrinsic spasm. When the hour-
glass contraction is the only roentgen sign this test
must be very carefully carried out, as otherwise the
roentgenologist may lead the surgeon into error. It
has been my experience that an hour-glass that resists
belladonna to the physiologic effect means a lesion
either of the stomach or duodenum; and regardless
of whether or not the hour-glass is present at opera-
tion, the surgeon will find the cause, if he looks for it
Corroboration signs (not diagnostic) :
1. Retention from the six-hour meal.
2. Gastric hypotonus.
3. Alterations of peristalsis.
These signs either singly or in combination have no
diagnostic value since they are seen in other diseases
and at times in normal stomachs.
DUODENAI, ULCER
Pathology. — Fully 95 per cent, of such ulcers are
found in the first 4 or 5 cm. of the duodenum, usually
on the anterior wall. Less than 5 per cent, are more
distantly located and may be found in any part of the
duodenum. A duodenal ulcer, although commonly sin-
gle, may have a companion or contact ulcer on the
opposite wall, or there may be several ulcers variously
grouped and in various stages of development. The
macroscopic appearance of an ulcer depends on its
age and the resulting amount of scar tissue. A recent
ulcer may be so small and shallow that no evidence of
it can be seen on the serosa. External scarring is
visible in a large number of ulcers, but this may occur
without marked contraction or deformity. They vary
in diameter from i mm. to 2 or 3 cm. ; in exceptional
instances they may attain a diameter of 5 cm. The
chronic ulcers with extensive cicatrical contraction
cause organic deformity, and in 25 per cent, stenosis
is evidenced by a six-hour retention. Although
chronic duodenal ulcers may show crater formation
similar to that of gastric ulcer, it is a notable fact that
they are characterized by surface extension rather,
than by depth. Duodenal ulcers may also penetrate to
the serosa or perforate the duodenal wall. The per-
foration may be sealed by the adhesion of adjacent
tissues, or the ulcerative processes may invade the
pancreas, liver, or gall bladder, and produce an ex-
cavation similar to that of perforated gastric ulcer.
An actual diverticulum or pouching of the gut is
rarely seen proximal to a stenosing ulcer.
The roentgenologic indications of duodenal ulcer
may be classified as follows:
1. Direct signs.
a. Deformity of the duodenal bulb.
b. Duodenal diverticulum.
2. Indirect signs (diagnostic).
a. Gastric hyperperistalsis.
b. Gastric retention from the six-hour meal (the
combination of hyperperistalsis with gastric
retention and a normal gastric outline is diag-
nostic of duodenal ulcer with obstruction).
The deformities more or less characteristic of duo-
denal ulcer may be enumerated as follows:
I. General distortion with the entire contour of the
bulb deformed. This distortion is largely due to
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PROPAGANDA FOR REFORM
261
spasm, which is practically always persistent and un-
varying.
2. The niche type in which the excavation of the
ulcer is seen projecting from the bulb. This type is
rare and may or may not be accompanied by organic
or spastic deformity.
3. The incisura type of deformity, either single or
bilateral. The incisura occurs in the plane of the
ulcer, and may be the sole abnormality of contour ob-
served. Usually narrow" but of variable depth, per-
sistent and permanent as to situation, it suggests the
nature of the lesion and indicates its site. No cavity
or organic deformity produced by the ulcer is dem-
onstrable, but the spasm alone is diagnostic.
4. The diminutive bulb. This is represented by a
small, compact mass of barium in the cap. It is usu-
ally produced by an ulcer stenosing the duodenum, so
that only the proximal portion of the bulb is filled.
Unless other signs are present, such as gastric reten-
tion, antral dilatation, and hyperperistalsis, a diminu-
tive cap should not be considered indicative of ulcer.
5. The accessory pocket. This results from a per-
forated ulcer which has invaded tissue outside the
duodenum, forming a cavity outside the bulbar contour.
6. The diverticulum. A diverticulum in the first
part of the duodenum is relatively uncommon. It is
found near the pylorus, and its relationship with duo-
denal ulcer and scars se'ems well established. The few
duodenal diverticula that I have observed have alt been
associated with duodenal ulcer. Both the true and
false type are recognizable roentgenologically and,
when present, constitute an excellent sign of duodenal
ulcer. — From California State Journal of Medicine for
November, 1920.
PROSTATIC INFECTION— TREATMENT
By E. O. Smith, M.D.
Cincinnati, Ohio
Acute and tuberculous infections of the prostate
should not be massaged.
Most prostatic abscesses can be drained through the
urethra.
A fluctuating prostatic abscess that bulges promi-
nently into the rectum is best drained through the
rectum.
A few prostatic abscesses are best drained through
the perineum. — From The West Virginia Medical
Journal for October, 1920.
PROPAGANDA FOR REFORM
A CouNcn. ON Pharmacy and Chemistry for thb
Netherlands. — The minister of labor of the Nether-
lands officially inaugurated, on September i, the gov-
ernment Instituut voor Pharmaco-Therapeutisch
Onderzoek, which seems tp be modeled after the
Council on Pharmacy and Chemistry of, the American
Medical Association. The minister of labor remarked
in his opening address that the Netherlands has had a
permanent pharmacopeia commission since 1899. But
this does not attempt to keep pace with the flood of
new remedies, and the government has finally heeded
the appeals of the Netherlands Medical Association
and the Pharmaceutical Association and has founded
this institute. The Council on Pharmacy and Chem-
istry of the Netherlands is to have the support and
backing of the government ; the Council on Pharmacy
and Chemistry of the American Medical Association
has only the backing of the medical profession. —
{Jour. A. M. A., Nov. 6, 1920, p. 1279.)
Misbranded Venereal Nostoums. — The following
products have been the subject of prosecution by the
federal authorities on the ground that the therapeutic
claims made for them were false and fraudulent;
Musser's Capsules (Musser-Reese Chemical Co.), con-
sisting essentially of copaiba balsam and oil of santal
with indications of oil of cubebs and oil of mace.
Dr. Sanger's Capsules (Edward J.. Moore Sons, Inc.),
consisting essentially of copaiba, cubebs, santal oil,
matico, licorice root and magnesium oxid. Rid-It
Caps (S. Pfeiffer Mfg. Co.), consisting essentially of
salol, oils of juniper and sassafras, turpentine, a fixed
oil and coloring matter. _ Black and White Capsules
(Wilson Drug Co.), consisting of capsules containing
hexamethylenamine and of capsules containing a mix-
ture of volatile oils, including cubebs and copaiba.
Benetol (Benetol Co.), consisting essentially (in
agreement with a previously reported analysis by the
A. M. A. Chemical Laboratory) of alphanaphthol,
soap, glycerin, water and traces of essential oils and
alcohol. G-U-C Capsules ( Hollander-Koshland Co.),
consisting of a sulphurated oil with volatile oils, in-
cluding copaiba, cinnamon and santal oils. Merz
Santal Compound (Merz Capsule Co.), consisting of
balsam copaiba, cassia, sandal wood oil and a sul-
phurated oil. Enoob Antiseptic Injection and Cap-
sules (Tropical Cooperative Co.), the "injection" be-
ing essentially a solution of phenol, menthol, thymol,
boric acid and zinc sulphate in water, and the "cap-
sules" consisting essentially of cubebs, copaiba, gum
turpentine and pepsin with indications of santal oil.
White Swan Injectioiv (Stacy Chemical Co.), essen-
tially a watery solution of boric acid, salts of alumi-
num, zinc and ammonium, glycerin and phenol with
bismuth subgallate in suspension.^ (/owr. A. M. A.,
Nov. 6, 1920, p. 1285.)
Vaccines for Com mon Colds. — There is no scientific
evidence that common colds can be prevented by the
use of vaccines, despite the glowing recommendations
of vaccine makers and the patter of the detail man.
Colds characterized by catarrhal inflammation of the
mucous membranes of the nose and the throat are
caused by various organisms. The organism concerned
in one epidemic is different from that in another. It
is impossible to anticipate what organism is about to
invade the household or community. Inoculation of
mixed vaccines fails to produce immunity. — {Jour. A.
M. A., Nov. 13, 1920, p. 1361.)
Iron, Arsenic and Phosphorus Compound. — The
Council on Pharmacy and Chemistry reports that
Hypodermic Solution No. 13 Iron, Arsenic and Phos-
phorus Compound (Burdick-Abel Laboratory) was
found unacceptable for New and Nonofficial Remedies
for the following reasons : i. It does not contain
ferrous citrate as claimed ; instead, the iron is in the
ferric condition, apparently in the form of the unof-
ficial and unstandardized "iron citrate green" for
which there is no evidence of superiority over the of-
ficial iron and ammonium citrate. 2. Its name gives
no information on the form in which the iron, the
arsenic or the phosphorus occurs therein. The term
"arsenic" does not indicate that the preparation con-
tains the mild cacodylate. Nor does the term "phos-
phorus" tell that it contains the practically inert sodium
glycerophosphate. 3. The preparation is unscientific
because (a) it is irrational to prescribe iron and ar-
senic in fixed proportions; (b) there is no evidence
that the hypodermic or intramuscular administration
of iron has any advantage over its oral administration,
and (c) glycerophosphates have not been shown to
have properties other than inorganic phosphates, and
hence the administration of sodium glycerophosphate
as a hematinic is illogical. — {Jour. A. M. A., Nov. 13,
1920, p. 1358.)
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THE PENNSYLVANIA MEDICAL JOURNAL
January, 1921
THE PENNSYLVANIA
Medical JOURNAL
Publiibed monthly under the •uperrision of the Publication
Committee of the Trustees of the Medical Society of the Sute
of Pennsylvania.
Editor
FRBOBRICK L.' VAN SICKLE, M.D HairUburg
Awiitant Editor
FRANK F. D. RBCKORD Harrlsburg
Astooiato Editors
TosiPH McFaxund, H.D., Philadelphia
Giotci E. PrAHUB, M.D Philadelphia
LawKNCl LiTCHFixu), M.D Pittsburgh
Gioaci C. Johnston, M.D Pittsburgh
J. Sthwmt Rodman, M.D Philadelphia
OHM B. McAi.isTXK, M.D., Harrisburg
Bbbnabd J. Hybrb, Esq., Lancaster
FuhUoatioa Oommltteo
IxA G. Shoihaksk, M.D., Chairman, Reading
Theodou B. Appel, M.D., Lancaster
FaANK C. Hammond, M.D Philadelphia
All communications relative to exchanges, books for review,
manuscripts, news, advertising and subscription are to be ad-
dressed to Frederick L. Van Sickle, M.D., Editor, aia N.
Third St., Harrisburg, Pa.
The Societ)[ does not bold itself responsible for opinions ex-
pressed in original papers, discussions, communications or ad-
vertisement*.
Subscription Price — $3.00 p«r year, in advance.
January, 1921
EDITORIALS
STOP! LOOK! LISTEN!
All who do not treat diabetes mellitus unth
. satisfaction !
Hundreds of diabetics are suffering because
the medical profession is so slow in adopting the
modern treatment of that disease — the Allen
treatment. The doctor is busy, his experience
with diabetes has made him pessimistic and apa-
thetic. The old Naunyn-von Noorden treatment
was complicated, arbitrary, irrational, and un-
successful; the Allen treatment is very simple,
elastic, rational, and so satisfactory that, after
you have had a little experience with it, you
seek cases of diabetes instead of dodging them.
It is not a slight modification of the old treat-
ment ; it is radically different. The old treat-
ment began by cutting out carbohydrates from
the diet, and giving unlimited fats, and the pa-
tient died sooner or later of "diabetic coma" due
to acidosis. The new treatment, recognizing that
unburned fats are the death of the diabetic, be-
gins by cutting out fats from the diet, and does
not dare withdraw carbohydrates as long as there
is any diacetic acid in the patient's urine. The
patients no longer die of diabetic coma, unless
they are practically comatose when the treatment
is begun.
There are other radical differences between the
old and the new treatment. The old treatment
aimed at increaesing the patient's weight; the
new treatment aims at keeping the patient's
weight at the lowest point consistent witii health
and efficiency. The old treatment condemned
the patient to keeping in constant touch with his
physician; the new treatment teaches the pa-
tient to test his urine for sugar and diacetic acid,
and to regulate his diet accordingly, only consult-
ing his physician when he needs further advice.
Under the old treatment we were taught that
certain conditions in the diabetic, such as arterio-
sclerosis, made it advisable to permit a certain
amount of glycosuria, and under the old treat-
ment the other patients frequently, if not as a
rule, were more or less glycosuric. Allen has
taught us that there is no condition which makes
glycosuria advisable, and that all diabetic pa-
tients should be kept sugar free continuously.
This is only possible when the patient himself,
or some member of his household, makes the
tests. The two tests necessary (that is for sugar
and diacetic) require less than five minutes, and
they should be done daily until the carbohydrate
and the fat tolerance are established and the most
satisfactory diet possible is worked out, then at
longer intervals. Under the old treatment we
were harassed by the need of quantitative esti-
mation of sugar in the urine. We had no other
way to judge our patients' condition and prog-
ress, for they generally had some glycosuria most
of the time. Now we know that after a few
days' fasting, or possibly several periods of fast-
ing of a few days each, our patient is going to be
sugar free, and that we are going to keep him
sugar free (at the most it will be a question of
a mere trace of sugar from time to time while we
are establishing the tolerance), therefore, we are
not concerned in the quantity of sugar in the
urine. In the rare cases of suspected "diabetes
without glycosuria," we send our patients to the
laboratory for a blood sugar test. It is inter-
esting to watch the blood sugar in ordinary
cases, and in obstinate cases and in cases of renal .
glycosuria and other anomalies it is often very
helpful. I wish to emphasize here, the impor-
tance of testing each specimen of urine for sugar,
regardless of the specific gravity. If sugar is
found, eliminate alimentary, emotional, and renal
glycosuria, levulosuria, lactosuria, and diseases
of the thyroid, pituitary, biliary tract, and spinal
cord, before making a diagnosis of diabetes
mellitus. Under the old regime we were led into
a maze of proprietary preparations in the search
of more efficient "anti-diabetic foods." Now the
patient readily learns to choose his ration from
any well supplied kitchen. He is not forever
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January, 1921
EDITORIALS
263
trying to find substitutes for forbidden foods but
learns to do without them. Even saccharine is
rarely employed. One can ignore and forget the
craving for sweets, just as one can ignore and
forget the craving for tobacco and alcohol.
Joslin has grouped the various articles of diet
in such a way as to make it very easy to choose
a ration of a certain value, or to eliminate the
chloric value of a given ration. He has arranged
this dietary scheme on a pink card smaller than
a postal card, which also contains all the infor-
mation that is absolutely necessary for the man-
agement of a case of diabetes mellitus according
to the most approved method. Doctor and pa-
tient should have these pink cards always at hand.
They may be obtained from Thomas Groom &
Company, Inc., io6 State Street, Boston, Mass.
L. L.
Bibliography:
Allen, Stillman & Fitz. — ToUl DieUry Regulations in the
Treatment of Diabetes.
Monographs of the Rockefeller Institue for. Medical Re-
search.
Joslin (i) — The Treatment of Diabetes Mellitus. Second
edition, 191 7, I.ea & Febiger.
Joslin (2) — A. Diabetic Manual for the Mutual Use of
Doctor and Patient. Second edition. 1919, Lea & Febi*
ger.
THE NEW TUBERCULOSIS VACCINE
Recent editions of the Philadelphia daily news-
papers have devoted considerable Space to the
announcement of a new anti-tuberculosis vac-
cine, emanating from the Institute Pasteur of
Lille, France, and from no less eminent an au-
thority than Albert Calmette. This name and
this source are sufficient to make the alleged dis-
covery worthy of consideration the whole world
over, and it is not surprising that such an emi-
nent American authority upon tuberculosis as
Baldwin of Saranac Lake should speak in its
praise. It is therefore timely that we should
look into the matter and see what it is, what it
has done and what may be expected of it.
The first two of these questions are answered
in the original articles that have appeared in the
Annales de I'lnstitute Pasteur of Paris, Febru-
ary, 1913, and September, 1920.
The first of these contributions deals with the
results obtained by the continuous cultivation of
the tubercle bacillus upon a medium of which
glycerine and bile are essential ingredients, and
shows that as the result of prolonged cultivation
upon this medium, there develops a race of the
bacilli entirely avirulent for cattle. This obser-
vation is the starting point of the new contribu-
tion which tells of the results obtained by the
employment of cultures of these avirulent bacilli
as a vaccine for the immunization of cattle.
Here, in brief, are the experiments: Five
tuberculosis cows were stood in a row in a close
and unsanitary stable, and their position changed
about at weekly intervals, so that all parts of the
stable might become equally infected by their
presence. Behind them was placed a second row
of animals, comprising ten heifers, known to be
free of tuberculosis. Their position was such
that their litter was constantly contaminated by
the dejecta of the diseased cows in front of them.
The cows therefore served as the contaminating
and infecting agents, the heifers as the experi-
ment animals. Of the ten heifers, four acted
as controls, and received no treatment. Of the
six remaining, each received on November 21,
1912, a single injection of 880 millions of the
avirulent tubercle bacilli, given into the jugular
vein, and all were placed the same day in the
stable described above. At the end of a year,
three of the six heifers were given a second in-
jection of 880 millions of the bacilli, and at the
end of another year, two of them received a third
similar injection. As the cows used to furnish
the infection died, others were introduced in
their places so that the experiment might pro-
ceed without interruption. But the experiment
was most brutally interrupted by the war, the
taking of the city of Lille by the Germans, and
an order that all cattle must be delivered to the
invaders. In order not to lose the result of an
experiment that had continued over so long a
time, the heifers were serreptitiously slaughtered,
and the results studied, in August and October,
1915-
Here are the results of the examination of the
ten heifers:
A. Four heifers used as controls, i. Showed
no tuberculous lesion. The bronchial lymph
nodes removed and inoculated into guinea pigs,
produced no tuberculosis in them. 2. In the
right lung of this animal there were nine tuber-
culous lesiops the size of a hazelnut, and another,
caseous lesion the size of a walnut. In the bron-
chial lymph nodes there were also 7 tubercles the
size of a hemp seed. 3. The mediastinal lymph
nodes were three times the normal size, and upon
section showed numerous areas of tuberculosis*
varying in size from a millet seed to a hazelnut.
The bronchial lymph nodes showed a number of
tubercles the size of hemp seeds. 4. In this ani-
mal there were very discrete lesions. In a
mesenteric ganglion there was a caseous tubercle,
the size of a millet seed. Also in the bronchial
lymph nodes two caseous tubercles the size of
millet seeds.
Now it is most important to consider the con-
dition of these control animals as it is upon the
contrast with what they show and what the in-
oculated or vaccinated animals show, that the
merits of the treatment depend. Out of four
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THE PENNSYLVANIA MEDICAL JOURNAL
January, 1921
animals, one showed no tuberculosis at all (25%
of the control animals remain well), and the
other three (75%) show very little.
Now let us see what happened to the six vac-
cinated animals. These are divided into three
groups, according to the number of vaccinations
that they received, i. e., one, two, and three doses
of the vaccine.
B. Anitttals receiving one dose of the vaccine.
I. In the two lungs of this animal there were 15
tuberculous lesions, caseous and varying in size
from a pea to a hazelnut. The bronchial and
mediastinal lymph nodes were stuffed with
tubercles. 2. In a mesenteric ganglion of this
animal, there was a tuberculous lesion the size of
a hazelnut; in a mediastinal node, a lesion the
size of a pea. The bronchial nodes appeared
healthy, but in the right lung there were two
tubercles the size of hazelnuts. 3. There were no
apparent tuberculous lesions in this animal. The
bronchial lymph nodes were removed, triturated
and inoculated into guinea pigs, which remained
healthy.
If we analyze these results for comparison
with the controls, we find three of them against
four, so that no exact parallel can be formed.
But we cannot help being struck by the fact that
they are no better off than the controls, in fact
seem to be somewhat worse off. It is true that
only two out of three, as contrasted with three
out of four show tuberculosis, but the extent of
the disease in one of them greatly exceeded any-
thing seen in the control animals, and in the
other is about the same. It seems to us that we
can learn nothing at all from this part of the ex-
periment.
C. Animals receiving two doses of the vac-
cine. I. The one animal in this group showed no
tuberculous lesions, and its ground up bronchial
lymph nodes inoculated into guinea pigs failed to
infect them.
How is anyone to draw any conclusion from
this single observation ? With which of the con-
trol animals shall it be compared?. With the
one that had no tuberculosis, or with those that
did? Would that have been the result if there
had been four heifers that received two of the
vaccinations, one wonders. As a single obser-
vation it seems to merit scanty attention, espe-
cially in lieu of the uninfected control animal.
D. Animals receiving three doses of the 7/ac-
cine. I. This animal was accidentally strangled
to death in the stable, by twisting its collar. It
was autopsied, and no tuberculous lesions were
found, nor did a guinea pig, inoculated with the
triturated bronchial lymph nodes develop tuber-
culosis. 2. This animal also showed no tubercu-
lous lesions, and its bronchial nodes did not pro-
duce tuberculosis in guinea pigs.
Here we find 100% protection 1 But in how
many animals? Only two! We are willing to
admit, however, that the result is twice as good
as the controls show, for of them only one did
not develop tuberculosis. But how can anybody
accept these experiments as evidence of any-
thing ?
Now let us pursue the criticism a little .further,
with respect to the deductions made by the inves-
tigators, and consequently also by a too guillible
lay press and hopeful public.
Calmette is the chief exponent of the French
school of medical philosophers, who in opposi-
tion to the German school, lead by Koch, teach
that infection in tuberculosis is caused by bacilli
from cattle, and that it takes place through the
swallowing of the bacilli in milk. It was the
earnest hope of Koch to be able to settle the con-
tention before long, but his death brought to an
end a great series of experiments that had been
begun under his direction in many of the large
laboratories of the world. It was the object of
these to show what bacilli were found in the le-
sions of human tuberculosis, and those who con-
tinued and published their experiments after the
death of Koch, are quite in accord with him in
finding that it is human, and not bovine bacilli
that commonly occur. The careful experiments
of Fugge also are very conclusive in showing
that the usual mode of infection is through the
inhalation of the bacilli in the fresh matter dis-
charged from the respiratory passages of the pa-
tient with open lesions, when he coughs.
We find then, that Calmette and Guerin, in the
paper under discussion, carry us nowhere. They
begin an experiment upon the theoretical as-
sumption that tuberculosis in cattle and in hu-
mans depends upon the ingestion of the tubercle
bacilli, and arrange their animals in such manner
as to make the ingestion of bacilli possible ; they
find that as the result only 75% of the very few
animals used in the experiment become infected.
They prepare a vaccine with which they inoculate
.so small a number of animals that the results if
in perfect harmony would be no more than sug-
gestive, and attain to results that are incapable
of interpretation by any one in the least degree
skeptical — as all scientific men should always be,
— and yet come to the conclusion thqt they are
justified in deducing that the continuous cultiva-
tion of the bovine tubercle bacillus upon glycer-
inated, bilated potato, so destroys its virulence
as to make the cultures a vaccine ; that this vac-
cine has protected animals; that if it be used
upon a sufficiently extensive scale, tuberculosis in
cattle will disappear, and that with its disappear-
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January, 1921
EDITORIALS
265
ance tuberculosis in man will diminish and finally
disappear !
It is always extremely unfortunate when the
lay press is guilty of medical exploitation. Those
who remember the untimely announcement of
tuberculin, and the hopes that the sick were led
to entertain, cannot forget the broken hearts that
followed that bitter disappointment. J. McF.
NORMAL DELIVERY AFTER CESA-
REAN SECTION
Csesarean sections have now become so com-
mon that many practitioners must from time to
time be called upon to consider the question of
whether or not a pregnant woman can safely be
allowed to go to an uninterrupted labor after
a Caesarean operation. Considerable light has
been thrown upon this question by Dr. A. Grosse
of Nantes in Gynecologic et Obstetriq'ue, Vol. 2,
No. 2, 1920.
Dr. Grosse relates the case of a woman who at
the age of thirty-five had a Caesarean section made
necessary by the presence of a large ovarian cyst.
This woman had three normal labors with well
developed healthy children five, eight and eleven
years, respectively, after her Caesarean section.
This case would, therefore, definitely prove
that there is no necessary reason why a woman
who has had a Caearean section cannot have a
normal delivery afterwards.
The greatest cause of worry has, of course,
been the possibility of a rupture of the uterus
through the old scar during a subsequent labor.
The case quoted shows that this accident does
not necessarily have to happen. This case would
seem to teach distinctly that when the condition
which made a previous Caesarean section neces-
sary has been removed or has disappeared the
woman should be allowed to go to labor without
interference. Caesarean sections should be al-
lowed to become a habit only when there is a per-
manent obstruction such as deformed pelvis, etc.
J. M. W.
PNEUMOPERITONEUM
The inflation of the peritoneal cavity with
oxygen, or carbon dioxide gas, in order to in-
crease the transparency of the abdomen, to bring
into view adhesions between the viscera and the
abdominal wall, for the diagnosis of obscure ab-
dominal tumor masses, etc., has sprung suddenly
into great popularity. The results obtained are
sometimes startKng. The diagnostic aid thereby
given is frequently unique. The procedure is
even being carried out, apparently with impunity,
in the office by many roentgenologists. It has
been described as quite without danger. Occa-.
sionai instances of extreme pain, great distress,
cold sweating, thready pulse, even surgical shock,
appear upon inquiry among those of much expe-
rience in this work. It may be that there is no
danger in such a procedure, but it is at least per-
missible to suggest that the interabdominal pres-
sure so produced be permitted to subside slowly ;
that the patient be required to assume and retain
a recumbent posture until pain and discomfort
have disappeared ; and that as little manipulation
of the patient as possible be indulged in during
the time of abdominal distention. The procedure
has great possibilities. It will be unfortunate if
lack of judgment and care in its use be produc-
tive of bad results. G. E. J.
CONTAGIOUS DISEASES: DO THE
PRESENT QUARANTINE LAWS
NEED REVISION?
REMEDY
The weakest point in getting results from
quarantine regulations is the fact that damage is
done before the diagnosis is made. Quarantine
measures fail to produce desired results largely
because of the inherent characteristics of the
communicable diseases themselves, plus failure
upon the part of the parents to consult a physi-
cian for any of the milder infections, or fre-
quently in the more severe forms, to wait for
medical help until relatively late. Also the fail-
ure of the parents in case no physician is sum-
moned, to report the illness to the health authori-
ties.
A third cause is the physician who often gives
as an excuse "f orgetf ulness" ; or the type who
is "negligent" and does not recognize his rela-
tion to his community in a public health sense;
lastly the "mercenary physician" who wilfully
does not report his cases because he thinks that
he should be paid for all such public services.
The physician can also help by handling every
doubtful case as an infectious possibility until
absolute diagnosis is made. In all cases of suspi-
cious diphtheria, the cultures should be taken
early and if uncertain as to diagnosis, it is wise
to quarantine without waiting for laboratory re-
ports. It does not impose hardship upon wage
earners, and a provisional diagnosis can always
be revised and quarantine restrictions removed
after consultation with the county medical di-
rector in rural districts or the medical officer of
the local board of health in municipalities.
The rounding up of contacts is very, essential
particularly in diphtheria, smallpox, and scarlet
fever. Special attention should be paid to car-
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THE PENNSYLVANIA MEDICAL JOURNAL
January, 1921
riers with respect to those diseases where it is
possible to identify the carrier state as in diph-
theria, typhoid fever, other intestinal diseases
and streptococcic sore throats.
Conclusions: Thus the remedy does not re-
quire changing the "quarantine regulations," but
it is up to the physicians and the general public
to adhere to the present requirements. Less
time must be consumed in diagnosing and re-
porting. The public must be further educated to
consult a physician early in cases of infectjon.
Loss of time is an important element because
probably all the communicable diseases are in-
fectious from the first. F. F. D. R.
ILLEGAL PRACTITIONERS
The Medical Society of the State of Pennsyl-
vania, through the office of the Executive Secre-
tary, is preparing a plan of procedure to assist
the county medical societies in ridding this state
of the undesirables who are obtaining money
under false pretense from the people of this
state; and for that purpose, we desire to call
the attention of the profession to one instance
wherein it has been made possible by a county
society to bring about the proper procedure,
with a result which we trust will occur in every
case in the future.
Allegheny County Society is to be congratu-
lated upon its good work in this case. The
Federal authorities have brought to the bar of
justice in Pittsburgh, Allegheny County, "Dr."
Leonard L. Parry, who was arrested for the use
of the United States mail in the distribution of
his "Nature's Vegetable Compound" remedies.
"Dr." Parry had previously been convicted, sen-
tenced and served a term in jail for the illegal
practice of medicine in connection with the dis-
tribution of this remedy. The United States
government authorities alleged fraud in the dis-
tribution of this remedy in the treatment of such
diseases and diseased conditions as adenoids,
cancer, hemorrhoids, tuberculosis, typhoid fever,
tumors, insanity, curvature of the spine, dia-
betes, blindness, small pox, etc. \Vitnes.ses for
the government included Drs. Edward B.
Heckel, Lawrence Litchfield, C. L. Palmer, T.
G. Graig and Walter' F. Donaldson, of Pitts-
burgh.
Some of the testimony introduced by Parry,
in answer to questions asked at his trial in
United States Court, by Federal Attorney Dan-
iel S. Horn as to how he came to prepare the
Parry medicines, was :
"By reading the Scripture, prayer and the Al-
mighty."
The medicine. Parry testified, is composed of
olive oil, water, alcohol, and 12 different kinds
of oils "and some more." Parry refused to tell
the amount of each ingredient used. Parry tes-
tified that he did not know why it cured.
On page 1732 of the Dec. 18, 1920, volume of
the Journal of the American Medical Associa-
tion will be found a more full exposition of this
case.
We desire to call the attention of organized
medicine to the fact that many such charlatans
exist in this state, and they should be treated in
the same manner as Parry ; and we believe that,
if a thorough cooperation on the part of the of-
ficers and members of the component county
medical societies is assured, it will not be long
before the State of Pennsylvania will have much
to its credit through this field of endeavor.
It is to the credit of the members of Alle-
gheny County who testified in the Parry case,
and men should not hesitate to lay aside their
business, appear in court, and devote the neces-
sary time in giving evidence which will aid in
the conviction of illegal practitioners of the
healing art.
"SOCRATES REDUX'
THE MEDICAL BOOK REVIEW
"I came in this morning because I saw the re-
ceipt of Wilson's book noted in the Journal and
wanted to talk to you about it."
We knew that trouble was brewing, but there
was no way by which we could escape it for, as
we have pointed out, the old man has unlimited
time, and talks just the same whether one listens
to him or not. So we contented ourselves with
asking which book it was to which he referred.
"Why, that new book on 'How WE MAKE
OUR TEETH.' "
"Well," we asked, "what do you think of it?
It looks like a very useful work."
"I have just come from the publisher's. He
showed me 26 reviews of it from as many medi-
cal journals. They were all favorable, he said,
and assure sufficient sales to pay the cost of pub-
lication."
"Then," we said, "the author and the publisher
are both to be congratulated."
"Yes, I supopse so." There was so much sar-
casm evidenced in the tone in which these words
were said that we looked up from the letter upon
which we were making notes for the stenog-
rapher, to see what the old man had in his mind.
"I will read you a sample review":
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January, 1921
EDITORIALS
267
"How We Make Our Teeth," by Reginald Wilson,
A.M., M.D., LL.D. In this work of something over 250
pages, the author presents to the medical profession,
for the first time, a mass of facts painstakingly col-
lected during an active professional life. The vast
importance of the teeth to the health of the patient,
justify the publication of a work that shall call the
attention of every physician to the care that he should
exert to see that they are kept in perfect order.
"In addition to a text that seems to be above criti-
cism, there are over 100 illustrations printed on superb
paper in the style well-known to characterize the
books produced by the house of Blank, Paper and Co.,
of Squantum, Ct.
"The book is also well bound, and has an index of
4 pages.
"We feel that no member of the profession can af-
ford to be without a book of this character, and take
pleasure in recommending it."
"That with scarcely any variations, is what 20
medical journals say about this book."
"Well, is there any reason why they should
not say so ?"
"Not at all. On the contrary there is every
reason why they should."
We waited to learn what more he had to say.
"You see, the publisher told me he had a type-
written slip with those words upon it inserted
into every one of the copies sent to the journals
for review. He said that he knew that the doc-
tors were so busy that it would help them out in
preparing their reviews of the book."
"Well, that was kind of him."
"Oh, very, indeed. You see it saved the re-
viewer all the trouble of reading the book, and
in most cases the ruse succeeded, and the jour-
nals published exactly what was wanted."
"Our review has not been published as yet, but
has come in this morning and will appear in the
next issue."
"Would you mind showing it to me?"
"Certainly not ; here it is." But in passing it
to him, we paused a moment to make a hasty
perusal of it, saw that it was exactly in the form
that he had read, and to save ourselves, laid it
again to the pile of papers from which we had
taken it, saying as we did so, "Perhaps it would
be better for you to wait until you see it in the
Journal."
"I thought so," he chuckled, divining the truth
of the situation. "Don't publish that; listen to
this. Here is what a reviewer says after he
really read the book."
"It is but rarely that we feel it to be our duty to
condemn what is undoubtedly a sincere effort on the
part of an inexperienced but ambitious author. But
in this case, not to do so would be to place ourselves
in the position of not seeming to know foolishness and
error when we see it.
"We desire to be just, and believe that we are when
we say that this book is unprecedented in the number
of follies that it presents to the reader, and in the
number of mistakes it contains.
"In- the section on page 3, 'General Considerations,'
we find the following:
"'The possession of teeth is an interesting example
of herdity; a child has teeth because its parents had;
it comes into the world without teeth because its par-
ents did; it leaves the world without teeth because its
parents did. It is doubtful whether any better ex-
ample r)f the force of heredity could be found.'
"On page 26 we find, 'It is an undoubted mistake to
state, as most of the textbooks do, that the normal
number of teeth is 32, for many persons fail to cut
their wisdom teeth and therefore have only 28 or 30.
If we average together, 28, 30 and 32, we come out
with 30, which ought therefore be regarded as the
true number of the human teeth.'
"Is it necessary for us to go on with the matter and
point out the errors that appear upon every page ? We
think that we have given enough to satisfy every
reader that the book is worthless unless it be read as
a piece of humor. As a scientific textbook, it is
ridiculous. No well-informed man could have written
it, no qualified publisher should have accepted it, no
one should buy it."
"I am glad I came in. The purpose of a book
review ought to be to tell the reader the real
merit or demerit of the book. The publisher will
see to it that the profession is promptly informed
when books appear, and what they are about."
SEX AND BLOOD PRESSURE
It has long been realized that age is a factor which
must be taken into consideration in giving an answer
as to what constitutes the normal arterial blood pres-
sure. There are also variations that seem to be asso-
ciated with sex. In examining the numerous data
collected by Alvarez at the University of California,
it appears that the women before the menopause rep-
resent almost exclusively a type endowed with a com-
paratively low blood pressure. There is far greater
imiformity and less variation in the blood pressure
readings of large numbers of them tlian is true of men
at the same periods of life. Alvarez has therefore
suggested that perhaps the ovary is in some way able
"to cover up or hold latent the tendency to hyperten-
sion which we will presume the women inherit equally
with the men." When the ovarian function fails,
therefore, the natural tendency for the appearance of
higher arterial pressures soon makes itself appreciated.
Perhaps this hypothesis will help to explain the asser-
tion sometimes made that hypertension often develops
early in women who show signs of insufficient ovarian
function, such as scanty and painful menstruation,
sexual anesthesia, male distribution of body hair, in-
fantile uterus, etc. At any rate, the phenomena of
hypertension appear to be suppressed in women as
long as the ovaries function well. On the other hand,
the statistics show that the large increase in the in-
cidence of hypertension comes ten years later jn men
than in women. Apparently, Alvarez concludes, a
strenuous life has less to do with this disease than
has the quieting down of the sexual functions. — Jour.
A. M. A., Nov. 27, 1920.
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The Medical Society of the State of Pennsylvania
OFFICERS' DEPARTMENT
WALTER P. DONALDSON. M.D.
Secretary
8014 Jenkins Arcade Bldg., Pittsburgh, Pa.
BENEVOLENCE
Chapter VI, Section 6, of the By-Laws of the
Medical Society of the State of Pennsylvania
provides for a Committee on Benevolence,
which shall have absolute and confidential juris-
diction over the distribution of such part of the
Medical Benevolence Fund as may be placed in
its hands. The beneficiaries shall be designated
by number, and after each annual audit, all com-
munications tending to show the personality of
the same shall be destroyed. The annual allot-
ment (15 cents) from the state per capita tax
does not permit of rapid growth of this fund,
and the interest on the principal of the Medical
Benevolence Fund does not yet permit of pay-
ment of adequate benefits to more than a very
few beneficiaries. These facts, however, should
not deter worthy members of the society from
applying to the Benevolence Committee for as-
sistance. All communications regarding this
fund should be addressed to the chairman of
the committee, Dr. William T. Sharpless, 100
South Church Street, West Chester, Pennsyl-
vania.
This committee is also empowered to solicit
subscriptions, donations and legacies to be
added to the principal of the Medical Benevo-
lence Fund, and this kindly phase of member-
ship in the State Medical Society is certainly
entitled to forethought and remembrance by the
individual membership of the society.
It is possible that many members or the fami-
lies of many members may now or in the near
future be in straits that make modest, unosten-
tatious forms of financial assistance not only
welcome but absolutely essential to the most or-
dinary comforts of life. That all entitled to
and in need of such assistance should feel at
liberty to apply to this fund is the ambition of
the officers and members of our State Society.
ATTENTION OF SECRETARIES
The attention of the secretaries of the sixty-
three component county medical societies of the
Medical Society of the State of Pennsylvania
is respectfully drawn at this time to Chapter 8
of the By-Laws of the State Society. He or
she will note among other duties outlined that
"the secretary of each component county med-
ical society shall during or before January of
each year furnish the secretary of this Society
with a list of the officers and members of his
county medical society, and shall report new
members as soon as they are qualified as mem-
bers of his society." Also "that each component
county medical society shall notify the secretary
of this Society of any new by-laws or rules that
have been adopted;" and, furthermore, that
"the secretary of each component county med-
ical society shall keep a roster of its members
and of the nonaffiliated registered physicians of
the county, in which shall be shown the full
name, address, college and date of graduation,
date of registration or license to practice in the
state, and such other information as may be
deemed necessary. In keeping such a roster the
secretary shall note any change in the personnel
of the profession by death, or by removal to or
from the county, and in making his annual re-
port he shall endeavor to account for every phy-
sician who has lived in the county during the
year." This latter duty of the county society
secretary should be shared by "each and every
member of his society.
1921 MEMBERSHIP
Have you paid your county medical society
dues for 1921 ? At this writing (December 21)
the 1921 state per capita tax for 302 members
has been received from twenty-two societies at ,
the office of the State Secretary. Same date last
year, 184 had been received from eighteen so-
cieties, indicating progress toward that happy
day when the great majority of members will
have paid their dues for the current year when
due ; i. e., January i of any current year.
Early payment of dues is evidence of virtue,
and carries its own rewards, not the least of
which is that of assurance or perfect protection
against suits for alleged malpractice.
As evidence of the fact that such suits may
mean more than the mere annoyance of a more
or less prolonged fight and a subsequent suc-
cessful outcome, your attention is called to the
experience of a Pennsylvania physician of good
repute, who was early in the month of Decem-
ber, 1920, assessed damages by a jury to the ex-
tent of $2,250,. on account of an alleged bad
result subsequent to his treatment of a condition
that may occur frequently in the practice of 90
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January, 1921
OFFICERS' DEPARTMENT
269
per cent, of the members of this Society. The
defendant physician in this case was not a mem-
ber of this Society at the time of his alleged
malpractice. Remember his unfortunate ex-
perience when you are tempted to postpone im-
mediate payment of your 1921 dues, because
Section 2 of Article 4 of our Constitution states
that "members whose assessments are received
by the Secretary of this Society on or before
March 31 shall be entitled to all the privileges
of this Society for the current year. One whose
assessment is received after March 31 shall be
entitled to all the privileges of this Society, ex-
cept that he shall not be entitled to any benefit
from the Medical Defense Fund from January
I up to the date of the receipt by the Secretary
of this Society of his name and assessment."
BOARD OF TRUSTEES
There was a meeting of the entire Board of
Trustees in the offices of the Executive Secre-
tary, Harrisburg, on Dec. 13, 1920. The next
meeting will be held at the same place on the
date provided by the Constitution, namely, the
first Wednesday in the month of February
(February 2).
CHANGES IN MEMBERSHIP OF COUNTY
SOCIETIES
The following changes have been reported to De-
cember 21 :
Adams: AVar Member — George A. Stock,
V.S.P.H.S., Saranac Lake, N. Y.
Allegheny: New Members — George A. Calhoun,
Clairton ; Francis M. Joyce, 501 Lincoln Ave. ; Charles
F. Metzgar, 137 S. Bryant Ave., Bellevue; Frederick
M. Jacob, 4818 Baum Boulevard; John D. Donovan,
815 Greenfield Ave. ; Isolde T. Zeckwer, 135 N. Craig
St.; Samuel R. Cohen, 1915 Beaver Ave., Pittsburgh.
Reinstated New Members — E. P. Buchanan, Mercy
Hospital, Pittsburgh; C. S. Hunter, N. Bessemer.
Transfer — Madison U. Stoneman to Los Angeles
County Medical Society, Los Angeles, California. Re-
moval— David E. Hemphill from R. D. 2 Tarentum. to
1432 Potomac Ave., Dormont, Pittsburgh. Death —
Theophilus R. Van Kirk (Jeff. Med. Coll. '64), of
McKeesport, recently, aged 8b.
Armstrong: Netv Member — Robert D. Redinck,
Yatesboro.
Beaver: New Member — Francis H. McCaskey,
Freedom. Removal — Ernest W. Campbell from Mid-
land to 22 N. Laird .\ve., Warren, Ohio.
Bucks : Reinstated New Member — Harvey D.
Webb, Bristol.
Cambria: New Members — Harry F. Garman,
Emeigh; James J. Monahan, Johnstown Trust Co.
Bldg.; Calvin C. Rush, 342 Main St., Johnstown.
I>Elaware: Removal — Clifford H. Arnold from
Chester to 107 Ardmore Ave., Ardmore (Montgomery
Co.) Resigned — Francis W. Diez, New York.
Elk: New Members — Albert C. Shannon, St.
Mary's; Walter M. Atkinson, Brockwayville (Jeff.
Co.).
Erie: New Members — Joseph K. Tannehill, Fred
K. McCune, Girard ; A. B. Miller, E. Eighth St., Erie.
Lancaster: Reinstated New Members — ^John De-
Witt Denney, Coluthbia; John B. Price, 134 N. Duke
St., Lancaster; George H. Kohlbraker, 130 E. Main
St., Ephrata.
Lehigh : Removal — Margaret H. Bynon from
Muncy to 405 E. Pine St., Mahanoy City (Schuylkill
Co.).
Lycoming: New Members — Mahlon T. Milnor,
Omar R. Etter, Warrensville ; F. C. Lechner, Wil-
liamsport Hospital, Williamsport. Removal — Ray-
mond J. Bower from DuBoistown to 324 Court St.,
Williamsport.
MimiN : New Member — O. M. Weaver, 35 Chest-
nut St., Lewistown.
Montgomery: New Member — Mary P. H. Hough,
Ambler. Transfer — Stanley E. Bettle, of Conshocken,
from Philadelphia Co.; John O. Bower, of Wyncote,
to Philadelphia County.
Northampton: New Members — Burtis M. Hance,
19 S. Third St., Easton; James E. James, 253 E.
Broad St., Bethlehem; Walter J. Cathrall, 116 E.
Fourth St., South Bethlehem.
Northumberland: New Member — William S.
Wentzel, 414 Market St., Sunbury.
PHaADELPHiA: Andrew B. Kirkpatrick (Jeff. Med.
Coll. '84), of Philadelphia, Nov. 22, aged 66.
Somerset : New Members — Creed C. Glass, Meyers-
dale ; Jerry M. James, Hooversville.
Venango: New Members — Theodore H. Jones,
West Hickory; John L. Hadley, Oil City. Removal
— ^James E. Dwyer from Polk to 1633 Boston St.,
Tulsa, Okla.
Washington : New Member— Willium H. MacKay,
Slovan.
PAYMENT OF PER CAPITA ASSESSMENT
The following payment of per capita assessment has
been received since November 24. Figures in first
column indicate county society numbers ; second col-
umn, State society numbers :
For
1920—
Nov.
24
Allegheny
"34
7103
$5.00
26
Erie
115-117
7104-7106
15.00
Dec.
6
Lancaster
129-131
7107-7109
15.00
Lawrence
58
7110
5-00
For
1 921
— .
Nov.
24
Cambria
1-3
34-36
15-00
Allegheny
i»-i8
37-43
3500
Northampton
1-2
44-45
10.00
Nov.
26
Elk
2-5
46-49
20.00
Northampton
3
50
5-00
Bucks
1-34
51-84
170.00
Nov.
30
Montgomery
4
85
5.00
Dec.
2
Allegheny
15-47
86-114
145 00
Somerset
1-4
11S-118
20.00
Dec.
4
Mifflin
1-2
I 19-120
10.00
Dec.
6
Montgomery
5-12
121-128
40.00
Dec.
7
Northumberland 1-3
129-131
1500
Dec.
10
Venango
1-2
132-133
10.00
Armstrong
I
134
5. 00
Allegheny 49-95. 97-II3
135-198
320.00
Dec.
II
Beaver
1-14
199-212
70.00
Columbia
I-2S
213-237
125.00
Dec.
12
Adams
1-3
238-240
1500
Dec.
IS
Lycoming
1-3
241-243
1500
Allegheny
I 14-142
244-272
145 00
Dec.
18
York
^3
273-274
10.00
Wayne
1-9
275-283
4500
Washington
3-21
284-302
9500
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270
THE PENNSYLVANIA MEDICAL JOURNAL
January, 1921
FREDERICK L. VAN SICKLE. M.D.
Executive Secretary
Harrisburg, Pa.
LEGISLATIVE DIRECTORY
For the information of the officers, committees and
members of the county medical societies of the state
of Pennsylvania, we publish the names and addresses
of the members of the Senate and House of Represen-
tatives for the Session of 1921 :
MEMBERS OF THE SENATE OF
PENNSYLVANIA
(The terms of the Senators from the even-numbered
districts expire December, 1922, and from the odd-
numbered district, December, 1924.)
Philadelphia.
I District. 1st, 26th, 36th, 39th and 48th wards —
Edwin H. Vare, R., 2221 South Broad Street,
n District. 2d, 3d. 4th, 7th, 8th, pth and 30th wards-
Samuel W. Sakis, R., 614 South Eleventh Street.
III District, 5th, 6tb. loth, nth, 12th, 13th, 14th, l6th
and i8th wards —
William J. McNichol, R.. 1637 Race Street.
IV District, 24th, 27th, 34th, 40th, 44th and 46th
w-ards — •
Edward W. Patton, R., 226 South Forty-fourth
Street.
V District, 17th, 19th, 20th, 31st and 37th wards —
Max Aron, R., 041 North Eighth Street.
VI District, 21st, 22d, 38th and 42d wards —
George Woodward, R., Mount Airy, Philadelphia.
VII District, isth, 28th, 29th, 32d and 47th wards —
Augustus F. Daix, Jr., R., 1613 North Thirty-
third Street.
VIII District, 23d, 2Sth, 33d, 35th, 41st, 43d and 45th
wards —
George Gray, R., 1224 Wakeling Street, Frank-
ford. Philadelphia.
IX District — Delaware.
.Albert Duttoii MacDade. R., Chester.
X District — Bucks.
Clarence T. Buckman, R., Langhorne.
XT District— Berks.
James E. Norton, R., Reading.
XII District — Montgomery.
Tames .S. Boyd. R., Norristown.
XIII District — Lancaster (part of).
John G. Homsher, R., Strasburg.
XIV District — Carbon. Monroe. Pike and Wayne.
Wallace J. Barnes, R., Beachlake, Wayne County.
XV— District— Dauphin.
Frank A. Smith, R., Harrisburg.
XVI District— Lehigh.
Horace W. Schantz, R.. Macungie.
XVII District — Lebanon and Lancaster (part of).
Cleon N. Bernthcizcl. R., Lancaster, Lancaster
County.
XVITI District— Northampton.
W. Clayton Hackctt, D., Easton.
XIX District— Chester.
T. Larry Eyre, R.. West Chester. (Office 1535-37
Commercial Trust Building, Philadelphia).
XX District — Luzerne (part of).
Asa K. DcWitt. D., Plymouth.
XXI District — Luzerne (part of).
P. F. Joyce, R.. Pittston.
XXII District — Lackawanna.
.-\lbert Davis, R.. Scranton.
XXIII District — Wyoming, Susquehanna and Brad-
ford.
Edward E. Jones, R.. Harford, Susquehanna
County.
XXIV District — Columbia, Montour, Sullivan . and
Lycoming.
Charles W. Sones, D.. Williamsport, Lycoming
County.
XXV District— Tioga, Potter and McKean.
Frank E. Baldwin, R., Austin, Potter County.
XXVI District— Forest, Elk, Clinton, Cameron and
Clarion.
Charles E. Donahue, R., Lock Haven, Clinton
County.
XXVII District — Northumberland, Snyder and Union.
William C. McConnell, R., Shamokin, Northum-
berland County.
XXVIII District— York.
George Marlow, R., York.
XXIX District— Schuylkill.
Robert D. Heaton, R., Ashland.
XXX District — Huntingdon and Blair.
Plymouth W. Snyder, R., Hollidaysburg, Blaii
County.
XXXI District — MifHin, Juniata, Perry and Cumber
land.
Frederick W. Culbertson, R., Lewistown, Mifiiii
County.
XXXII District— Fayette.
William E. Crow, R., Uniontown.
XXXIII District— Adams and Franklin.
D. Edward Long, R., Chambersburg, Franklii
County.
XXXIV District— Clearfield and Centre.
Summerfield J. Miller, R., Madera. Clearfiel-
County.
XXXV District— Cambria.
W. Irving Stineman, R., South Fork.
XXXVI District— Fulton. Bedford and Somerset
John S. Miller, R., Somerset, Somerset County.
XXXVII District — ^Jefferson and Indiana.
Joseph O. Clark, R., Glen Campbell, Indian
County.
XXXVIII District— Allegheny (part of).
M. G. Leslie, R., Jenkins Arcade Building. Pitts
burgh.
XXXIX District— Westmoreland.
James B. Weaver, R., Latrohe.
XL District — Allegheny (part of).
Cadwallader M. Barr, R., Aspinwall.
XLI District — Armstrong and Butler.
Alfred M. Christley, R., Butler, Butler County.
XLII District — Allegheny (part of).
Morris Einstein, R., McClintock Street and Per
rysville Avenue, Pittsburgh, North Side.
XLIII District— Allegheny (part of).
Wilson S. McClintock, R., 6425 Fifth Avenue
Pittsburgh.
XLIV District— .Allegheny (part of).
W. Crawford Murdoch, R., Wilkinsburg.
XLV District— Allegheny (part of).
Norman A. Whitten, R., Munhali.
XLVI District — Washington and Greene.
Joseph A. Herron, R., Monongahela, Washington
County.
XLVII District — Beaver and Lawrence.
William David Craig, R., Beaver, Beaver County
XLVIII District — Warren and Venango.
Marshall L. Phipps, R., Franklin, Venango Coun-
ty.
XLIX District— Erie.
A. E. Sisson, R., Erie.
L District — Crawford and Mercer.
Fred A. Service, R., Sharon, Mercer County.
MEMBERS OF THE HOUSE OF
REPRESENTATIVES
Philadelphia.
1st District, 1st and 39th wards —
Leopold C. Glass, R., 1613 South Sixth Street
Thomas F. McGowan, R., 2332 South Tenth Street
2d District, 2d ward —
Charles C. A. Baldi, Jr., R., 1341 Ellsworth Street
3d District, 3d, 4th and 5th wards —
Arnold M. Blumberg, R., 409 South Fifth Street
Henry J. Trainer, R., 758 South Tenth Street
\
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January, 1921
OFFICERS' DEPARTMENT
271
4th District, 6th, 8th and 9th wards-
James V. Laflferty, R., 809 Spruce Street.
Sth District, 26th, 36th and 48th wards-
Daniel J. Green, R., 1251 South Twenty-third
Street.
John M. Love., R., 2338 South Twentieth Street.
Isaac L. S. Smink, R., 2220 South Twenty-third
Street.
6th District, 7th ward-
Andrew F. Stevens, R., 1345 Lombard Street.
7,th District, 30th ward-
John C. Asbury, R., 1710 Christian Street.
Sth District, loth, 13th and 14th wards —
Timothy J. McCarthy, R., looi Fairmount Avenue.
Jefferson W. Smith, R., 706 Green Street.
9th District, nth and 12th wards —
Herman Dilsheimer, Sr., R., 523 North Fourth
Street,
loth District, iSth ward —
William J. Brady, R., 847 North Twenty-sixth
Street
Richard D. Burns, R., 752 North Nineteenth
Street,
nth District, 17th and i8th wards-
Frank H. Stackhouse, R., 11 16 East Columbia
Avenue.
I2th District, 19th ward —
Harry Keene, R., 144 West Cumberland Street
Lawrence F. McOwen, R., 2529 North Eighth
Street
13th District, i6th and 20th wards —
Joseph Marcus, R., 1445 North Eighth Street.
Clinton A. Sowers, R., 1239 North Eleventh Street
14th District, 21st ward —
Wallace Bromley, R., 126 Sumac Street.
ISth District 22d and 42d wards —
Franklin Spencer Edmonds, R., 133 South Twelfth
Street
Howard Smith, R., 1129 East Chelten Avenue.
i6th District 23d, 3Sth and 41st wards —
James A. Dunn, R., 5131 Milnor Street.
17th District 24th, 34th and 44th wards —
Theodore Campbell, R., 2101 North Sixty-third
Street
James J. Hefferman, R., 324 North Fifty-second
Street
Horace W. Leeds, R., 107 North Thirty-fourth
Street
i8th District 'asth and 45th wards-
Samuel J. Perry, R., 3014 Salmon Street.
John F. Snowden. R., 3363 Amber Street.
19th District 28th and 37th wards —
Edward Haws, R., 1240 Hazzard Street
Jeremiah J. Miller, R.. 2326 North Natrona Street
20th District, 29th and 47th wards —
Patrick Conner, R., 2807 Oxford Street.
John H. Drinkhouse, R., 2002 Oxford Street
21 st District 27th, 40th and 46th wards —
James Franklin, R., 5726 Thomas Avenue.
James A. Walker, R., 5313 Baltimore Avenue.
22d District, 32d ward —
Benjamin M. Colder, R., 2011 North Thirty-third
Street
23d District, 38th ward —
Albert S. C. Millar, R., 2815 North Twenty-sixth
Street
24th District, 33d ward—
Thaddeus S. Krause, R., 535 East Allegheny
Avenue.
25th District 43d ward —
Thomas Bluett R.. 728 West Erie Avenue.
26th District, 31st ward —
Philip Sterling, R., 2042 East York Street
Adams.
Eugene Elgin, R., East Berlin.
Allegheny.
1st District
Harry Feldman, R., 2136 Webster Avenue, Pitts-
burgh.
Joseph C. Marcus, R., 615 Berger Building, Pitts-
burgh.
2d District
William J. McCaig, R., 323 Fourth Avenue, Pitts-
burgh.
William F. McCann, R., 2219 Penn Avenue, Pitts-
burgh.
3d District.
Archie McKnight, R., 4717 Second Avenue, Pitts-
burgh.
4th District
Exlward B. Goehring, R., 597 Union Arcade, Pitts-
burgh.
Sth District.
William I. Goss, R., 613 Hale Street, Pittsburgh.
6th District
Albert G. Krugh, R., 2319 Jane Street, Pittsburgh.
William J. Mangan, R., 99 South Eleventh Street
Pittsburgh.
George H. Soffel,- R., S5 Wyoming Street Pitts-
burgh.
7th District
Charles A. Michel, R., 715 East North Avenue,
Pittsburgh, North Side.
James Wettach, R., IS4S Spring Garden Avenue,
Pittsburgh, North Side.
8th District.
Edward M. Hough, R.. 2651 Perrysyille Avenue,
Pittsburgh, North Side.
William F. Stadtlander, R., 802 Frick Building,
Pittsburgh.
9th District.
Clifton L. Kelly, R., McKeesport.
loth District.
Joseph N. Huston, R., Pitcairn.
Samuel J. McKim, R., Swissvale.
William H. Martin, R., Wilkinsburg.
nth District.
W. Heber Dithrich, R., Coraopolis.
William R. Dunlap, R., Knoxville.
Cornelius J. McBride, R., Lincoln Place.
Joseph G. Steedle, R., McKees Rocks.
I2th District
Nelson McVicar, R., Tarentum.
John W. Vickerman, R., Bellevue.
Armstrong.
Charles F. Armstrong, R., Leechburg.
Albert E. Curry, R., Kittanning.
Beaver.
Daniel W. McClure, R., Woodlawn.
John G. Marshall, R., Beaver.
Bedford.
Ralph Hoover, R., Everett, R. D. i.
Berks.
1st District
Paris E. Eaches, R., 1027 North Front Street
Reading.
Ernest B. Posey, R., 846 North Tenth Street,
Reading.
2d District.
Cyrus K. Brendle, D., Shillington.
Frank B. Brown, D., West Leesport.
B. Morris Strauss, D., Mohnton.
Blair.
1st District.
Frederick A. Bell, R., Altoona.
2d District.
Samuel McCurdy, R., Hollidaysburg.
Simon F. Zook, R., Curryville.
Bradford.
Charles P. Dewey, R., Gillett
Curtis M. Harding, R., Canton.
Bucks.
W. Albertson Haines, R., Bristol.
William H. Weamer, R., Springtown.
Butler.
Thomas O. Cratty, R., Butler.
George L Woner, R., Butler, R. D. 3.
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THE PENNSYLVANIA MEDICAL JOURNAL
January, 1921
Cambria.
1st District.
J. Ross Home, R., Johnstown.
2d District.
Isaac M. Chaplin, R., Johnstown.
William G. Griffith, R., Johnstown, R. D. 7.
Cameron.
C. Jay Goodnough, R., Emporium.
Carbon.
William J. Hatrick, R., Mauch Chunk.
Centre.
Thomas Beaver, R., Bellefonte.
Chester.
Thaddeus W. Harry, R., Toughkenamon.
William W. Long, R., Coatesville.
Samuel A. Whitaker, R., Phoenixville.
Clarion.
E. Marion Sweitzer, D., Shippensville.
Clearfield.
William T. DeHaas, R., Clearfield.
Donald D. Miller, R., Grampian.
Joseph E. Phillips, R., Clearfield.
Clinton.
Richard S. Quigley, R., Lock Haven.
Columbia.
Charles A. Shaffer, D., Berwick.
Crawford.
John A. Bolard, R., Cambridge Springs.
H. H. Finney, R., Meadville.
Cumberland.
Ross L. Beckley, R., New Cumberland.
George H. Stewart, Jr., R., Shippensburg.
Dauphin.
1st District.
Albert Millar, R., Harrisburg.
David L Miller, R., Harrisburg.
2d District.
Charles C. Baker, R., Halifax.
Lawrence A. Hetrick, R., Harrisburg, R. D. 4.
Delaware.
1st District.
John K. Hagerty, R., Chester.
2d District.
William C. Alexander, R., Media.
Henry F. Miller, R., Drexel Hill.
Elk.
John M. Flynn, D., Ridgway.
Erie.
1st District.
J. Reed Craig, R., Erie.
2d District.
Joseph M. Schilling, D., Erie.
3d District.
Fred W. Blair, Pro. (R.), Girard.
Fayette.
1st District.
Russel Smiley, R., Uniontown.
2d District.
Ernest R. Kooser. R., Connellsville.
Duncan Sinclair, R., Brownsville.
Lee Smith, R., Uniontown.
Forest.
Ira M. Fox, R., Endeavor.
Franklin.
John O. Craig, R.. Greencastle.
Frank S. Magill, R., Chambersburg. .
Fulton.
George A. Comerer, R., McConnellsburg.
Greene.
John C. Hampson, D., Waynesburg.
Huntingdon.
Lawrence N. Crum, R., Mount Union.
Indiana.
John Thomas Davis, R., Blairsville.
Jefferson.
Wade M. Henderson, R., Brookville.
George W. Stevenson, R., Punxsutawney.
Juniata.
John H. Shellenberger, R., McAlisterville, R. D. 2.
Lackawanna.
1st District.
David Fowler, R., Scranton.
2d District.
Hugh A. Dawson, R., Scranton.
3d District.
Frederick C. Ehrhardt, R., Scranton.
4th District
Michael J. Ruddy, D., Dtmmore.
Sth District.
William W. Jones, R., Olyphant.
6th District.
Walter W. Kohler, R., Old Forge.
Lancaster.
1st District.
Aaron B. Hess, R., Lancaster.
2d District.
G. Graybill Diehm, R., Lititz.
Joseph T. Evans, R., Ephrata.
Michael R. Hoffman, R., Maytown.
Harry L. Rhoads, R., Gap, R. D. i.
Lawrence.
David J. Jones, R., Ellwood City.
Charles G. Jordan, R., Volant.
Lebanon.
Harry H. Bamhart, R., Lebanon.
Charles Z. Weiss, R., Avon.
Lehigh.
1st District.
Harry J. Smith, R., Allentown.
2d District.
Howard E. Mautz, R., Saegersville.
3d District.
Albert E. Rinn, D., Bethlehem, R. D. 3.
Luzerne.
1st District.
Christian Miller, R., Freeland.
2d District.
Charles J. Morris, D., Lee Park, Wilkes-Barre.
3d District.
William F. McHugh, D., Pittston.
4th District
Thomas G. Roman, R., Alden.
5th District
Joseph H. Schwartz, R., Plymouth.
6th District
Lorenzo D. Thomas, R., Wyoming.
7th District
Richard Aston, R., Wilkes-Barre. •
James Gibbon, R., Wilkes-Barre.
Lycoming.
Charles F. Bidelspacher, R., Williamsport.
Warren Clyde Harer, R., Williamsport.
McKean.
Charles W. Catlin, R., Port Allegany.
John A. Fitzgibbon, R., Bradford.
Mercer.
Edward L. Allum, R., Sharon.
Samuel J. Orr, R., Greenville.
Mifflin.
James W. Mitchell, R., Lewistown.
Monroe.
Alvin O. Seig, R., Tobyhanna.
Montgomery.
1st District
Harold C. Pike, R., Cheltenham.
2d District
Joseph A. Ruth, R., Conshohocken.
3d District.
Isaiah T. Haldeman, R., Schwenkville, R. D. r.
4th District.
Thomas R. Brown, R., Stowe.
Montour.
J. Beaver Gearhart, R., Danville.
Northampton.
John N. Hoffman, R., Bangor.
Irwin P. Richards, R., Easton.
Titus M. Ruch, R., Hellertown.
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January, 1921
OFFICERS' DEPARTMENT
273
Northumberland.
Charles A. Lewis, R., Shamokin.
John T. McMuUen, R, Shamokui.
Timothy O. Van Allen, R., Northumberland.
Perry.
Clark M. Bower, R., Blain.
Pike.
Walter R. Shannon, R., Lackawaxen.
Potter.
J. Walter Wells, R., Coudersport
Schuylkill.
1st District.
Adam C. Schaeffer, R., Mahanoy City.
2d District.
James Donneley, D., Pottsville, R. D. i.
3d District.
Robert J. Kantner, R., Tamaqua.
4th District.
Joseph M. Denning, R., Saint Clair.
Clarence A. Whitehouse, R., Pottsville.
Snyder.
John I. Woodruff, R., Selinsgrove.
Somerset.
Paul D. Clutton, R., Meyersdale.
John G. Ogle, R., Somerset.
Sullivan.
Veil Burr Holcombe, R., Dushore.
Susquehanna.
Frederick T. Gelder, R., Forest City.
Tioga.
Philip H. Dewey, R., Gaines.
George W. Williams, R., Wellsboro.
Union.
Samuel B. Wolfe, R., Lewisburg.
Venango.
Joseph T. Foster, R., Franklin.
Brooks Haslett, R., Oil City, R. D. 2.
Warren.
Williston P. Wood, R., Grand Valley.
Washington.
David M. Curran, R., Washington.
J. Add Sprowls, R., Donora.
George T. Walker, R., Washington.
Wayne.
Edward E. Kinsman, R., Honesdale, R. D. 2.
Westmoreland.
1st District.
Roy W. Hayes, R., Latrobe.
Thomas M. Whiteman, R., Latrobe.
2d District.
Elmer Henderson, R., Trafford.
Alexander McConnell, R., Greensburg.
Howard F. Rieder, R., Arnold.
Wyoming.
Oscar D. Stark, R., Tunkhannock, R. D. 4.
York.
1st District.
Robert S. Spangler, R., York.
2d District.
Calvin E. Cook, R., Dillsburg, R. D. 4.
3d District.
Thomas E. Brooks, R., Red Lion.
4th District.
Bert L. Brenneman, D., York New Salem.
RECAPITULATION
R. D.
Senate 47 3
House of Representatives 193 14
IN MEMORIAM
Republican majority on joint ballot, 223.
240 17
SAMUEL PHILIP HEILMAN, M.D.
It has pleased Providence to remove from our midst
our friend and coworker. Dr. Samuel Philip Heilman,
who for more than three quarters of a century dwelt
in the county and city of Lebanon, and who was al-
ways proud to call this his home by birth as well as
choice.
He labored faithfully and well through a life
crowded with good works; as a Christian gentleman,
prominent in the work of the church which he loved;
as a skilled and successful physician, sympathetic and
beloved of those to whom he was privileged to min-
ister; as an honored and respected citizen in the com-
munity which honored him and reflected honor upon
itself by choosing him to represent it upon manifold
occasions ; as a teacher and scholar of culture and re-
finement; and as a lover of the home fireside, where
in his leisure hours he dwelt in contentment, commun-
ing as a student of history with kindred spirits of the
past, surrounded by those near and dear to him within
the family circle.
It was our pleasure to have associated with_ him as
fellow members of the Lebanon County Medical So-
ciety, and by virtue of this intimate association and
the high honor and respect entertained for him by the
members of the society, we hereby convey to the mem-
bers of his family this testimonial of the esteem and
extend our sympathy for the loss of one who could
face his Creator in the evening of life as a faithful
disciple of Christ and a servant to man.
May we suggest that a copy of this expression of
deep regard be sent to the members of his family, to
the Journal of the State Society, to the press, and be
recorded upon the minutes of the society.
Committee of the Lebanon County
Medical Society:
W. M. GuiLFOKD,
E. B. Marshall,
D. M. Rank.
WILLIAM THOMAS BISHOP, M.D.
This society is called to record the removal by nat-
ural death of one of its fellows, William Thomas
Bishop, M.D., born in Hummelstown, this county, died
in Ebensburg, Cambria County, Pa., at the mature age
of 80 years.
He was officially identified with organized delegat-
able American professional associations, namely: the
Dauphin County Medical Society, the Medical Society
of the State of Pennsylvania, and the American Medi-
cal Association, and did his duty faithfully.
His life career was varied. In the early part of it,
he was a lawyer, as was his prominent father before
him, and then subsequently studied medicine. His
keen legal training bore fruit, when a member of the
Judicial Council of the American Medical Association.
There he shone to great advantage in the adjudication
of medical ethical questions which came before it for
final decisions. His genial presence will be noted by
its absence.
He was a member of this Necrological Committee.
(Signed) H. McGowan, M.D.,
Hugh Hamilton. M.D.,
Committee.
WARREN F. KLEIN, M.D.
In the recent death of Dr. W. F. Klein the Lebanon
County Medical Society has lost an active and valued
member.
We desire to place on record our appreciation of his
many kindly qualities as a man and physician, and
recognize his devotion to the interests of our profes-
sion at large.
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THE PENNSYLVANIA MEDICAL
]0^k^.
AL
January, 1921
At the height of his ambition and activities, sud-
denly called hence by an inscrutable Providence, he
will be greatly missed by us, as well as by those he
served so faithfully in their need.
We tender our sincere sympathy to his wife and
family in their bereavement.
Resolved, That a copy of this action be presented to
the family of Dr. Klein, also placed on the minutes of
our society, and sent to the local papers and The
Pennsylvania Medical Journal.
W. M. Guilford,
E. B. Massbau,,
D. M. Rank,
Coinmittee.
THOMAS COPE, M.D.
Or. Thotnas Cope, of Nazareth, Pa., died suddenly
at his home of cerebral hemorrhage on June 27, 1920.
Dr. Cope graduated from Jefferson Medical College,
Philadelphia, in the year 1869, and was in active prac-
tice since his graduation up to the time of his death.
He was a member of the Pennsylvania, State and
Northampton County Medical Societies, closely allied
with each, but especially active in the Coimty Medic&I
Society.
He was affiliated and served in the capacity of vis-
iting physician to the Northampton County Home for
more than twenty years, and was also a district phy-
sician for the poor, for an equal number of years.
Dr. Cope was born in Pennsylvania, Aug. 18, 1847,
and despite his advanced years, he was not only ac-
tively engaged in practice, but was associated in the
promotion of business interests in his community;
being president of the Nazareth National Bank, di-
rector of the Dexter Portland Cement Company of
Nazareth, and Clinchfield Cement Company of Ala-
bama.
Dr. Cope was a_ man of wide reputation, and was
frequently called in consultation by his neighboring
practitioners. Possessed of a genial disposition, and a
character above reproach, he enjoyed the loyalty of a
host of friends.
Resolved, That we regret his sudden death, believ-
ing him to have been a wise councilor, and that we
feel the Northampton County Medical Society has
sustained a great loss in being thus deprived of a
member who was always willing to help maintain the
high standards of our profession.
J. A. Fraunfelder,
Victor J. Koch,
Harry C. Pohl,
Committee.
COUNCIL ON HEALTH AND PUBLIC
INSTRUCTION FORMULATES ITS
SOCIAL PROGRAM
The House of Delegates of the American Medical
Association, at its recent meeting in New Orleans, di-
rected the Council of Health and Public Instruction
to make a report at the next annual meeting on the re-
lation of the medical profession toward the public.
At its meeting, November nth, the Council considered
this matter and in doing so asked to sit with it Dr.
Frank Billings, of Chicago ; Dr. Hugh Cabot, of Ann
Arbor ; Dr. Wadsworth, of the New York State De-
partment of Health, and Dr. F. E. Sampson, • of
Creston, Iowa.
The Council considered the following subjects and
took action as stated below :
I. The Council believes it highly desirable that the
nature and transmission of communicable diseases
should be taught in the public schools of the country.
This is already a leSal requirement in a few states. In
other states such instruction is confined to tubercu-
losis. The secretary of the Council was requested to
gather such information as he may be able to find
bearing in this matter and to have framed a model
bill for introduction into the leg^islatures of the states
which do not already provide for such instruction.
2. The Council believes that teachers in our public
schools should know something about the communica-
ble diseases and what should be done with pupils under
their charge developing these diseases. The Council
believes that a course in epidemiology should be re-
quired in all normal schools and in schools of educa-
tion in our universities; in short, that no one should
be licensed to teach without having had instruction in
epidemiology. The secretary of the Council was re-
quested to have formulated a model bill bearing upon
this subject.
3. The Council is of the opinion that there should
be a closer cooperation between the medical profession
and laymen who are interested in public health, and
the Council recommends that sections on public health
and sanitation be organized in state and local medical
societies, and that laymen ■ interested in public health
be admitted as associate members of this society and
referred to the sections. In the opinion of the Coun-
cil, this matter should be discussed more fully at the
next meeting of the Council in March, 1921.
4. In the opinion of the Council, it is highly desira-
ble that the American Medical Association should, as
soon as possible, begin the publication of a popular,
up-to-date ' journal on sanitation and epidemiology,
which should give to the public the latest, most com-
plete and most scientific information concerning the
prevalent and communicable diseases. It is the wish
of the Council that this matter be referred to the
Board of Trustees of the American Medical Associa-
tion.
5. The Council on Health and Public Instruction be-
lieves that the American Medical Association should
take steps to secure the following results :
(o) To assist local medical practitioners by supply-
ing them with proper diagnostic facilities.
(6) To provide for residents of rural districts, and
for all others who cannot otherwise secure such bene-
fits, adequate and scientific medical treatment, hospital
and dispensary facilities and nursing care.
(f ) To provide more efficiently for the maintenance
of health in rural and isolated districts.
(<f) To provide for young physicians who desire to
go to rural localities, opportunities for laboratory aid
in diagnosis.
ie) The Council believes that these results can be
best secured by providing in each rural community a
hospital with roentgen-ray and laboratory facilities to
be used by the legally qualified physicians of the com-
munity. The secretary of the Council was requested
to study the laws of the different states bearing upon
this subject and to prepare a model bill to be studied
more fully at the meeting of the Council in March,
1921.
Victor C. Vaughan, M.D., Ann Arbor, Mich.
Chairman, Council on Health and Public Instruction.
— Jour. A. M. A., Dec. 4, 1920.
"Lepso"— Epilepsy Cure.— Like most epilepsy "cures,"
Lepso was found by the A. M. A. Chemical Laboratory
to be essentially a bromid mixture. It was found to
contain the equivalent of 51 grains of potassium
bromid to the dose. — (Jour. A. M. A., Nov. 20, 1920,
p. 1443)
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County Medical Societies
REPORTERS OF COUNTY SOCIETIES:
Adams — Henrr Stewart, M.D., Gettysburg.
AuECHSNY — Paul Titus, M.D., Pittsburgh.
Akustiiomc — ^Tay B. F. Wyant, M.D., Kittanning.
Bkaver — Fred B. Wilson, M.D., Beaver.
Bedfokd — N. A. Timmins, M.D., Bedford.
Bekks — Clara Shetter-Keiser, M.D., Reading.
Blair — James S. Taylor, M.D., Altoona.
Bdadfokd — C. L. Stevens, M.D., Athens.
Bt;CKS — Anthony F. Myers, M.D., Blooming Glen.
BcTLEX — L. Leo Doane, M.D., Butler.
Cambria — Frank G. Scharmann, M.D., Johnstown.
Carbon — Jacob A. Trexler, M.D., Lehighton.
Center — James h. Seibert, M.D., Bellefonte.
Chester — Henry Pleasants, Jr., M.D., West Chester.
Clarion — Sylvester J. Lackey, M.D., Clarion.
Clearfield — J. Hayes Woolridge, M.D., Clearfield.
Clinton — R. B. Watson. M.D., Lock Haven.
Columbia — Luther B. Kline. M.D.. Catawissa.
Crawpord — Cornelius C. Laffer, M.D., Meadville.
Cumberland — Calvin R. Rickenbaugb, M.D., Carlisle.
Dauphin — Marion W. Emrich, M.t)., Harrisburg.
Delaware — George B. Sickel, M.D., Chester.
Elk — Samuel G. Logan, M.D., Ridgway.
Erie — ^J. Burkett Howe, M.D., Erie.
Fayette — George H. Hess, M.D.. Uniontown.
Franklin — John J. Coffman. M.D.. Scotland.
Greene— Thomas B. Hill, M.D., Waynesburg.
Huntingdon — John M. Beck, M.D., Alexandria.
Indiana — Alexander H, Stewart, M.D., Indiana.
Jefjerson — John H. Murray, M.D., Punxsutawney.
Juniata — Isaac G. Headings, M.D., McAIisterville.
Lackawanna — Harry W. Albertson, M.D., Scranton.
Lancaster — Walter D. Blankenship, M.D., Lancaster.
Lawrence — William A. Womcr, M.D., New Castle.
Lebanon — Samuel P. Heilman, M.D., Lebanon.
Lehich — Martin S. Kleckner, M.D., Allentown.
Luzerne — Peter P. Mayock, M.D., Wilkes-Barre.
LvcoMiNG — Wesley F. Kunkle, M.D., Williamsport
McKean — James Johnston, M.I3., Bradford.
Mercer — M. Edith MacBride, M.D., Sharon.
Mifflin — Frederick A. Rupp, M.D., Lewistown.
Monroe — Charles S. Logan, M.D., Stroudsburg.
Montgomery — Benjamin F. Hublcy, M.D., Norristown.
Montour — Cameron Shultz, M.D., JJanville.
Northampton — W. Gilbert Tillman, M.D., Easton.
Northumberland — Charles H. Swenk, M.D., Sunbury.
Perry — Maurice I. Stein, M.D., New Bloomfield.
Philadelphia — Samuel McClary, 3d, M.D., Philadelphia.
Potter — Robert B. Knight, M.D., Coudersport.
Schuylkill — George O. O. Santee, M.D., Cressona.
Shvder— Percy E. Whiffen, M.D., McClure.
Somerset — H. Clay McKinley, M.D., Meyersdale.
Sullivan — Carl M. Bradford, M.D., Forksville.
Susquehanna — H. D. Washburn, M.D., Susquehanna.
TioOA— Lloyd G. Cole, M.D., Blossburg.
Union — William E. Metzgar, M.D., Allenwood, R. D. a.
Venango — John F. Davis, M.D., Oil City.
Warren~M. V. Ball, M.D., Warren.
Washington — Homer P. Prowitt, M.D., Washington.
Wayne — Sarah Allen Bang, M.D., South Canaan.
Westmoreland — Wilder J. Walker, M.D^ Greensburg.
Wyoming — Herbert L. McKown, M.D., TunkhannocL
York — Nathan C. Wallace, M.D., Dover.
January, 1921
COUNTY SOCIETY REPORTS
BERKS— NOVEMBER
Following is an abstract of the excellent paper read
before the Society by Dr. Henry I. Klopp, superin-
tendent of the Homoeopathic State Hospital at Al-
lentown, on "The Mentally Sick Patient."
Medicine is an art, therefore examination of a men-
tal case is an art, acquired by practice. Mental dis-
orders at best are obscure phenomena, and no pains
should be spared to illumine them from every quar-
ter. It is not expected that every possible physical
and laboratory test will be applied to each case, but a
complete examination of a patient suffering from
mental disease is as important in psychiatry as in any
department of medicine. Examination should include
not only the symptoms that the patient presents when
seen, both objectively and subjectively, but also the
family and personal history. The examination of pa-
tients requires a knowledge of the symptomatology of
mental disease.
What constitutes mental disease? It is a departure
from the normal which, however, varies in different
individuals. A mentally diseased person may be sub-
ject to delusions, illusions or hallucinations. A delu-
sion is a false belief in which the patient is unable to
accept reality, such as a feeling that he may be damned
or robbed or killed. An illusion is a misinterpreted
sense perception, as mistaking a row of trees for a
row of serpents. A hallucination is a false sense per-
ception without objective reality, as hearing voices or
seeing ghosts.
The basic principle in the making of an examina-
tion is to determine what constitutes the patient's
normal standard of feeling, thinking and acting, and
to know if there is a prolonged departure from the
normal. A person may temporarily depart from the
normal, as in the delirium of tj^ihoid, without being
mentally diseased.
In the examination of the patient the physician must
have
I. The family history;
2 The personal history previous to disease ;
3. The history of the onset of the present disease;
4. The condition and general observation of the pa-
tient at the time of examination ;
5. Special examination, which includes general, re-
spiratory, circulatory, gastro-intestinal, neurological
and mental phases.
In obtaining the family history, ascertain the mental
characteristics, the disposition, temperament, eccen-
tricities and peculiarities. Have there been nervous
disorders, as convulsions in infancy, tuberculosis,
hysteria, mental disease or syphilis? In securing the
personal history, find out what kind of person he was
before becoming unbalanced. It is important to know
the makeup of the individual, as well as the circum-
stances causing the disorder, such as the conditions
of childhood. Did he walk and talk early in life, or
was he backward? In securing the history of the
present illness, learn the cause, and whether the onset
was gradual or sudden, due to disease or accident, or
connected with business stress or worry. Among the
general observations note the emotional condition,
whether depressed, exhilarated or apathetic, whether
irritable, impulsive, angry, homicidal or suicidal. Note
if indifferent or restless, and whether he jumps from
one. seat to another or whether he takes a long time to
move, dress or eat
IntellBctuai, and Memory Tests on essential men-
tal symptoms.
Orientation — Knows the surroundings and people
with whom he is in contact.
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January, 1921
Content of train of thought — Is he jumping from
one subject to another ? Mental disorders are a chang-
ing phenomena ; is there a prolonged departure from
normal standards of thinking, feeling and acting?
Among disorders of train of thought are flight of
ideas, circumstantiality, retardation.
Disturbances of memory — Ask patient to count up
to twenty. Give different numbers and see if he can
recall them.
Speech disturbances — Test by giving test phrases.
Some cases have lost control of will. Another type is
mutism and negativism, when the patient will not co-
operate, answer or do tests. Ask him if he considers
life worth living, and if not why not. Get his com-
ment, coherence, attention and expression, judgment
and insight, and judge as to his clouding of conscious-
ness.
General observations — Demeanor and appearance,
conduct, clothing ; facial expression, whether sad, dull,
suspicious, expressionless, apathetic or indifferent;
movements, whether active or passive; mannerisms;
volitional field, whether increased or decreased psy-
chomotor activity, stereotypy, negativism, suggestibil-
ity or stupor.
Facts that should precede diagnosis — Those observed
by you, appearance and manner of patient ; those com-
municated by patient, and those communicated by oth-
ers. Claba S. Keiser, Reporter.
COLUMBIA— DECEMBER
The annual meeting of the society was held at the
Hotel Magee, Bloomsburg, December 9, 1920, the presi-
dent, Dr. J. T. Macdonald, presiding, and with 24
members present out of a total membership of 47.
The report of the secretary revealed that five mem-
bers were added during the year, with one death and
one transfer to the Lycoming County Society.
The scientific program was on the subject of "Otitis
Media and Modern Treatment of Deafness," by Dr.
Henry Bierman, who, in a well-prepared, practical and
up-to-date discussion of the subject, held the attention
of all. The paper was discussed by Drs. S. B. Arment,
J. S. John, M. W. Freas, H. V. Hower and F. R.
Clark. Dr. J. T. Macdonald was on the program for
an address as retiring president, but being called away
professionally, was unable to deliver it at this time.
The election of oflicers and the presentation of the
annual reports consumed time that is ordinarily used
in the discussion of medical subjects. Proposed or
threatened legislative bills inimical to the best inter-
ests of our people received some consideration at the
meeting.
Dr. Charles B. Yost was elected president, and as
required by the by-laws, appointed the Committee on
Public Policy and Legislation, consisting of Dr. J. W.
Bruner, Bloomsburg; Dr. J. M. Vastine, Catawissa,.
and Dr. H. S. Buckingham, Berwick. The other offi-
cers elected were Drs. M. W. Freas, and Clark S.
Long, vice presidents; Dr. L. B. Kline, secretary and
treasurer, and Dr. F. R. Clark, censor for .three years.
The next meeting will be held at Catawissa on Janu-
ary 13th. L. B. Kline, Reporter.
DELAWARE— DECEMBER
The December meeting of the Delaware County
Medical Society was held at the Chester Hospital,
Chester, on December 9th, President Dr. D. J. Moni-
han presiding.
After disposal of routine business. Dr. Ira G. Shoe-
maker, of Reading, District Councilor, presented a
number of subjects for the consideration of the soci-
ety. Among these was the work contemplated by the
Legislative Committee of the State Society during the
coming session of the state legislature. The usual bills
from the anti-vivisectionists, chiropractors, etc., need
to be watched. Health insurance was briefly discussed
and the need was emphasized for every physician to
acquaint himself with this most important subject, so
that the profession may intelligently act to the best in-
terest of all concerned in the matter. For the support
of this work an assessment of two dollars per member
was voted by the society. The need for a fair and
standard fee bill, especially one bearing on "compensa-
tion cases," was spoken of by Dr. Shoemaker.
Another question of interest and importance was
that concerning the establishment of county hospitals
and grot^ practice centers, in sparsely settled parts
of the state.
All of Dr. Shoemaker's remarks were very timely,
and impressed one with the fact that we as physicians
must take a more active part, not only in medicine as a
science, but in sociological problems connected with
the practice of medicine. The best solution of these
problems can only come with the help of medical men
and we should be keenly interested in this phase of the
profession.
The scientific paper of the evening was presented by
Dr. Thomas Klein, Philadelphia, on "The Clinical In-
terpretation of Modern Laboratory Findings Neces-
sary for the General Practitioner."
Dr. Klein's paper discussed a number of tests which
could be done by the general practitioner without ex-
pensive or complicated apparatus, without taking a
great deal of time, and which necessitated but little
practice in order to make the results of sufficient value
for clinical purposes.
The various tests in the nephritides were considered
and their value pointed out in each group, namely, the
acute and chronic glomerular nephritis, the degenera-
tive tubular type, and the arteriosclerotic kidney.
Among the tests were the water test and the test for
the power of concentration in the tubular nephritis, the
value of determination of chlorides and the associa-
tion of chloride retention and edema; the urease
method of determining blood urea; the use of the
Dunning colorimeter for the phenolsulphonphthalein
test for kidney function. These were all discussed and
the significance of the results indicated.
The importance of routine determinations of blood
sugar in cases of diabetes mellitus was broujght out
and illustrated by case histories. The use of the
Kuttner-Leitz" colorimeter for this test was advised.
One case quoted was that of a man, 72 years of age,
who had diabetic gangrene with abscence of urinary
sugar. Determination of blood sugar in this case
showed four times the normal amount present. When
fed upon a liberal diet preparatory to operation, sugar
appeared in the urine. Another case was that of a
young woman who could not take more than 10 grams
of starch per day without sugar being present in the
urine, indicating a very low kidney threshold. This
case showed a blood sugar about half normal. The
importance of this test in studying the diet of the dia-
betic was emphasized and also the estimation of acid-
osis by means of Marriott's method of determining
the alveolar carbon dioxide tension.
In speaking of analysis of gastric contents. Dr. Klein
made clear the importance of the fractional method.
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as it gives more accurate information, and indicates
the proper time for medication.
He also referred to the examination of bile obtained
by means of the duodenal tube. The paper was in-
tensely interesting and practical, and was well dis-
cussed by the members, of whom 32 were present.
Geo. B. SicKEL, Reporter.
SOMERSET— NOVEMBER
The November meeting of the Somerset County
Medical Society was held at Rockwood on the i6th
inst. This was the last regular meeting for the year
and was very slimly attended for a meeting of so much
importance. The annual reports of officers, auditing
of the financial business and the election of officers
for the ensuing year is the regular order of business.
The treasurer of the Society was absent on account of
an attack of rheumatism and audit of the finances was
postponed until January but there was evidence that
the finances are in good shape.
Two new members were received, Dr. C. C. Glass,
of Meyersdale, and Dr. Jerry M. James, of Hoovers-
ville.
A committee was appointed to voice the sentiment
of the Society on the vicious legislation that seems
most likely to come before the next legislature. The
action was as follows:
Whereas, At the coming session of the legislature
of the State of Pennsylvania certain bills are sure to
be presented, such as the Osteopathic bill, the Com-
pulsory Health Insurance bill and the Antivivisection
bill ; therefore, be it
Resolved, That it is the duty of every physician in
Somerset County who has at heart the best interests
of the profession and of the people- in general, to
strenuously oppose all such legislation.
The program of the State Department of Health
campaign for the elimination of venereal infection,
as addressed to each physician of the county was the
subject that took up the remainder of the time. The
"Outline of Medical Activities" in relation to the sub-
ject was discussed and considered feasible, but would
require continued united action for quite a period of
time although worthy of the best efforts the profes-
sion can put forth. ' H. C. McKinley, Reporter.
STATE NEWS ITEMS
DEATHS
Dr. Edward F. Backmann, 1823 S. Broad St., Phila-
delphia, died December 6.
On December 9. 1520, at 4 p. m., Margaret Burling-
ham Thomas, wife of Dr. C. M. Thomas, died. Fu-
neral services were held at the family home, 754
Brownsville Road, Knoxville, on Sunday, December
12, at 3 p. m. Interment was made in Southside ceme-
tery.
Dr. Henry L. Bollman, 60, died December 9 at his
home near Reading. He was one of Berks Coun-
ty's leading physicians and his death was due to over-
work in the "flu" epidemic two years ago, undermin-
ing his health.
Dr. R. G. Miles, a well-known physician of New
Castle, was found in his office December 10 dead. A
hat, filled with cotton that had been saturated with
ether or chloroform, was over his head. He had been
melancholy for some time, according to friends.
Mrs. Edward Everett, wife of Dr. Edward Everett,
one of the oldest members of the Lycoming Coimty
Society, died on Monday evening, November 15, at
her late home in Masten, after a rather short illness,
although she had not been in good health for some
time. She was buried on Thursday morning, Novem-
ber 18, at Wildwood cemetery, WilHamsport.
items
Born to Dr. and Mrs. Ralph S. Heilman, of Sharon,
a son, Dec. 13, 1920.
Dr. Walter J. Freeman, 1832 Spruce St., Philadel-
phia, has retired from practice.
Dr. H. Furness Taylor, Ridley Park, Pa., is con-
valescing from a serious attack of pneumonia.
Dr. and Mrs. J. J. O'Connor have moved into their
new home on Main St., Olyphant, Lackawanna Co.
, The Sunshine Society of Sharon had a tag day,
December 18, to raise money for a Free Dental Clinic.
Dr. R. C. Peters, Allentown physician, was elected
president of the Lehigh Medical Society on December
18.
Betty Jane Lacock is the latest addition to the
family of Dr. H. M. Lacock, of Bumsville, Nov. 18,
1920.
Ground will be broken for the building of the
Robert H. Crozer addition to Chester Hospital about
the first of January.
Dr. George L. Armitage, Chester, was married on
Nov. 16, 1920, to Miss Edna Osborne McCutcheon, of
Ben Avon, Pennsylvania.
Dr. J. George Bccht, of Harrisburg, addressed
members of the Social Service Club on "Tuberculosis,"
on the evening of December 13.
Dr. Walter E. Boyer, of 861 East Third St., Wil-
Hamsport, was married November 3, at Oil City, Pa.,
to Miss Margaret E. Shannahan.
Dr. Clifford H. Arnold, Chester, has removed his
office to Ardmore, Pa., where he will be associated
with his father. Dr. H. A. Arnold.
Dr. E. Pierce Shops, an interne in the Episcopal
Hospital, Philadelphia, visited his parents, Dr. and
Mrs. S. Z. Shope, 610 North Third St., Harrisburg,
recently.
Dr. D. J. McCarthy, University of Pennsylvania
professor, who visited Russia, in a speech at Lancaster
warned people against Lenine as one of the great
brains of the world.
Dr. and Mrs. John B. Deaver. 1634 Walnut St.,
Philadelphia, spent Christmas in Morristown, N. J.,
with their son-in-law and daughter, Mr. and Mrs.
George G. Thompson.
Dr. J. C. Gallagher on December 17 was appointed
chief surgeon for the Philadelphia and Reading Coal
and Iron Company collieries north of the Broad
Mountain, near Shenandoah.
Dr. George B. Kunkel, well-known physician of
Harrisburg, has been elected a member of the Y. M.
C. A. board of trustees. He will serve out the unex-
pired term of the late Judge S. J. M. McCarrell.
Dr. Charles AiTMaLER, of Bloomsburg, is laid up
with illness at the home of his father at Hazleton. He
had been ill at his home for a long time and had gone
to Hazleton to recuperate, where he had a relapse.
The engagement of Miss Daniel, who is a daughter
of Mrs. Hpnry May Daniel, of Chestnut Hill, Philadel-
nhia, and Dr. Norman H. Taylor, son of Mr. and
Mrs. Frank H. Taylor, was announced early in De-
cember.
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Ds. A. C. MoKGAN, of Philadelphia, a specialist on
internal diseases, addressed the doctors of the Harris-
burg Hospital in the staff room of the hospital Decem-
ber 14. Dr. Morgan spoke on the "Post Influenzal
Chest."
Dr. Luther C. Peter, of Philadelphia, by invitation,
addressed the Section on Ophthalmology and Oto-
Laryngology of the Medical Society of the District of
Columbia at the October meeting on "The Value of
Perimetric Studies in the Diagnosis of Accessory
Sinus Disease."
Physicians of Harrisburg and Dauphin County
heard an address by Dr. Walter L. Niles, of Cornell
University, during the observance of the twenty-sixth
anniversary of the Harrisburg Academy of Medicine
in the Penn-Harris Hotel, December 17. Dinner was
served after the address.
At a meeting held on Dec. 3, 1920, an organization
to be known as the Pittsburgh Qrthopaedic Club was
inaugurated and the following officers elected: Pres.,
Dr. Stewart L. McCurdy; vice-pres., Dr. David Sil-
ver; sec. Dr. Eben W. Fiske. Meetings will be held
on the third Friday of each month.
Dr. J. P. H. Ruddy, of Scranton, who saw considera-
ble service with the army medical corps, and who was
given a six months' course at the Post Graduate Hos-
pital in New York in recognition of his work, has
gone to Rochester, Minn., where he is to spend several
weeks at the famous Mayo Brothers' clinic.
The marriage of Miss Edith Craig Buvinger,
daughter of Dr. and Mrs. C. I. Buvinger, of Rebecca
Ave., and John J. Bornman, of Howe St., Pittsburgh,
Pa., took place Wednesday, December 8, in the Buv-
inger home, with Rev. Thomas J. Bigham officiating.
After an eastern trip, Mr. and Mrs. Bornman will be
at home in Howe St.
The Lycoming County Medicai, Society, at its De-
cember Meeting, endorsed the movement that the so-
ciety erect a tablet to the members of the society who
entered the service during the late war, with their
names inscribed thereon, and that Dr. Chaapel, to-
gether with assistants which he may select, be au-
thorized to raise the funds to pay for same.
Dr. J. R. Beckley, Lebanon, has been appointed by
Colonel Edward Martin, Commissioner of Health, as
medical inspector of schools of the Lebanon inde-
pendent district ; other inspectors named being Dr. C.
C. Piatt, Corydon, for Kinzua and Corydon Town-
ships, Warren County, and Dr. G. F. Drum, Miflflin-
town, for Briar Creek Township, Columbia County.
Dr. Honora Robbins Grimes died December 13. Dr.
Grimes was born in Hemlock Township, Columbia
County, Pa., April 23, 1859. She graduated from the
Woman's Medical College, Philadelphia, in June,
1886, practiced in Bloomsburg, Columbia County, was
married Dec. 22. 1898, to Josephus Grimes. She has
been in poor health for a few months, but was thought
to be improving, but had a paralytic stroke on Decem-
ber II and died without regaining consciousness.
Dr. Charles Gordon Heyd, of New York, attached
to the Post Graduate Hospital and one of the coun-
try's best surgeons, gave a highly instructive lecture
on the diseases of the stomach, gall bladder, and ap-
pendix, recently before the members of the Lacka-
wanna County Medical Society. Dr. Heyd, who was
invited to appear in this city by Dr. James P. H.
Ruddy conducted a very successful clinic at the State
Hospital in the afternoon in which he gave practical
demonstration of some of the latest surgical methods.
John. Meliter, chief of the bureau of housing of
the State Department of Health, has been named to
represent the Pennsylvania Department at the Na-
tional conference on housing at Bridgeport, Conn.
He will call attention to slum conditions in the small
towns where overcrowding and bad conditions in lodg-
ing and tenement houses have been discovered which
are considered dangerous. Attention will also be
called to the manner in which barns and cattle sheds
are built close to the houses in steel and mining towns
in Pennsylvania.
Dr. a. F. Hardt entertained the members of the Ly-
coming County Medical Society and a number of
other medical friends, about ninety in all, at the Wil-
liamsport Country Club, Friday evening, November
12, with a very elaborate dinner. Among his guests
were Dr. Henry D. Jump, of Philadelphia, President
of the Medical Society of the State of Pennsylvania;
Dr. George W. Reese, of Shamokin, Superintendent
of the State Hospital at Shamokin. It was Indeed a
very delightful affair and enjoyed to the fullest extent
by all present. Dr. Hardt was voted an ideal host and
all present, silently, voiced the hope expressed pub-
licly by Dr. Dewalt, tliat he would soon do the same
thing ag^in.
Sir Arthur Newsholme, Director of Public Health
for the British Empire, who is lecturing at Johns
Hopkins University to the sanitary health officers of
the United States, asked Colonel Edward Martin, a
personal friend, to send to the conference at Balti-
more representative public health officers of Pennsyl-
vania. Colonel Martin, recognizing the ability of C.
A. Emerson, Jr., one of the best-known sanitary engi-
neers in America, assigned Mr. Emerson to the Johns
Hopkins University, together with H. E. Moses, G.
Douglas Andrews, IvanM. Glace and C. B. Mark, all
of the engineering division. The course will be com-
pleted in about two weeks, when Mr. Emerson and his
staff will return to Harrisburg prepared to give the
State Department of Health the benefit of their
studies.
Indifference on the p.\rt of health officials, police
or whoever is charged with the duty of seeing that
quarantine regulations are enforced, is responsible for
the spread of contagious disease in Chester at the
present time, according to Dr. J. R. T. Gray, the city
bacteriologist. "Most rigid observance and enforce-
ment of the quarantine laws, as regards communicable
diseases, is absolutely necessary in this city," declared
Doctor Gray. When a case of contagious dis-
ease is reported to the health board, the house in
which the case exists is properly placarded, it is
claimed, but neither the members of the family living
there nor the neighbors pay any attention to the pla-
card warning people against going in and out of the
house. Local physicians look for a serious epidemic
of scarlet fever, diphtheria, or some other virulent
disease if something is not done to correct the evil
complained of by Doctor Gray.
Attention has been called many times to the
need of practitioners for rural sections of Pennsyl-
vania. We desire to call attention of the physicians
in Pennsylvania to the following letter: "Dr. Wright,
Erie City, Pa., Dear Sir: — Being asked to write for
information, I will say that the people of Mill Village
and vicinity are without a doctor. Dr. Andrews hav-
ing gone South and will stay until probably May or
June. With the drug store closed and the doctor
gone, the people have signed up a petition to the sum
of two or three hundred names for some help to get
the right kind of a man started here. Now, Mr.
Wright, if you could suggest a way to go about this,
it would be appreciated. Yours, (Signed) G. B. Run-
nels, Secretary, Board of Health, Mill Village, Erie
County, Pennsylvania." Should anyone know of a
physician seeking an opening to practice in Pennsyl-
vania, he will do well to immediately correspond with
Mr. Runnels, Secretary of the Board of Health, Mill
Village, Erie County, Pennsylvania.
Amendments to the State Workmen's Compensa-
tion Act bringing all of Pennsylvania's workers under
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its provisions and increasing the schedule of compen-
sation and the duration of the period for payments
will be sought at the next session of the legislature
by the United Mine Workers of America. Roger J.
Dever, of Wilkes-Barre, counsel for the miners, who
was in Philadelphia arguing a case before the Su-
perior Court, declared the act must be so amended as
to bring all the state's workers under the law and take
away from railroad companies and other businesses
engaged in interstate commerce the right to have the
claims brought under the provisions of the Federal
Employers' Liability Act. Thousands of wives, chil-
dren and othpr kin of railroad employees are without
any protection under the State Workmen's Compensa-
tion Act," Mr. Dever said. "Pennsylvania must
amend its law in such a manner that the dependents
of railroad employees as well as of other men em-
ployed by firms engaged in interstate commerce will
be as fully protected as those engaged in intrastate
commerce."
The Medical Protective Company of Fort Wayne,
Ind., has just completed statistics on the amount of
money involved in judgments that have been rendered
in the past few years and finds that the number of
judgments in excess of $S,ooo in 1915 was a little over
I per cent, while in 1920 the ratio of judgments in
excess of $5,000 was a trifle less than 54 per cent. This
indicates that courts and juHes are now assessing
higher damages against physicians found guilty of
malpractice than they did in 1915. The Medical Pro-
tective Company has met this situation by preparing
an added indemnity clause increasing the amounts
available for the payment of judgments to $10,000 in
a single case and $30,000 in any number of suits grow-
ing out of services rendered in any one year. The
premium for this additional protection will be $6, mak-
ing a total premium of $21 for indemnity in the
larger amounts. Physicians whose policies are now
limited to $S,ooo and $15,000, respectively, may take
advantage of this enlarged protection by having a rider
attached to their present policies on the payment of
the extra premium of $6.
Ofwcebs op the municipal court are satisfied now
they have discovered the "leak" which has permitted
drug addicts tmder treatment in hospitals of Philadel-
phia as wards of the court to obtain more dope, and
thus nullify to a large extent many of the cures.
Through constant watching of visitors to the hospital
patients, detectives intercepted a note which instructed
a patient to let a string down from a window at a cer-
tain hour. The arrest of two men was made by vice
squad officers at the Gynecean Hospital, 247 North
Eighteenth Street. The men, who gave their names as
Charles Cooper and Charles Thackery, were each held
under $2,500 bail when taken before judge McNichol
in the municipal court, at Twelfth and Wood Streets,
and held for further hearing December 20.
Development of surgery during the war and its
benefit to the human race, were described the evening
of December I by Dr. Stewart L. McCurdy, professor
of anatomy in the University of Pittsburgh, and or-
thopaedic surgeon to several Pittsburgh hospitals,
speaking before members of the Dauphin County Med-
ical Society in the Academy of Medicine, Second and
South Streets, Harrisburg. Dr. McCurdy reviewed
the work of the surgeons throughout the war and de-
scribed some of the more remarkable operations which
were successfully performed, particularly those in-
volving the grafting of limbs. Lantern slides illus-
trated his talk. Declaring that plaster casts were as
obsolete as splints, Dr. McCurdy explained his method
of incision and setting, without trusting to either of
the former methods. He warned doctors against
using field hospital methods in peace times. Dr. Mc-
Curdy is a railroad surgeon and has a national reputa-
tion on account of his splendid success in bone surgery
and bone disease. The emblem of the American Med-
ical Association was adopted and will be used by the
members on their automobiles. Dr. H. C. Myers,
president of the society, presided. Following the lec-
ture a smoker and supper were held.
The program committee of Luzerne County Med-
ical Society December i offered its membership an
evening of entertainment and education somewhat at
variance with the conventional scientific program of
essays, lectures and discussions. The floor was occu-
pied by Dr. Lewis Taylor, who spoke on "Some Old
Books and Their Owners," and Dr. H. H. Covell, of
Rochester, N. Y., who took as his subject, "The
Theory and Practice of genealogy." The books intro-
duced by Dr. Taylor were old leather tomes on med-
ical subjects and used in the early history of the val-
ley by the pioneer physicians. Not a little history was
injected into the discourse and review of the books
and the address by Dr. Taylor furnished wholesome
entertainment. Dr. Covell, who is in Wilkes-Barre
tracing his lineal connections in this valley and formu-
lating a permanent genealogical record for his own
use, consented to entertain the members of the med-
ical society at the request of Dr. Taylor. Dr. Covell,
who now practices in Rochester, traced his ancestry
to Dr. Matthew Covell, one of the first physicians of
this valley and also one of its early justices of the
peace. Dr. Covell humorously related how his great-
grandfather, the above mentioned Matthew Covell,
Used one side of the pages of his large diary to record
his legal transactions Jn pursuance of his duties as
justice of the peace and the other side to register the
events and business matters connected with his med-
ical profession. The doctor created laughter when he
quoted some of the entries in the diary which told of
potions and vials of medicine bought at ridiculously
low prices as compared with present rates. Dr. Covell
has an inimitable sense of humor and even the most
staid and fatigued practitioner was caught in smiles
and loud guffaws.
GENERAL NEWS ITEMS
The Court op Appeals of Argentina in a decision
announced December 7 sustained the decision of a
lower court for the extradition to the United States
of Dr. William H. Bricker, of Philadelphia. The ex-
tradition is based on the charge that Bricker com-
mitted perjury in obtaining a passport under the name
of William H. Moore. Doctor Bricker fled to Ar-
gentine, forfeiting $21,000 in bail, while awaiting the
decision of the Supreme Court upon an appeal taken
from thedecision of the Quarter Sessions Court sen-
tencing him to the Eastern Penitentiary for from four
to six years for criminal malpractice. Extradition on
the perjury charge was asked, as the offense Doctor
Bricker was sentenced for in Philadelphia was not
extraditable in Argentina. Assistant Chief County
Dettive James Irwin was sent to Argentina after
Bricker, and instituted the proceedings which resulted
in jresterday's decision. H no further appeal is taken.
Major Wynne will send a man to South America after
the fugitive.
Principle op Federal Aid Extension Sound and
Beneficent.— "A short-sighted view"; was Surgeon
General Cumming's terse comment on the opinion ex-
pressed at the recent Bankers' Convention that fed-
eral_ aid should not be griven to states for activities
carried on in state and local communities. "In health
work, especially," said the surgeon general, "it is ex-
tremely important to recognize that the prevalence of
communicable diseases in one part of the countnr is
of very direct influence on the people elsewhere. Thus
the investigations of the United States Public Health
Service have clearly shown that the use of a polluted
water supply in some remote rural district has often
resulted in extensive outbreaks of typhoid fever in
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large cities hundreds of miles away; the presence of
malaria in certain parts of the South has exacted a
heavy economic toll from the country as a whole, for
example, by raising the cost of cotton to the con-
sumer; the northern investor has paid dearly for the
continued prevalence of hook worm disease in various
parts of the country, for where this disease prevails
labor efficiency is seriously reduced. When the cir-
cumstances are carefully studied it is clear that the
control of disease is not merely a local responsibility,
but a joint responsibility of federal, state and local
authorities. "For every dollar of federal money spent,"
said Surgeon General Gumming, "we have secured five
or six dollars worth of effective health work. Under
the cost-sharing principles of the existing law, the
Public Health Service has been able to effect very
great sanitary improvements at a very minimum of
expense. It is the judgment of all who have studied
the results of this cooperative effort that the principle
of the federal aid extension under which this work
has been carried on is not only thoroughly sound but
has proved of the highest benefit to the country as a
whole."
United States Givn, Service Examinations. —
Roentgenologist, Associate Roentgenologist, Assistant
Roentgenologist, Junior Roentgenologist. Applica-
tions will be rated as received until April s, 1921. The
United States Givil Service Gommission announces
open competitive examinations for the positions listed
above. Vacancies in the Public Health Service
throughout the United States, in the position of roent-
genologist at $200 to $250 a month, associate roent-
genologist at $130 to $180 a month, assistant roent-
genologist at $90 to $130 a month. Junior roentgenolo-
gist at $70 to $30 a month, and vacancies in positions
requiring similar qualifications, at these or higher or
lower salaries, will be filled from these examinations,
unless it is found in the interest of the service to fill
any vacancy by reinstatement, transfer, or promotion.
For any of these positions the entrance salary within
the range stated will depend upon the qualifications
of the appointee as shown in the examination and the
duty to which assigned. Quarters and subsistence:
In addition to the salaries appointees will be allowed
quarters and subsistence when possible. Where quar-
ters are not furnished and_ when subsistence is not al-
lowed or is allowed only in part, the salaries may be
increased from $15 to $62.50 a month, according to
circumstances.
To GuRB Sale op Narcotics. — Boston, Dec. 4 — Gro-
cery and_ other stores will be prohibited from dealing
in medicinal preparations unless they take out a state
license if legislation recommended by the Registration
Department to-day is adopted. The bill is described
by William S. Briry, director of the department, as an
attempt to curb the sale of narcotics diguised as medi-
cine. Another recommendation would provide for the
appointment of investigators and prosecuting officers
for the protection of the public against the illegal
practice of medicine, pharmacy, dentistry, optometry,
chiropody, veterinary medicine, embalming and elec-
trical work.
Brothers, Take Notice! — Boston, Dec. 4. — A ban
on high heels is to be sought from the Legislature by
the Massachusetts Osteopathic Society. Such an an-
nouncement was made at its nineteenth annual con-
vention to-day. Dr. R. Kendrick Smith, of Brookline,
who read a paper on "High Heels a Crime," told his
associates that the advent of woman suffrage had
given the society courage to propose a bill prohibiting
the manufacture, sale and wearing of heels more than
one and one-half inches in height.
Gauze Left in Woman Costs Doctor $10,000. —
Chicago, Dec. 8. — Mrs. Hulda Anderson, wife of a let-
ter carrier, was awarded $10,000 damages by a jury in
Superior Court before Judge Oscar Hebel to-day
against Dr. Albert J. Ochsner, head of the medical
staff of the Augustana Hospital. According to Mrs.
Anderson's testimony Doctor Ochsner operated on her
for appendicitis May 29, 1918, and when, after seven
months, the wound had not healed properly, she went
to another surgeon and the wound was reopened in
December of that year and fourteen inches of gauze
removed. Mrs. Anderson sued for $20,000. Doctor
Ochsner said that he had no way of telling if he left
the gauze in the wound or not. "It is the duty of the
nurses to account for all gauze and sponges we use in
operation," said Doctor Ochsner. "In this case I was
told that everything was accounted for."
Lawyers in a Move To Guard Practice. — A reso-
lution directed toward curbing the gradual absorption
of several branches of law practice by trust and title
companies, conveyancers and other agencies was in-
troduced Dec. 7, 1920, at a meeting of the Law Asso-
ciation, in city hall, Philadelphia. The American Bar
Association, at its last annual meeting, urged local
and state bar and law associations to work for the
passage of statutes defining just what is "the practice
of law," in order to standardize the legimate practice
of lawyers and to prevent those who are not lawyers
from engaging in law practice. The matter was re-
ferred to the legislative committee for action.
The- Editor prints the above to show how the law-
yers attend to their business. They prepare legisla-
tion in the interests of their profession prior to having
it introduced into the legislature, while it has been
the rule for physicians to accept legislation after it
has been passed.
The Boston Session. — The local committee on ar-
rangements for the annual session to be held in Bos-
ton, June 6-10, 1921, has been organized as follows:
Chairman, F. B. Lund; secretary, Richard H. Miller.
Subcommittee on Finance: Chairman, Hugh Wil-
liams; secretary, Channing Frothingham; treasurer,
A. William Reggio. Subcommittee on Sections:
Chairman, William H. Robey, Jr.; secretary, H.
Archibald Nissen. Subcommittee on Exhibits and
Printing: Chairman, D. F. Jones; secretary, George
Gilbert Smith. Subcommittee on Hotels: Chairman,
John T. Bottomley; secretary, Stephen Rushmore.
Subcommittee on Entertainments: Chairman, C. A.
Porter; secretary, A. W. Allen. Subcommittee on
Registration: Chairman, A. S. Begg; Secretary,
Samuel R. Meaker. Subcommittee on Clinics : Chair-
man, J. C. Hubbard ; secretary, R. S. Eustis. All com-
munications for the attention of the local committee
on arrangements or any of its subcommittees should
be addressed to the proper officer at the Boston Med-
ical Library, 8 The Fenway. — Jour. A. M. A., Dec. 4,
1920.
In\'esticates European Immigration. — Surgeon J.
W. Kerr, of the United States Public Health Service,
sailed for Europe on November 20 with Commissioner
General of Immigration Caminetti to assist in the in-
vestigation of emigrant conditions in Europe. The
hope is to devise additional measures whereby the im-
migration laws may be given greater force and may
yet work less hardship on prospective emigrants.
Pellagra and Income Varv Inversely.— That pel-
lagra varies inversely with the family income in the
cotton mill villages of South Carolina is the conclu-
sion drawn after a three-year study by the United
States Public Health Service. This is the first re-
ported study in which the long-suspected relation of
•poverty and pellagra is definitely measured. As the
income fell the disease was found to increase and to
affect more and more other members of the same fam-
ily. As the income rose, the disease decreased and
was rarely found in families that enjoyed the highest
incomes, even though this highest was still quite low.
Differences among families with the same incomes are
attributed by the report to differences in the expendi-
tures for food, intelligence of the house-wife, and
ownership of cows, gardens, etc. Differences among
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January, 1921
GENERAL NEWS ITEMS
281
villages which were economically similar are attri-
buted to differences in the availability and condition
of food in local markets. A recent statement by one
of the largest life insurance companies in the United
States indicates that the food standards of southern
wage earners must have improved remarka'bly of late,
for the death rate from pellagra has fallen from 6.7
per 100,000 in 1915 to 2.3 in 1919.
Chaulmoogra. On, and Tuberculosis. — The recent
widely circulated statement that the United States
Public Health had found that chaulmoogra oil was as
efficacious in the treatment of tuberculosis as it had
been shown to be in that of leprosy is said by Surgeon
General Gumming to be unwarranted. Experiments
made some years ago with the oil gave no definite re-
sults. Recent experiments with the ester, or deriva-
tives, have been begun because of hopes based on some
similarities between the bacilli of leprosy and those
of tuberculosis; but these have not proceeded far
enough to indicate what results will be obtained.
Openings for Dietitians. — Opportunities are now
open in the hospitals of the United States Public
Health Service for the employment as dietitians of
many women graduates of schools of Household Eco-
nomics who have had student training or hospital ex-
perience in) civilian or army hospitals. The work,
which has to do with the victualing of the hospitals,
was transferred a year ago from the i^rmacists to
a newly established dietitian service. The section has
steadily expanded, but owing to the opening of many
new hospitals and the enlargement of those already
on operation the dietic personnel is as yet not nearly
up to the requirements. Applications for appointment
should be made to the Surgeon General, United States
Public Health Service, Washington, D. C.
New Public Health Service Film. — A new motion
picture film prepared at the instance of the United
States Public Health Service vividly presents the life
history of the mosquito, especially of the kind that
transmits malaria germs and costs the United States
people about $200,000 a year by so doing. Part of the
. film is i'animated" and part taken from actual life ;
all of it is lifelike. Most realistic are the views show-
ing how the female mosquito absorbs the malaria
germs with the- blood of a malaria patient ; how the
germs increase and multiply and pervade the salivary
glands of the mosquito ; and how the mosquito passes
them on to the nearest innocent bystander, who
promptly falls ill with the disease. The film was ex-
hibited for the first time at the meeting of the South-
ern Medical Association at Louisville, Kentucky,
November 15th to i8th.
Public Health Service Warns Consumptives. —
The migration of army patients suffering with tubercu-
losis to the semi-arid west is causing the United States
Public Health Service no little concern, for all the
Service hospitals and all the contract hospitals in that
region are now completely filled. It is considered to
be very unfortunate that the patients should leave
places where the government is ready and able to care
for them and go to other sections where it is abso-
lutely impossible for it to provide proper care and
where even ordinary housing accommodations are
largely unobtainable. The service is making and will
continue to make strenuous efforts tq meet the needs
of the patients, but the great amount of travel to that
part of the country makes the problem very serious.
St. Louis, Mo., December. — Announcement has been
made by the president of St. Louis University that Dr.
John Auer, pharmacologist of the Rockefeller Insti-
tute of New York, has been secured to institute and
conduct a Department of Pharmacology in the Col-
lege of Medicine of the University. It is the hope of
the faculty of the university to be able, through the
Centennial Endowment Fund of $3,000,000 now being
raised by the friends and alumni of the-insti.tution, to
establish complete departments in every line of medical
instruction and research. It is also intended, if possi-
ble, to secure as heads of these departments men of
professional standing equal to that of Dr. Auer, who
has been connected with the Rockefeller Institute
since its organization in 1903.
At the recent examinations for licensure conducted
by the Missouri State Board of Health, members of
the class of 1920 of the St. Louis University College
of Medicine were awarded sequentially, the fifteen
highest ratings in a class of eighty-five candidates rep-
resenting twelve universities.
A. Research Information Bureau. — The National
Research Council has established a Research Informa-
tion Service as a general clearing house and informa-
tional bureau for scientific and industrial research.
This "Service" on request supplies information con-
cerning research problems, progress, laboratories,
equipment, methods, publications, personnel, funds,
etc.
Ordinarily inquiries are answered without charge.
When this is impossible because of unusual difficulty
in securing information, the inquirer is notified and
supplied with an estimate of costs.
Much of the information assembled by this bureau
is published promptly in the "Bulletin" or the "Reprint
and Circular Series" of the National Research Coun-
cil, but the purpose is to maintain complete up-to-date
files in the general office of the council.
Requests for information should be addressed. Re-
search Information Service, National Research Coun-
cil, 1701 Massachusetts Avenue, Washington, D. C.
The New Surgeon General Rear Admiral E. R.
Stitt, MeUical Corps, U. S. Navy. — The selection of
Rear Admiral E. R. Stitt, Medical Corps, U. S. Navy,
to fill the position of Surgeon General W. C. Braisted,
Medical Corps, U. S. N., who is retired in conformity
with his own urgent request, will be one of the most
popular appointments ever made in the navy. This
officer will prove acceptable to his own corps, whose
members recognize him as without superior in his
special field of bacteriology and tropical diseases and
as an internist and diagnostician of consummate abil-
ity. The medical profession of America and of
Europe, to whom Admiral Stitt's brilliant success as
an educator, his remarkable attainments in laboratory
research, his scientific but simply written textbooks
are well known, will see in this nomination a recog-
nization of merit and years of faithful service.
Through his books. Admiral Stitt is known to thou-
sands of students and practitioners in Europe and
America. He is personally known to the leaders of
medical thought in both hemispheres and consulted by
them as one who has the right to speak with authority
and whose every utterance commands respect.
The Medical Corps of the Navy is fortunate in
counting among its number a man of Admiral Stitt's
calibre.
By reason of his work on "Practical Bacteriology,"
of which the sixth edition has just appeared; his
>vork on "Tropical Diseases," of which a fourth edi-
tion is in preparation : by his lectures on zoology in
the University of the Philippines, on tropical medicine
at Georgetown, George Washington University and at
Jefferson Medical College, Philadelphia ; by his labors
as member of the Advisory Board of the Hygienic
Laboratory, member of the Board of National Ex-
aminers, member of the committee for the tenth re-
vision of the U. S. Pharmacopoeia, Admiral Stitt has
shed lustre on the medical corps of which he is the
most representative medical man.
Automobile Fatalities. Startling Figures for
Automobile Fatalities in 1919. Deaths and Death
Rates from Automobile Accidents. — From the list of
automobile fatalities submitted by the Department of
Commerce, Bureau of Census, Washington. D.' C, are
a list of the cities of the United States' from which
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282
THE PENNSYLVANIA MEDICAL JOURNAL
January, 1921
we take the fatalities ocurring in cities of Pennsyl-
vania as follows :
Number of Deaths
1919 1918 1917 1916
Philadelphia 191 226 169 153
Pittsburgh <,4 105 100 64
Reading 10 8 7 7
Scranton 20 16 14 16
Other cities of the United States in proportion.
Each year the death rates from automobile accidents
are higher than the rates of the previous year. Each
year it becomes more and more dangerous for a per-
son to walk the streets. The reason usually given, and
probably the correct one, is that the number of auto-
mobiles in use is constantly increasing. How then
shall this ever-increasing danger be lessened? The
obvious remedy is to improve constantly the traffic
regulations to keep pace with the ever-increasing num-
ber of automobiles.
This call for better and better traffic regulations is
not a fanciful one. Everyone is familiar with the
.necessity for slow and orderly progress when a crowd
emerges from a circus tent and, similarly, automobile
traffic must be slowed down and controlled until it be-
comes safe.
The 1919 rates for Kansas City, Mo. : San Antonio
and Cleveland — all much lower than for 1918— furnish
a ray of hope that we are finally waking up.
The following are a few suggestions for traffic im-
provement :
I. At street crossings the erection of curbed safety
islands, which, at the most dangerous spots, should be
very close together.
II. Construction of additional crossings in the mid-
dle of blocks, where automobiles can approach from
only two directions.
III. Demonstration of great skill in driving each
machine before granting a driver's license for that
machine.
IV. Reduction of the speed limit, especially at
crossings.
V. Fine, revoking of license, and imprisonment,
each to have its place as an actual penalty.
The tendency of some writers to exonerate automo-
bile drivers and to place the blame of accidents upon
pedestrians indicates lack of a full comprehension of
the problems involved.
The teaching of caution is admirable and in time
pedestrians will undoubtedly become more and more
careful, but there will always be on our streets the
persons who misjudge the speed of an approaching
automobile and becoming confused know not which
way to go ; there will always be the child who has not
yet acquired the ultra-cautious habit, and there will
always be old people who cannot hear and see so well
as they used to and who are not so keen and active
as they once were. The preaching of more caution
to these people will never be sufficient. They must
be protected bv additional safeguards, and city gov-
ernments which will continue to make their traffic
regulations more and more rigid till they can point
to low death rates from automobile accidents will de-
serve the commendation of all thoughtful people.
BOOKS RECEIVED
Books received are acknowledged in this column,
and such acknowledgment must be regarded as a suffi-
cient return for the courtesy of the sender. Selections
will be made for review in the interests of our readers
and as space permits.
PsvcHOPATHOLOGY. By Edward J. Kempf, M.D.,
Clinical Psychiatrist to St. Elizabeth Hospital (for-
merly Government Hospital for the Insane), Washing-
ton, D. C. ; author of "The Autonomic Functions and
the Personality." Eighty-seven illustrations. St.
Louis : C. V. Mosby Company, 1920. Price, $9.50.
Theophrastus Bombastus vom Hohenbeim, called
Paracelsus. His Pebsonality and Influence as
Physician, Chemist and Reformer. By John Max-
son Stillman, Professor of Chemistry Emeritus, Stan-
ford Univ.ersity. Chicago and London: The Open
Court Publishing Company.
Chemical Pathology, being o discussion of general
pathology from the standpoint of the chemical proc-
esses involved. By H. Gideon Wells, Ph.D., M.D.,
Professor of Pathology in the University of Chicago
and in the Rush Medical College, Chicago; Director
of the Otho S. A. Sprague Memorial Institute. The
Fourth Edition, revised and reset. Philadelphia and
London: W. B. Saunders Company. Cloth, $7.00 net.
Practical Preventive Medicine. By Mark F. Boyd,
M.D., M.S., C.P.H., Professor of Bacteriology and
Preventive Medicine in the Medical Department of the
University of Texas, etc. One hundred and thirty-five
illustrations. Philadelphia and London: W. B. Saun-
ders Company, 1920. Cloth, $4.00 net.
An Epitome of Hydrotherapy for Physicians,
Architects and Nurses. By Simon Baruch, M.D.,
LL.D., Consulting Physician to the Knickerbocker and
Montefiori Hospitals, Hydrotherapeutist to the Sea
View Hospital for Tuberculosis, etc. Illustrated.
Philadelphia and London: W. B. Saunders Company,
1920. Cloth, $2.25 net.
The Endocrines By Samuel Wyllis Bandler, A.B.,
M.D., F.A.C.S., Professor of Gvnecology in the New
York Postgraduate Medical School and Hospital.
Philadelphia and London: W. B. Saunders Company,
1920.
BOOK REVIEW
19W COLLECTED PAPERS OF THE MAYO
CLINIC, Rochester, Minn. Octavo of 1331 pages,
490 illustrations. Philadelphia and London: W. B.
Saunders Company. Cloth, $12.00 net
It is always a pleasure to welcome the collected
papers of the Mayo Clinic. In the present volume the
papers are assembled under the following headings:
alimentary canal; tvogenital organs; heart; blood;
skin and syphilis ; head, trunk and extremities ; nerves ;
technic, and general. Such a volume is a library in it-
self. As many might suppose, it is not a book exclu-
sively for the general surgeon or surgrical specialist;
but should appeal very strongly to the general prac-
titioner, as it affords a wealth of material in internal
medicine. The very valuable research work, the daily
experiences, and the practical value of all that accrues
in the Mayo Clinic, are thus brought to the very door
of ever^ physician, that he may be Setter instructed, and
his patients profiting to the fullest extent. The price
of the book is used by not a few, as an argument
against its purchase, but there are many papers in the
volume, each of which is well worth more than the
price of the book, to any general practitioner or sur-
geon. This volume is strongly recommended to the
profession, as it contains much in the recent solution
of many of our problems. F. C. H.
THE ENDOCRINES. By Samuel Willis Bandler,
M.D., F.A.C.S., Professor of Gynecology in the New
York Postgraduate School and Hospital. Octavo of
486 pages. Philadelphia and London: W. B. Saun-
ders Company, 1920. Cloth, $7.00 net.
This very readable book, tersely and concisely gives
in compact form just what every physician should
know about the endocrines. As stated in the preface,
"what is known of the endocrine glands is bearing
more than sufficient root to form a working basis for
the understanding of the numerous hereditary, physi-
cal and psychic questions. Only by therapy and by the
use of the extracts of these glands can we be led to
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MUARY, 1921
TRUTH ABOUT MEDICINES
283
nite conclusions. Hence, every practicing physi-
I has in his hands the material with which he may
1 aid in the research along these lines." Every
sician should have a copy of this book on his desk
daily reference; because no physician satisfac-
ly can practice modern medicine, without a work-
knowledge of the role played by the ductless
ids. A series of cases are detailed, which prove
iable clinical material in illustrating the text. The
6 is large, clear, easily read, and the book is well
le. F. C. H.
lSSAGE and exercises combined. By
ilbrecht Jensen, formerly in charge of Medical
lassage Clinics at the Polyclinic and other Hos-
itals. New York. Eighty-six illustrations. Ninety-
iree pages. Published by author, General P. O.
(ox No. 73, New York, N. Y. Price $4.00.
I'his is a very interesting and useful book — well
itten, concise and of considerable importance to the
rsician in the treatment of disease. It treats of a
V system of the characteristic essentials of the gym-
;tic and Indian Yogis concentration exercises corn-
ed with scientific massage movements. The fact
t no apparatus is necessary for the combined mas-
;e exercises which are thus automatically graduated
ording to each person's strength and condition is a
St desirable feature and renders it generally ap-
:able. F. F. D. R.
TRUTH ABOUT MEDICINES
HoENTGeNOLOGIC DIAGNOSIS OP GALLBLADDER LESIONS.
Dudley Roberts, New York (Journal A. M. A., Dec.
1920), finds that the roentgenologic diagnosis of
llstones and the dilated gall bladder with a small
rcentage of failure is possible at the present time.
;gative diagnosis has a value that is proportionate
the intensity of detail and sharpness of image se-
red in the given case. Negative diagnosis has very
tie value in subjects so heavy that satisfactory
entgenograms cannot be made. Subjects of slight
medium body thickness can be roentgenographed
ith an intensity of detail that justifies an experienced
terpreter in a negative diagnosis of stones or a
lated gall bladder. The roentgenologic diagnosis of
llstones requires such an expenditure of time and
oney in the taking of satisfactory exposures, and so
uch experience in the interpretation of intensely de-
iled roentgenograms, however, that it is not at pres-
t a safe and practical method of diagnosis for gen-
al adoption. Ten or fifteen per cent, of stones can
: visualized even by an extremely poor equipment
id technic ; but under such conditions the importance
be attached to negative findings is negligible. An
superable limitation of roentgenologic diagnosis of
ill bladder lesions is the apparent impossibility of se-
iring roentgenographic evidence of chronic chole-
stitis without dilation or of new growth of the gall
adder and biliary ducts.
Amebic Abscess op Liver. — The extended use of
ver puncture, based on the observation of fifty cases,
recommended by Tom S. Mebane, Port Clinton,
ihio (Journal A. M. A., Dec. 4, 1920). This method
as employed in all cases of suspected liver abscess
1 this hospital, and no harm resulted. When pus was
oimd, an operation was performed immediately. In
l>e after-treatment of these cases, irrigations of fluid-
xtract of ipecac in saline were employed after the
irst week. The patient was also given a course of
metin injections.
"Preicriptioii Blanb $1.75 per 1000 m
5000 loU; ringle 1000-$2.75
Printed on good quality bond paper, made in tablets
of 100 and mailed Parcel Post prepaid — cash with
order. Write for samples including other stationery.
JACOBI, Fourth and Green Streets, Philadelphia."
TABLE OF CONTENTS— Continued
(Oonolndsd from page 11)
"BOCBATEB BEDTTX"
The ModJcal Book Review 266
Fbederick L.. Van Sickle, M.D.,
Executive Secretary, Harristurg, to.
Legislative Director — Session of 1921 270
IS MEMORIAM
Samuel Philip Heilman, M.D 273
William Thomas Bishop, M.D 273
Warren F. Klein. M.D 273
Thomas Cope, M.D 274
OOVNTT SOCIETY REFOKTS
Berks — November 276
Columbia — December < 276
Delaware — December 276
Somerset — November 277
STATE irZWS ITEMS
GENEBAI, NEWS ITEKS
BOOKS BEOEIVED
BOOK BETIEW
TBTTTH ABOTTT MEDICIKES
277
279
282
282
283
INDEX TO ADVERTISERS
Aloe, A. S., Company II
Armour A Company cover p. 4
B. B. Culture Laboratory 11
Bauer & Black Ill
Bets, Frank S., Company t
Hrady, Geo. W., & Company xvlU
Burn Brae xvl
Crest View Sanitarium xlU
Deutscb, Max, The Gravid Shoe xvlll
Devitt's Camp xlll
Peick Brothers Company xvlll
Gbodell, J. E., Laboratory xlv
Hynson, Westcott & Dunning xlx
Intra Products Company -. xv
Jefferson Medical College xvll
Kenwood Sanatarlum xvl
Kraus, A. H., Prescription Blanks xti
Langner Laboratory, The xr
McDonald, Jos. J , . Ix
Maltble Chemical Company Iv
Manhattan Bye Salve Co xlv
Massey Hospital, The xlv
Mead Johnson & Company Iv
Medical Protective Company Ix
Mercer Sanitarium xvl
Metz. H. A.. Laboratories, Inc xvHI
Moore's Hospital xill
Mosby, C. v., Company vll
Mulford, H. K., Company ylll
Mutual Pharmacal Company, Inc x
Parke, Davis & Company cover p. 4
Pomeroy Company '. ix
Physicians & Surgeons Adjusting Association vl
Radium Company of Colorado xlv
Radium Laboratory xlx
Saunders, W. B., Company front cover
Scherlng & Glatz, Inc yll
Storm, Katharine L., M.D xlx
Sunnyrest Sanitarium xvl
Takamlne Laboratory, The x
Taylor Instrument Company xlx
United Synthetic Chemical Corporation vl
University of Pennsylvania xvli
University of Pittsburgh xll
victor X-Ray Corporatlan xl
Woman's Medical College of Pennsylvania xrll
Zemmer Company, The x
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284 THE PENNSYLVANIA MEDICAL JOURNAL January, 1921
IS YOUR SOCIETY 100 PER CENT?
Application for Membership
To the officers and members of the County Medical Society, a com-
ponent county society of the Medical Society of the State of Pennsylvania.
Gentlemen: — I hereby make application for membership in your society, and, if
accepted as a member, I agree to support the Constitution and By-Laws of your
society and of the Medical Society of the State of Pennsylvania, and the Principles of
Ethics of the American Medical Association. I hereby subscribe for the Pennsylvania
Medical Journal until forbidden.
The accompanying $ which includes annual dues in the county society, the
benefits of the Medical Benevolence Fund and the Medical Defense Fund of the Medi-
cal Society of the State of Pennsylvania, and my subscription to the Pennsylvania
Medical Journal, each and all for llie year 1920, is to be returned to me if I am not
accepted as a member.
WRITE LEGIBLY
1. I was born at on the day of 18
2. I graduated in medicine from
aire name of college in full.
on the day of ■. ., 1
3. My State Certificate was issued by the Bureau of Medical Education and Licensure
at Harrisburg
(Dmte)
Name in full
WRITE Post Office.
LEGIBLY Street and Number.
County
Recommended by
The tmdersigned censors of the Society having fully considered the above application
recommend the acceptance of the doctor as a member of our Society.
.1920
TfaU blank ii to be fonratded bj tbe Oonnt/ Secrctarjr to tbe State Secretary at soon at the applicant bas become
a full member of tbe Oouutj ttoclety.
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The Pennsylvania Medical Journal
Owned, Controlled and Published by the Medical Society of the State of Pennsylvania
Issued monthly under the supervision of the Publication Committee
VoLVUt XXIV
NUMBII S
212 North Third St., Harrisburg, Pa., February, 1921
Subsckiptioh:
$3.00 Pk« Y%aii
ADDRESSES
TUBERCULOSIS IN CHILDREN*
WILLIAM N. BRADLEY, M.D.
PHILADELPHIA
The Pediatric Section of the Medical Society
of the State of Pennsylvania, now completing its
fourth year, has, I believe, demonstrated its
right to a permanent existence. In October,
1914, the writer, while president of the Phila-
delphia Pediatric Society, sugge.sted that the chil-
dren of the state might be benefited by the or-
ganization of a Pediatric Section of the Medical
Society of the State of Pennsylvania. A com-
mittee was appointed to place the matter before
the Board of Directors of the State Society, who
vetoed the suggestion. However, the next year
it received favorable action and a Pediatric Sec-
tion was organized on trial. Its chairmen in
order of service have been : Dr. S. McC. Hamil
of Philadelphia, Dr. P. J. Eaton of Pittsburgh,
Dr. Charles Miner of Wilkes-Barre, and the
present incumbent who has had the honor of
serving as secretary under each former chairman.
In compliance with the custom of presenting
a chairman's address, I should like to take a few
minutes to direct your attention to the subject
of tuberculosis in children. In a recent com-
munication to me the Deputy Commissioner of
Health of Pennsylvania stated that, "In spite
of the vast expenditure of time and money, sta-
tistics show that the death rate from tuberculosis
in the state has not been lessened."
It is my belief that this discouraging condition
is due to the fact that a lot of the work has here-
tofore been done from the wrong end. It is
now generally recognized that tuberculosis is
nearly always contracted in childhood. There-
fore, the only effective work must be done with
the children. With this in mind, I should like to
consider briefly the results of some investiga-
tions showing the frequent incidence of tubercu-
losis in early life, discuss modes of transmission
and suggest means of prevention and control.
Incidence. — Dr. J. C. Gittings in a work, as
yet unpublished, on Tuberculosis in Children,
•The Chairman's address delivered before the Section on
Pediatrics of the Medical Society ot, the State of Pennsylvania,
Pittsburgh Session, October s, 1920.
stated that: "In 1903 Von Behring advanced the
theory that tuberculosis infection divays occurs
during infancy, and as a rule, remains latent until
the bodily powers of resistance are lowered,
either at puberty, parturition, lactation, or as a
result of malnutrition, overexertion or acute in-
fectious disorders." This theory later was modi-
fied by Schlossman and Hamberger, who believe
that to a very large degree tuberculosis is ac-
quired in childhood to lie dormant until adult life.
Hamberger, in Vienna, found 40% of tuber-
culosis lesions in 848 autopsies in children.
Conby (Griffith loc. cit.) stated that 638 cases of
tuberculosis were found in 1,675 autopsies up to
fifteen years, as follows: These figures average
practically the same as those of Hamberger.
Up to 3 months of age i .8%
3 to 6 months 18%
6 to 12 months 26%
1 lo 2 years 40%
2 to s years 60%
S to 10 years 67%
10 to IS years , 71%
There is a lack of uniformity in results ob-
tained in various cities from a "Von Pierquet"
upon children. In Vienna, where tuberculosis is
notoriously frequent, Hamberger and Monti ob-
tained a positive reaction in about 59% of 532
children convalescing from diphtheria and scar-
left fever. Von Pierquet testing the same class of
children obtained a positive reaction in 42% of
cases. "These children were living in an environ-
ment found only in the slums of the old conti-
nental cities." In St. Louis, Veeder and Meredith
obtained positive reactions in but 32% of cases
tested ; these children also being from the lower
stratum ©f society. The same variation in re-
sults is noted throughout the literature. This is
accounted for by Veeder and Meredith with the
explanation that the extent of tuberculosis among
children is dependent on such factors as living
and social conditions, the degree of tuberculosis
in the community and the extent of the effort to
prevent the spread.
While the mortality from tuberculosis in no
way indicates the prevalence of the disease, this
mortality is by no means negligible as is seen by
the following statistics. In the state of Penn-
sylvania last year there were 11,709 deaths from
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THE PENNSYLVANIA MEDICAL JOURNAL
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tuberculosis. Of these 2,207 were under 19
years of age, as follows :
Under one year 460
1 to 2 years 270
2 to 3 years 150
3 to 4 years 93
4 to S years 63
^ S to 9 years 215
ID to 19 years 956
In Philadelphia for the same period there were
515 deaths under 19 years of age, as follows:
Under 2 years 1 19
2 to S years 67
5 to 9 years 50
ID to 14 years 54
15 to 19 years 226
It is unfortunate for our purpose that the sta-
tistics of the state do not designate the respec-
tive mortality from 10 to 15 years.
It is a matter of history that tuberculosis has
been recognized as a contagious disease since
1765, and the custom prevailed even at that time
in Italy of burning the bedding of a patient who
had died from tuberculosis. It is generally recc^-
nized that the chief mode of dissemination of tu-
berculosis is through the sputum which contain
vast numbers of tubercle bacilli. These organisms
have been known to survive a temperature of 10°
below zero for six weeks ; and dried sputum, not
exposed to light, does not lose its virulfence for
three months, and rarely, from six to eight
months, but when exposed to direct sunlight, be-
come inert within thirty minutes.
House contact through the medium of sputum
is probably responsible for the largest number of
infections. The use of utensils or other articles
in common ; kissing ; collecting of floor dust by
the crawling baby, which is carried to the mouth
by the hands, tasting of the child's food by a
tuberculous mother, all these contribute to the
spread of the disease. In many instances the in-
fection can be directly traced to another mem-
ber of the family or frequent visitor. This defi-
nite knowledge concerning the dissemination of
tuberculosis makes it a positively preventable
disease and its present frequent incidence in
childhood unnecessary. By building up and
maintaining the child's normal resistance and by
the exercise of certain simple precautions this in-
cidence could be reduced to a minimum.
Every physician should constitute himself a
health officer and endeavor to educate his pa-
tients concerning the widespread existence of
tuberculosis among children and the necessary
measures for avoiding the infection. Any im-
pairment of the general health breaks down re-
sistance to disease. Any obstruction in the nose,
adenoids, or enlarged tonsils, causing mouth
breathing, should be immediately removed.
Early attention should be given to colds and
bronchial affections, and the teeth should be care-
fully preserved. Every effort should be made by
parents and physicians to keep the child in ro-
bust health and the early treatment of any or-
ganic disease such as anaemia, gastrointestinal
disease, debility or scrofula will often prevent
the subsequent development of tuberculosis.
Hygiene of the home is important. It should be
airy with plenty of windows, admitting sunlight
and fresh air. It should be free from accumula-
tions of dust, dirty hangings, carpets and furni-
ture, for the tubercle bacillus lives for months
in dirt, dampness and darkness, but dies in a few
hours when exposed to the direct rays of the
sun. Children should not be permitted to live in
contact with a person suffering from any form
of tuberculous disease, and no child should be
permitted to play with another who is the sub-
ject of ear, nasal or bronchial affections. Abund-
ance of fresh air, moderate exercise, adequate
rest and good nourishing food are the funda-
mental requirements for sturdy childhood. The
avoidance of contagious diseases is important,
particularly measles and whooping cough, both
of which are so frequently followed by tubercu-
losis. Poor patients with advanced tuberculosis
should be cared for in hospitals or sanitoria in
order to remove from the home a focus of in-
fection.
Realizing that the greatest hope of eradicating
the disease lies in the coming generations, the
state is now turning its attention to the children.
At Mt. Alto and Cresson, physical treatment and
care are given 465 tubercular children as well as
all the facilities of a wdl equipped school and
playground. Here also the children are taught
some useful occupation, and receive definite
classroom instruction in hygiene. The depart-
ment further maintains 100 clinics throughout
the state for the treatment of tuberculosis, the
dissemination of knowledge to prevent the
spread, and as portals of admission to the state
sanitoria.
One of the finest pieces of preventive work is
the open air schctol. In Philadelphia, there are
three such schools where children who are
known to have temperature or to suffer from
malnutrition, loss of weight, etc., are cared for.
There are seven other schools where there are
classes for the undernourished. The.se classes
provide for lessons in the open air, special rest
periods, and additional nourishing food, includ-
ing milk. A few such schools are in operation
in certain cities throughout the state, supported
in part or whole by the Pennsylvania Society for
the Prevention of Tuberculosis. There is need
for many more and every community should be
urged to make similar provision for its under-
nourished children.
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ACROD Y N I A— CARTI N
287
The Pennsylvania Society for the Prevention
of Tuberculosis is also engaged in certain forms
of propaganda, such as talks, demonstrations,
pictures, etc. One plan is to secure the enroll-
ment in the society of school children upon a
pledge to observe certain prescribed hygienic
rules. There are already over 200,000 school
children so enrolled.
In the light of the prevalence of tuberculosis
among children, the many casts already existing
in the state, and the far greater number of un-
dernourished children, most of whom will
sooner or later succumb to the disease, one can-
not but be impressed by the very inadequate at-
tempt which the combined efforts of state, mu-
nicipal and private agencies make toward the
stamping out of this eminently preventable
plague. All are doing something, but does there
not appear to be a lack of uniformity of pur-
pose? Some are working among children, oth-
ers among adults, some are trying to prevent the
disease, others caring only for the afflicted. As
an army fighting an enemy without any well de-
fined plan of battle, so we find here a group,
there another, grappling with some phase of the
disease, hoping that the sum total will spell suc-
cess.
A definite policy is imperative! A well de-
fined plan of campaign with two separate aims is
a necessity — one, to prevent tuberculosis, the
other to care for those already infected ; always
remembering that there is greater hope for the
coming generation than for the present which is
already gripped by this deadly disease. Such a
plan to meet with success must be supported by
and with the heartiest cooperation of all agencies,
state, city, and private, working towcird a com-
mon goal — the eradication of tuberculosis.
REFERENCES
Dr. T. C. Gittings, Tuberculosis in Children (not yet pub-
lished).
Dr. J. P. Croier Griffith, Tuberculosis in Children, N. Y.
Med. Journal, March 22, igio.
Dr. Borden S. Veeder and Dr. Meredith R. Johnston, The
Frequency of Infection with the Tubercle Bacillus in Children,
Amer. Tour. Dis. Children, June, 1915.
Dr. Judson Daland, Prevention of Tuberculosis (address),
1909.
ORIGINAL ARTICLES
ACRODYNIA*
HARRY J. CARTIN, M.D.
JOHNSTOWN, PA.
During the past three years five patients caijie
under my observation, presenting a peculiar
symptom complex. Early, I had no diagnosis.
Later, after hearing Weston's' paper at New
•Read before the Section on Pediatrics of the Medical So-
ciety of the State of Pennsylvania, Pittsburgh Session, October
7, ■920.
Orleans and the discussion that followed, and
from information kindly furnished by Byfield,''
1 accepted their diagnosis of Acrodynia. Little
is known, apparently, of the etiology. Brocq,
claims it to be a metallic poisoning ; Goldberger,
a deficiency disease related to pellagra ; Byfield,
takes the stand "that the affection is probably
of influenzal origin"; Weston, claims it is due
to an undetermined bacteria.
The five cases were of varying severity, pre-
senting all, or nearly all, of the following symp-
toms: an eruption, papular, lying in an
erythematous base; at times macular; photo-
phobia ; parathesia and irritability ; burrowing
of the head; chewing of fingers and hands;
profuse nasal discharge ; apathy ; lack of appe-
tite; leucocytosis ; pigmented spots; scanty
urine.
Case I. Dora W., female, aged 4, was brought
to the hospital in March, 1918. The family history
was negative except that they all had influesza, three
months before I saw the patient. She had had a
slight attack and did not entirely recover. Three
weeks before admission it was noticed that she was
more irritable and- wanted to be in bed. Light seemed
to cause her to burrow her head to protect her 'eyes,
which were inflamed. One week later a rash appeared
on legs and arms. On examination the feet and hands
were cold and bluish in color. The rash had the ap-
pearance of fading scarlet fever. She complained of
pain in hands and feet. She scratched her body until
many abscesses appeared. She did not vomit and
would not eat. She always wanted her feet placed on
pillows. .The urine was normal except for a slight
trace of altHimin. .The temperature ranged from 99.5
degrees to loi degrees F. The leucocyte count was
i2,aoo. The Wasserman was negative. The patient
remained in the hospital three weeks, during which
time her condition improved but little. In the spring
of 1920 the father informed the hospital that her re-
covery was complete but the convalescence had been
slow.
Case 2. Margaret E., female, aged 3, was the only
child of healthy parents. She was well until Novem-
ber, 1918, when it was noticed by parents and neigh-
bors that her disposition was changing. She had
become irritable, and cared only to lie in bed with her
head covered. She did not vomit. She was consti-
pated, very restless and very hard to manage. A rash,
papular, on an erythematous base, appeared first upon
arms and le^s, with a rash macular in character over
the body, front and back. She complained of pain in
feet and hands. She scratched so vigorously that the
entire body was covered by marks suggesting scabies.
She had a profuse pussy discharge from the nose.
She could not stand apparently, and to assume an
erect position had to crawl up on her legs. A diag-
nosis of pseudo-muscular hypertrophy was made in a
Pittsburj^ hospital. The urine was normal except for
a slight trace of albumin. The leucocyte count was
15,000. No other laboratory examinations were made.
In the spring of 1920 her parents reported complete
recovery.
Case 3. Albert P., of Italian parentage, male, aged
4 years, was admitted to the hospital in February,
1920. He had been breast-fed, but was very irritable
until six months old. He was always well until May,
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1919, when it was noticed that he laid around but did
not sleep, was restless at night, and had no appetite.
In September a rash appeared, first on arms and legs.
It was papular on an erythematous base. Two weeks
Case 3.— Albtrt P.
later bullae appeared on the buttocks and abdomen,
which, when broken, discharged pus profusely. He
had pain on voiding. At this time he had pain, said
by him, to be in his fingers. During these attacks he
chewed his hands at the base of the thumbs. Two
teeth were broken oflf in one of these seizures of pain.
Examination at the time of admission showed a pro-
fuse discharge from the nose; the eyes were in-
flamed; pigmented spots were over trunk and back
where the bullae had first appeared. He had lost the
outer half of the ring finger of the right hand; the
same amount of the little finger of the left hand ; the
middle toe of the right foot, and one-half of the great
toe of the left foot. The mother stated that they had
become black and dropped off. The boy had experi-
enced no pain at these times. The stumps were all
healed. While in the hospital he would burrow under
the bed covers and remain there constantly unless dis-
turbed. His hair came out in large quantities. His
teeth became loose. Gangrene developed in the ring
finger of the left hand and the finger dropped oflF.
Later as a result of infection the little finger of the
left hand was amputated. The X-Ray showed no
necrosis of the bones of hands or feet. The urine
showed slight traces of albumin, and a few hyalin and
granular casts. The leucocyte count was 15,920. His
family physician reported on October I, 1920, that the
boy had made a complete recovery.
Case 4. Atta A., male, aged 18 months. He had
been fed irregularly from breast and table. He had
had two attacks of vomiting, lasting two or three days
each, six months ago. With this exception he had
never been sick. Four months before my seeing him,
the mother noticed that the child was cross and irrita-
ble, and did not play. He had a pussy discharge from
the nose and his eyes were inflamed. He kept his
head covered. His appetite was poor. A rash ap-
peared over the entire body, papular with surround-
ing erythema on legs and arms; marbilliform on
chest, front and back. He was very itchy. The baby
cried with pain spasmodically. During these attacks
of pain he would try to bite his hands or the bed-
clothes. He wanted his mother to hold his feet.
Bullae, filled with pus, were scattered over his trunk.
The patient did not eat. He was perfectly contented
if allowed to keep his head covered. The urine was
normal. No blood examinations were made. No
form of treatment gave any satisfaction. -Warm baths
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ACRODYNIA— DISCUSSION
289
and sedatives made him more comfortable. His re-
covery was slow. At this date he is in good health.
Case 5. Al. H., female, aged 18 months. She was
breast-fed and given in addition cooked cereals and
cow's milk. She was well until May, 1920, when her
eyes became inflamed. She was satisfied to sit on her
mother's lap, with a covering over her head. She had
had no gastric nor intestinal disturbance. Her appe-
tite was poor and would go, from three to five days,
taking nothing but water. She had a profuse nasal
discharge which excoriated the upper lip. In June a
rash appeared, first on hands and feet and over the
shoulders. The child began grabbing her hands.
The mother thought this was due to the itchiness of
the rash, but later determined it to be from pain be-
cause the child would scream. When I saw the patient
in August, 1920, much of the acute condition had dis-
appeared. The urine was normal. The leucocyte
count was 12,200. No further laboratory examina-
tion was made. The reflexes were diminished. The
mother reported in September, 1920, that the child was
entirely well except for a slight inflammation in one
eye.
These five cases c?ime from different localities,
and differed from each other only in the severity
of the symptoms presented. Because of their
lack of desire to eat I endeavored to force the
feeding, but did not resort to gavage. For the
itching I tried various ointments, hot baths and
hot applications. For the pains I used codeine
phosphate. No treatment seemed to be of any
benefit. I had no deaths, but the patients had a
slow convalescence.
1. Weston, William. Acrodynia. Read before the Section
of Diseases of Children, A. M. A., April 30, 1920.
2. Personal communication from A. H. Byfield.
DISCUSSION
Herbert G. Wertheimer, M.D. ( Pittsburgh ) : The
Doctor was indeed very kind to send me his paper and
after thought and study, with your kind permission,
I will read my discussion.
Dr. Cartin reports such a rare disease in derma-
tology that I find it difiicult to approach. And for
one to attempt to diagnose from the history and
symptoms as given, might find himself entirely wrong
upon seeing the cases. I cannot help feel that as a
dermatologist, I have been asked to discuss this very
interesting paper simply because of the cutaneous
symptoms which to my mind may be only a coinci-
dence or a complication.
Acrodynia from a dermatological standpoint, "oc-
curs in prisoners and soldiers, mostly in eastern
countries, with an acute onset, constitutional symptoms
consisting of anorexia, nausea, vomiting and diar-
rhoea ; the face, hands and feet are noted to be swol-
len and conjunctivae injected. It is accompanied by
disorders of the nervous system, characterized by
pricking and burning sensations, marked hyperesthesia
of the extremities, followed by anxsthesia; severe
pain in the extremities is one of the characteristic
features of the disease. Early in the course of the
malady, erythematous spots appear primarily on the
hands and feet, especially the palms and soles, spread-
ing upward on the arms and legs and sometimes in-
volving the trunk. The affected portions of the skin
desquamate and a're thickened and brownish black;
pigmentation may supervene. The disease is afebrile.
usually runs a favorable course in two to four weeks.
In aggravated cases, paresis, edema of the limbs, and
toxic spasms may ensue." There are only about twenty
cases in all reported in dermatology.
If we compare these findings in literature with the
cases as presented, we note a discrepancy in the age
of the patients, which may mean much or little.
The nervous symptoms were the first to appear and
predominated, followed by slight constitutional symp-
toms and finally the eruption, the latter appearing
from three weeks to four months after onset. Do not
these symptoms, in part at least, suggest a pellagra
rather than an acrodynia. These patients were fed on
railk and a mixed diet, the very food given in the
treatment of the pellagra, all his cases recovering.
This is extremely rare in pellagra, except in very mild
cases.
Case 2 seems to point to pellagra in so far as the
weakness of the lower extremities is concerned, e, g.,
to the point of assuming the erect posture by the as-
sistance of her hands and arms but may have only the
significance of weakness.
Case 3 has the earmarks of a Raynaud disease but
no one ever saw a case of this disease so acute in its
onset with gangrene ever recover unless due to a spe-
cific endarteritis.
The cutaneous phenomena of redness followed by a
papular eruption on the extremities and macular on
the body, with intense itching, does this not look like
an urticaria? The pustules, excoriations and pigmen-
tation are merely a secondary pyogenic dermatitis.
The neurological syndrome as presented in the
introductory remarks of the paper and also through-
out the discussion of the individual cases, shows irri-
tability, restlessness, hyperesthesia, pajn, photophobia
and apathy. Add to this the profuse nasal discharge
and are we not dealing with some infection other
than acrodynia, the cutaneous symptoms being a com-
plication or coincidence?
I am at a disadvantage in not having seen the cases
and I may have overstepped my domain as a derma-
tologist, but I give you my criticisms as they appear
to me.
Fred E. Ross, M.D. (Erie) : If the diagnosis in these
cases is correct, I feel very grateful to Dr. Cartin for
diagnosing a case with which I had to deal this sum-
mer. This child had a disturbance of the nervous
system and a rash. In some places his body was al-
most covered. He had a photophobia and he later had
a bleb on his heel. As the case did not do well the
mother in desperation took the child to a specialist in
Cleveland who attributed the condition entirely to the
use of milk and stopped it at once, but the condition
did not improve. He is now treating it for intestinal
indigestion due to faulty assimilation of carbohydrates
and the child is gradually getting better, but w)iether
due to the treatment or the natural course of human
events, it is pretty hard to tell.
Lester Hollander, M.D. (Pittsburgh) : The discus-
sion as opened by Dr. Wertheimer, from the stand-
point of a dermatologist was very concise, I am glad
he emphasized the point, that we seldom see cases of
acrodynia.
In 1828 acrodynia occurred in an epidemic form in
France and was described by Chardon as "Mai des
pieds et des mains."
In Dr. Cartin's paper I failed to find any similarity
lo the eruption, to the epidemic erythema as described
by Tholozan in 1861 with the exception of one case,
where the erythema occurred on the hands and feet.
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Four of the described cases, judging from the
author's description, belong to the group of toxic
erythemata instead of the epidermic type.
The fifth, where the involvement caused a loss of
digits, would be better placed as a Raynaud's disease.
I am sorry that the author does not call attention to
the duration of the areas of erythema; the French
writers say that the eruption fades in two or three
weeks but may recur.
Dr. Cartin (in closing) : I am informed by Dr.
Weston, who went into the question rather carefully,
that cases like Albert P., who lost his fingers from this
condition, occurred during the time of the French revo-
lution but since then rarely.
I regret very much that I was not able to give more
details as to the length of time of the skin eruptions,
but I lost control of the patients early and in order to
view their progress would have had to visit them out
of the city, in some cases thirty miles away.
While I may have failed to state it, all of the patients
had eruption on the hands and feet varying only in the
severity of the attack.
It might be of interest to call attention to what
occurred at the meeting in New Orleans immediately
after the reading of Dr. Weston's papers. He took
the position that he was on thin ice when he made the
diagnosis of acrodynia. Dr. Byfield, of Iowa City,
arose and stated that he had had sixteen such cases
in which he had been somewhat at a loss for a diag-
nosis. His cases all varied a little from mine and
were in breast-fed children. You will notice in the
report of Dr. Weston that this condition occurred in
a widespread epidemic in the state of Oregon. In one
or two cases referred by Dr. Weston to Dr. Morse
of Boston, a diagnosis was made of a deficiency dis-
ease. The Section at New Orleans was rather divided
as to whether it was a deficiency disease or of bac-
terial origin. Dr. Byfield in his paper seems to present
enough evidence to satisfy me that it is one of the
manifestations of the late influenza epidemic.
OBSTETRICS AND THE GENERAL
PRACTITIONER*
J. WHITRIDGE WILLIAMS, M.D.
BALTIMORE
I am very glad to be able to address the phy-
sicians of Pennsylvania, and my first duty on
this occasion is to thank the Society for the
honor of asking me to appear before it.
The title of my paper is "Obstetrics and the
General Practitioner," and I owe it to you to
say that it was suggested to me by the chairman
of your Committee on Scientific Work, and
would probably have been quite different had the
choice been entirely in my hands. Nevertheless,
I feel that a talk upon such a subject may serve
a useful purpose, as there is a tendency on the
part of many specialists in obstetrics to overlook
the fact that at least 80%. of all deliveries must
be conducted by the family physicians or by mid-
wives, and that the services of trained specialists
'Read before the general meeting of the Medical Society of
the State of Pennsylvania, Pittsburgh Session, October 6, 1920.
are available only in the large cities and largest
towns. Consequently, advice is often given
which cannot be followed by the average prac-
titioner, of whom expert knowledge can scarcely
be expected and all that can be demanded is that
he have sufficient knowledge to treat his patients
so that they may be assured of a reasonably suc-
cessful outcome.
With these prefatoty remarks, I am sure you
will not be surprised that I confine myself to sev-
eral simple topics, which I have learned from
experience are of great practical importance, and
which are often neglected by those doing obstet-
rical work.
In the first place I shall say a few words con-
cerning prenatal care, and then pass on to a brief
consideration of the conduct of labor compli-
cated .by contracted pelvis. Afterwards I shall
consider the prophylaxis of puerperal infection,
the necessity for a more accurate knowledge of
the mechanism of labor, and finally I shall make
a few remarks concerning postnatal care, particu-
larly in its bearing upon the subsequent health of
the woman.
Prenatal Care. — By this term we understand
such supervision of the pregnant woman that she
may pass through pregnacy and labor with a
minimum of difficulty, and give birth to a nor-
mally developed child, which shall have a reason-
able prospect of reaching adult life, while she
herself can suckle her child and be left in such
physical condition that she can readily attend to
her usual avocations. This aspect of practical
obstetrics is of a comparatively recent origin, and
offers a wide field of usefulness. I think it safe
to say that it has been immensely neglected in the
past and it is only recently that women have
learned the necessity of placing themselves under
medical care as soon as they are aware of the ex-
istence of pregnancy.
Generally speaking, prenatal care concerns
both the mother and the child. In the case of
the former, the essential prerequisite is that she
come under the supervision of a physician at an
early period of pregnancy, so that he may be able
to watch her throughout its course. One of the
most important features of prenatal care is the
routine and frequent examination of the urine
for the detection of the early stages of the tox-
aemia of pregnancy, and for preventing the de-
velopment of eclampsia by proper treatment.
This is neither the time nor the place to enter
into details concerning the technique of the
urinary examination, nor to consider the diag-
nostic and prognostic value of the determination
of the blood pressure in such conditions.
What I desire to emphasize is that eclampsia
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OBSTETRICS— WILLIAMS
291
is the most serious of all conditions with which
well trained obstetricians have to cope, and in
their hands has a mortality of approximately 20
per cent. Dublin has estimated that 26 per cent,
of the entire mortality connected with childbirth
in this country is due to this disease, and these
figures do not include the deaths of the newly
bom children, which are so frequently associated
with it. At the same time it is generally ad-
mitted that the disease is almost entirely prevent-
able, and that the means of prevention consists
in the early recognition of the existence of pre-
eclamptic toxaemia and its appropriate treatment.
Another important point in connection with
prenatal care is so to regulate the life of the
woman, particularly by guarding her against un-
due exertion in the last third of pregnancy, that
the incidence of premature labor may be dimin-
ished. In this country very little attention has
been paid to such prophylactic measures, but in
France a compulsory period of rest is granted by
law to all pr^^ant women.
Another important feature of prenatal care is
to direct the patient's attention to the serious
significance of any form of uterine bleeding,
which early in pregnancy may indicate the begin-
ning of an abortion, or later in pregnancy may
be the first evidence of the existence of a pla-
centa praevia. In such circumstances it is often
possible to prevent the occurrence of the abor-
tion, or to treat the placenta praevia before seri-
ous hemorrhage makes its appearance, so that
the patient may be spared the serious dangers in-
cident to that condition.
With the exception of the prevention of ec-
lampsia, probably the most important practical
feature in prenatal care is insistence upon a thor-
ough antepartum examination six or eight weeks
before the expected onset of labor. At this time
the pelvis should be carefully measured for the
purpose of ascertaining the existence of a con-
tracted pelvis, and of disproportion between it
and the head of the child. Abnormal presenta-
tions of the child should be diagnosticated, and
in many instances it will be possible by suitable
manipulations to transform them into normal
ones. In rarer instances the size of the child will
be found to be greater than corresponds to the
supposed duration of pregnancy, when its devel-
opment to excessive size may be prevented by
suitable dietetic treatment, while occasionally the
dangers incident to foetal dystocia may be ob-
viated by the induction of labor at an appropriate
period.
From the point of view of the child, the scope
of prenatal care is immense, as can readily be
understood from the fact that the average fer-
tility is 25 per thousand, which means that two
and one-half million children are born each year.
According to the U. S. Census in 1917, the aver-
age mortality of infants during the first year of
life was 10. i per cent., which means that a quar-
ter of a million children die each year between
the time di birth and the completion of the first
year of life. It has been estimated that one-sixth
of these die during the first twenty-foUr hours
after delivery, one-third during the first week,
and one-half during the first month of life. In
other words, in this country 125,000 children die
each year before they have completed four
weeks of existence, and it is particularly with
the prevention of such deaths that prenatal care
has to deal.
Upon studying the causes of death during this
period, it is found that they can, roughly speak-
ing, be grouped under the following categories :
congenital deformities, birth injuries and the re-
sults of complicated labor, prematurity, toxcemia,
and syphilis, as well as a considerable group in
which no apparent cause for death can be ascer-
tained at autopsy, not to speak of another group
in which death may be due to one of a num-
ber of comparatively rare but definite causes.
Of these various factors in the causation of
infant death the first cannot be prevented, as
it is due in great part to defects in development
originating during the earliest weeks of preg-
nancy; while in the unknown group improve-
ment cannot be expected until further knowledge
is available; but all of the others offer a very
considerable field for improvement, and I think
that it is not too optimistic to calculate that at
least one-half of such deaths could be prevented
by proper prenatal care.
Last winter I studied critically 302 foetal
deaths occurring in 4,000 consecutive deliveries
in my service from the time of viability onward
and including the two weeks immediately fol-
lowing delivery, and found that 72 per cent, of
the entire number were due to syphilis, dystocia,
toxaemia, and prematurity, in the order named.
Syphilis was responsible for 34.4 per cent., and
was thus the most common single cause of death
and was almost equal to the sum of the other
three causes combined.
I shall very briefly consider each of these
causes. It should be understood that the figures
which I have given for syphilis apply only to
sudi children as were born dead or died within
two weeks after delivery, and do not include the
syphilitic children which were discharged alive,
or those which developed congenital syphilis
later. At the same time it must be admitted that
our figures will not apply to all communities, and
probably one of the reasons for their large size
with us is due to the fact that approximately one-
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THE PENNSYLVANIA MEDICAL
jO^k^,
AL
February, 1921
half of our patients are black. Furthermore, it is
highly probable that the incidence will be consid-
erably less in rural communities than in large
cities ; but, whatever the incidence, the important
fact to be remembered is that syphilis is a fre-
quent cause of foetal death and is undoubtedly
the most usual factor in the causation of the re-
peated birth of macerated children.
From the point of view of prenatal care, it is
important to remember that in the majority of
instances the mothers of syphilitic children pre-
sent no palpable evidences of the disease, so that
its existence will not be suspected until a syphi-
litic child is bom, or unless the patient's blood
has been found to present a positive Wasscrmann
reaction during pregnancy. In well organized
clinics a Wassermann upon every woman imme-
diately upon registration should be a matter of
routine, with the idea of detecting such patients
as require intensive treatment during pregnancy,
whereby not only the mother, but also the child
in utero is cured. Such demands, however, can-
not be made of the average practitioner in cities,
and are out of the question for those practicing
in country districts. What they must remember
is that syphilis must always be borne in mind
imtil its existence has been disproved by repeated
negative Wassermanns in the case of women who
have given birth to dead children without appre-
ciable cause, and particularly when macerated
children are repeatedly born at premature labors.
In all such cases treatment should be instituted
during the puerpefium, so as to cure the disease
before the occurrence of a new pregnancy.
Under dystocia I have included a large num-
ber of deaths from various mechanical compli-
cations of labor. The prevention of this type of
death simply means good bedside obstetrics, and,
as was indicated in the section under the mother,
implies the early recognition and proper treat-
ment of abnormal presentations, excessive size
of the child, contracted pelves, etc. It should,
however, be recognized that diminution along
such lines can only be relative, and that ideal re-
sults can never be attained.
In addition to the maternal deaths incident to
toxaemia, this condition was responsible for 11.55
per cent, of the foetal deaths in our series. These
were due to several factors : first, that many pa-
tients did not come into our hands until after
eclampsia had supervened, so that the child suc-
cumbed during the course of delivery; second,
that in many instances the toxaemia occurred be-
fore the child had reached the period of viability
so that its death became inevitable; and third,
that occasionally the child succumbs directly to
the suppositious poison circulating in the blood
of its mother. As has already been indicated, a
large proportion of such foetal deaths are. pre-
ventable by appropriate prenatal care.
Our figures showed that 10.59 P^"* c^"*. of the
children in our series apparently died from no
other reason than that they were born prema-
turely, and consequently were unable to stand
the strain of extra-uterine existence. It must
clearly be understood, however, that we have not
included under this heading premature children
suffering from s)rphilis nor those bom of tox-
aemic mothers. Consequently, it becomes ap-
parent that had it been possible to prevent the
occurrence of premature labor, a large number
of children might have been saved. Unfortu-
nately, our knowledge concerning the mode of
production of this accident is very fragmentary,
and offers a wide field for further investigation.
For practical purposes, all that we can do at
present to prevent its occurrence is to supervise
the mode of Kfe of the mother xluring the last
months of pregnancy, to guard her against over-
exertion, and to see that she has abundant and
suitable nourishment. I confidently expect that
in the future great improvement may be ex-
pected along these lines.
To recapitulate, I think it quite possible that
conscientious prenatal care could obviate the loss
of at least one-half of the children who now die
during the first month following delivery. In
other words, 62,500 babies which die each year
could be saved. Of course such care m.ay in-
fluence the mortality after the first month, but
great improvement along such lines must be as-
sociated with propaganda for maternal suckling,
and improved methods of treatment in diseases
of the digestive find respiratory systems.
I shall now pass on to the consideration of cer-
tain phases of the treatment of labor complicated
by contracted pelvis. One of the great advances
ill obstetrics in this country during the past gen-
eration has been the recognition of the frequency
of contracted pelvis, and the part it plays in the
production of dystocia. In my student days it
was taught that contracted pelves were practically
unknown among native-born white women, and
were met with only in the immigrant population.
Careful study since that time, however, has
shown that they are extremely frequent, particu-
larly in colored women, in whom their incidence
varies from 35 to 40 per cent., while in white
women they are fortunately less common. In
my experience, roughly speaking, 8 per cent, of
the latter present abnormalities of the pelvic in-
let, and an additional six per cent, abnormalities
of the outlet. Most of the former are moderate in
degree, although occasionally extreme examples
of deformity are met with. The important prac-
tical conclusion which I have drawn from many
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February, 1921
OBSTETRICS— WILLIAMS
293
years' study of contracted pelivs, is, that the
chances of the occurrence of spontaneous labor
in women possessing them are much greater than
is ordinarily believed ; as 75 to 80 per cent, of
all my patients have given birth to their babies
spontaneously. Of course the incidence of con-
tracted pelvis probably varies in different locali-
ties, and is likely to be less in healthy rural dis-
tricts than in large centres of population.
Unfortunately, the treatment of labor compli-
cated by this condition is less satisfactory in lo-
calities where it is rarely encountered, than
where it is common, and it is particularly in the
latter that its significance is exaggerated, with
the result that caesarean section is sometimes per-
formed unnecessarily and occasionally, in my es-
timation, is greatly abused.
Of course the average practitioner cannot be
expected to be trained in the niceties of pel-
vimetry, nor in the exact estimation of the degree
of disproportion between the size of the child's
head and the mother's pelvis. In my experience
it takes an assistant three years in a fairly large
lying-in service to acquire such facility ; and con-
sequently I believe that all that can be expected
of the average practitioner is that he should send
to a specialist for diagnosis such primiparous
women as are of unusually small stature or who
present some evident deformity. Of course this
means that a certain proportion of seriously con-
tracted pelves will escape early diagnosis, and
will not be recognized until serious dystocia de-
velops. As the disproportion in such cases is too
excessive to yield to forceps, the physician has
then to face the chofce between craniotomy upon
a live child and casarean section. Generally
speaking the former should be chosen, as from
my point of view, those who teach that crani-
otomy upon the living child is never justifiable
are in error, as I hold that in the type of cases
under consideration, it is preferable to a caesa-
rean section late in labor, in which the maternal
mortality is usually so high as to render it unjus-
tifiable.
On the other hand, in women who have had
previous labors, the problem is very different,
and I consider it is the duty of the practitioner
to send to a specialist for expert opinion all pa-
tients who have gone through difficult labors for
which a satisfactory explanation is not available ;
as I hold that in the present state of obstetrical
knowledge the repeated delivery of mutilated
children is not defensible and physicians should
be held to a rigid accountability when it occurs.
Puerperal Infection. — The cause and general
methods of prevention of puerperal infection
have been known for a generation, and yet its
incidence at present differs greatly in hospital
and in private practice. In the former, the ma-
ternal mortality from this cause has been reduced
to a very small fraction of one per cent., whereas
in the latter it shows practically no change since
preantiseptic days, and according to some au-
thorities is even greater than previously.
Dublin has calculated that 45% of all deaths
occurring in childbed in this country are due to
this preventable disease, and Dr. Grace Meigs
states that in 191 3 4,542 women had died from
puerperal infection in the registration area. As
only about two-thirds of the population of the
country are included in this area, it means that
no less than 7,000 women perished that year
from this almost entirely preventable complica-
tion.
What do such results indicate? Most prac-
titioners will deny that they have any appreciable
mortality from this cause, and I believe that they
are quite truthful in making such statements.
Explanation for the discrepancy between their
belief and the truth will probably be found in
the fact that they do not keep accurate records
of their cases, and thus tend to overlook the oc-
casional deaths from this cause in their practice.
A little calculation will render this evident. For
example, if a physician averages 50 deliveries a
year, and loses a single patient from infection
during the course of five years, he tends to feel
that his mortality is almost negligible; yet on
the other hand, when he comes to figure it out
accurately, he will find that it means four deaths
per one thousand deliveries, which is a mortality
several times greater than occurs in well regul-
ated hospitals.
How can puerperal infection be prevented?
From my experience I believe that the average
physician has excessive confidence in the possi-
bilities of hand disinfection, and certainly be-
lieves if he uses rubber gloves that the danger of
infection has been entirely abolished. On the
other hand, extensive laboratory experiments
have taught that absolute hand disinfection is an
illusion, and, even though carefully sterilized
gloves are worn, that bacteria may be carried by
the sterile gloved finger from the external geni-
talia up into the birth canal during a simple vagi-
nal examination. Therefore, those of us who
are responsible for the conduct of lying-in hos-
pitals, have come: to recognize that every vaginal
examination exposes the woman to a slight dan-
ger of infection, and consequently that its em-
ployment must be limited to the greatest possible
extent.
Fortunately, we have at our disposal two meth-
ods of examination which make this restriction
possible of fulfillment. I refer to abdominal pal-
pation and to rectal examination, and I earnestly
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THE PENNSYLVANIA MEDICAL JOURNAL
February, 1921
advise every physiciarr who is doing obstetrical
work to perfect himself in these methods of ex-
ploration, as I can assure him from my own ex-
perience they give almost as satisfactory infor-
mation as vaginal examination, and are free from
its dangers of infection, and, furthermore that
at least 80 per cent, of all deliveries can be con-
ducted satisfactorily by their means alone.
The Mechanism of Normal Labor and Us
Bearing Upon Operative Delivery.— "Prom my
experience in consultation practice, I am fre-
quently surprised by the ignorance of many
otherwise competent physicians concerning the
essential steps of the mechanism of labor, and
particularly by their neglect of the general rule
that complete dilatation of the cervix is the nec-
essary prerequisite for any attempt at delivery,
and I have learned that these factors, together
with defective diagnosis of the position of the
child and too great a tendency to resort to the
use of forceps and other methods of artificial de-
livery, result in immense harm to the women and
unborn children entrusted to their care.
. Time will not permit me to consider this sub-
ject extensively, but I wish to impress upon you
the absolute importance of establishing an accu-
rate diagnosis before determining to terminate
labor artificially, and to urge you to adopt as a
working rule the decision never to undertake any
obstetrical operation without a sharply marked
indication, so that, no matter what the outcome
may be, your conscience will be clear when you
consider the details of the case later.
In this connection I desire to say a few words
concerning the use and abuse of pituitary ex-
tract. As is generally known this medicament,
which is derived from the posterior lobe of the
pituitary gland, has the property of stimulating
unstriped muscle to active contraction, and has
Come into very general use as an ocytocic within
the last few years. In my opinion this powerful
agent is extremely beneficent when rightly used,
but gives rise to disastrous results when em-
ployed under unsuitable conditions. From my
experience, I would lay down the general rule
that its administration is indicated only when the
cervix is fully dilated, the head upon the pelvic
floor, and only a few strong pains are required
to complete delivery. In other words, it should
be employed as a substitute for the ordinary low
forceps operation. Occasionally in multipara
with deficient uterine contractions and with the
head still high in the pelvis, it may be employed,
provided there is no disproportion between the
size of the head and pelvis and the cervix is fully
dilated. When used in such circumstances, the
action of pituitary extract is highly beneficent, as
it enables us to reduce the incidence of low for-
ceps delivery by at least one-half, and occasion-
ally results in easy Spontaneous delivery-in multi-
parse in whom operative delivery, after they had
become exhausted, would otherwise be required.
It should, howrfever, be borne in mind that even
under such favorable conditions the" administra-
tion of pituitary txtriict may cause tetanic con-
traction of the uterus, with the result that the
placental circulation becomes so interfered with
that the child dies from intrauterine asphyxia,
even though it is expelled spontaneously. On the
other hand, as a constantly increasing literature
impressively shows, it has when improperly used
killed many women by causing rupture of the
uterus, and it w:ill continue to kill many more
unless the profession learns the proper limita-
tions for its use, and the manufacturing drug
houses change the character of their advertising
propaganda.
In order to impress upon you the dangerous
possibilities of the drug, I desire to refer very
briefly to a case of rupture of the uterus, which
followed its injudicious administration. In this
instance a physician administered pituitrin to a
multiparous woman, with a normal pelvis, be-
fore the cervix was fully dilated. Intense tetanic
contractions immediately developed, and in a few
minutes the patient passed into a condition of
collapse, and was sent to the hospital. When I
saw her she was pulseless at the wrist and was
apparently in extremis, the child lying free in
the abdominal cavity. Notwithstanding the ap-
parently hopeless condition of the patient, lapa-
rotomy was immediately done and the abdomen
was found to be full of blood. Upon removing
the child it was found that the hemorrhage came
from a rupture in the right lower segment of the
uterus, which had extended outward, and had
torn off the attachments of the broad ligament
and ovary from the pelvic wall. It was also
found that the right uterine artery had been torn
through just before it entered the uterus, and
was feebly spurting with each beat of the heart.
After clamping the artery, the uterus was ampu-
tated supravaginally and the broad ligament
wound closed. Contrary to our expectations the
patient made an uneventful recovery, but the
wide-spread lesions occurring in her case illus-
trated very forcibly the disastrous effects of
pituitary extract when improperly administered,
and I am sure that everyone who was present at
the operation will in future be most cautious in
the use of the drug.
Postnatal Care. — As is well known many phy-
sicians consider their task practically completed
with the delivery of the child, and pay scant at-
tention to the patient during puerperal period.
Time will not permit me to consider in extenso
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February, 1921
OBSTETRICS— DISCUSSION
295
the care of the patient at that time, but I desire
to lay stress upon one point in connection with it,
and that is the necessity for a careful pelvic ex-
amination before the patient is discharged from
observation.
In my experience vaginal examination three
or four weeks after delivery will reveal that the
uterus is retroflexed in at least every third pa-
tient. If such an abnormality be found, this is
the time to treat it, as I have found in the ma-
jority of instances that it can be cured by simple
means.
In such circumstances the uterus should be re-
placed by manual manipulations and a suitable
pessary inserted. When the patient is reexam-
ined at the end of a week, it is usually found
that the pessary maintains the uterus in normal
position. In this event it is left in situ for three
months, and upon its removal at the end of that
time a large proportion of the patients will be
found to be permanently cured, so that no fur-
ther treatment will be necessary. In my expe-
rience, it is only during the puerperium that pes-
saries have more than palliative value, but I can
assure you that at that time they act in an almost
ideal manner. Possibly this experience may ex-
plain the difference in opinion of obstetricians
any gynecologists concerning their value ; as we
treat the condition early and the pessary cures it,
while they see the patient only after the displace-
ment has become chronic and find that it can
rarely be permanently cured except by operative
means.
Such a discharge examination also serves other
useful purposes. Occasionally it reveals the ex-
istence of unsuspected lesions, and enables the
practitioner to tell his patient that some opera-
tive procedure will be required for its relief in
the future, and thus obviates the reproach, so
often made when its necessity is discovered later.
Furthermore, a critical survey is essential in all
patients w;ho have passed through a difficult
labor, and particularly those who suffered from
toxaemia or from a cardiac lesion during preg-
nancy. In the latter type of cases a careful gen-
eral physical examination should be made for
the purpose of ascertaining the extent of the in-
jury sustained, and of giving the patient such ad-
vice concerning her mode of life as may result in
the permanent cure or alleviation of her condi-
tion. Occasionally, this includes advising against
the early repetition of pregnancy, and in such
cases the physician should feel that it is as much
his duty to give such advice as to advocate other
less radical prophylactic measures.
In concluding these somewhat rambling re-
marks, I desire to express the hope that you will
understand that it has not been my intention to
preach to you. I have merely attempted to im-
press upon you certain points which I believe
are not ordinarily sufficiently appreciated by
many practitioners. I am well aware how diffi-
cult many may find it to put into practice the
advice given by specialists in various fields, so
that, when I consider my shortcomings in my
own field of work, I often marvel at the great
practical accomplishments of the general practi-
tioners, and particularly those whose work is in
isolated country districts.
DISCUSSION
Dr. Barton Cooke Hirst (Philadelphia) : I have
listened to Dr. Williams' paper with pleasure and
profit, as I always do. I should like to supplement it,
however. There is a great future for the reduction, of
mortality and morbidity. I have been particularly in-
terested in the reduction of morbidity in women after
childbirth. It is possible in obstetrics on the part of
the general physician to cut off 6i% of all the diseases
of women by attention to just two factors: the proper
repair of injuries and the prevention of retroversion.
If we who are teaching the subject in the United
States do our duty by the students, we can turn out
graduates competent to repair the injuries of child-
birth.
Of all the women who consult a physician on ac-
count of something peculiar to their sex, 51% are
found to have lacerations of the birth canal, although
almost all of these women were repaired immediately.
Another 10% of disease can be eliminated if the gen-
eral physician is taught the preventive treatment of
displacement of the uterus. One cannot repair the in-
juries of childbirth immediately after delivery. By
making formal intermediate operation all the injuries
of childbirth can be repaired. In the preventive
treatment of retrodisplacements, postural treatment
and repeated examinations during the puerperium
will reduce the percentage of these displacements to
about 3%. This small number may be dealt with tem-
porarily by a pessary until the radical cure by opera-
tion is elected by the patient. .In this way with 61%
erf his business cut off we can hasten the disappear-
ance of the kind of professed specialist in gynecology
we have in America, who has been leading a somewhat
parasitic existence, flourishing on the poor work of
his fellow physicians.
Dr. William N. BradLEV (Philadelphia) : In my
work at the Starr Center in Philadelphia I have had
uttder -my care for the past year 252 expectant mothers.
Of this number 131 have been delivered. Of the 131 we
had two abortions, one premature labor with a living
baby. I am happy to say to Dr. Williams that the en-
tire number of 128 were being breast fed at the end of
one month, which is important from the pediatrist's
standpciint.
As to early registration, the importance of this can-
not be overestimated. As an illustration there came
into our dispensary one day a woman who had a blood
pressure of 180; she was suffering from headache. I
instructed that she report immediately to the South-
eastern Dispensary for obsterical care. She went
immediately and, while there had a convulsion. This
woman had failed to register before. If she had re-
ceived prenatal care I am confident this eclamptic con-
dition could have been prevented.
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THE PENNSYLVANIA MEDICAL JOURNAL February, 1921
I have noted in my work these expectant mothers
run low blood pressures. I should like to ask Dr.
Williams whether this is in accordance with his expe-
rience. I find in the class of women ° (Italian) with
whom we have to deal, that the blood pressure dur-
ing pregnancy rarely exceeds an average of 105. Of
this same group of women three months after de-
livery the average blood pressure is usually 115 or 120.
The point I wish to make is that we should not go to
the extreme in underfeeding these women in preg-
nancy in order that they may have a delivery free from
danger, which I know some obstetricians are in the
habit of doing. I think this is a mistake.
Dr. Paui, Titus (Pittsburgh) : There are two
points which I wish to make in connection with Dr.
Williams' paper, and Dr. Hirst's discussion. The first
is in respect to the need for the avoidance of frequent
vaginal examinations during labor. Rectal examination
can almost entirely take the place of vaginal examina-
tion of parturient women with the utmost satisfaction
to the examiner, to say nothing of its greater safety to
the patients. It is quickly and easily done, and by this
method there is little or no possibility of contaminat-
ing the birth canal. This possibility always exists with
vaginal examinations no matter how careful one's
technique may be. A man may readily become pro-
ficient in rectal examination. Our students in the
School of Medicine here are on duty only 18 days (9
in the hospital and 9 in the out-patient department)
but in that short time become quite skillful in this
method of examination. I believe that this is a matter
which is largely overlooked by the general practitioner,
and that rectal examination should be substituted for
vaginal examinations wherever this is possible during
labor.
Dr. Hirst is an advocate of late rather than imme-
diate repair of the lacerated perineum. With due def-
erence to his opinion, I must decidedly differ with
him. His chief objection to primary repair is that' 51
per cent, of these patients, according to his figures,
come back for secondary repair because of the imper-
fect results obtained originally. Granting even this
high percentage of failure, we must not lose sight of
the 49 per cent in whom good results were obtained.
These patients, at least, were spared the necessity of
an operation on the tenth day with all that that im-
plies. Certainly it does no harm to attempt repair arid
I believe a certain amount of granulating surface open
to suppuration, i^ avoided by the closure of the lacer-
ated perineum immediately after the birth of the child.
If we fail to get an anatomical result then it is time
enough to think of further operative interference.
Db. Williams (in closing) : Had I had time, sir, I
should have taken up both the points which Dr. Hirst
and Dr. Titus have made, but I had bitten off more
than I could chew and I could not reach them. One of
the things I wanted to say was that puerperal infection
in the hands of the profession at large in this country
causes as many deaths as it did 30 years ago. That is
not my statement, but is based upon reliable statistics.
Thus, Dublin states that 45% of the deaths in child-
birth are due to infection. Dr. Meigs in 1913 stated
that 7,000 women died from infection and these women
died almost entirely in private practice and not in the
hospitals or, if in the hospitals, they died there after
having been infected outside. 'The consequence is that
there is radical need of restricting the frequency of
vaginal examination. There are two preferable ways
of examination : one is by attaining facility in abdomi-
nal palpation and the other is by rectal examination.
And I am sure that it is possible for students to learn
both of them quite satisfactorily. Anyone who has
obtained facility can conduct 85% of all labors with-
out vaginal examination with marked good to the
women. Dr. Hirst's point I am very glad he made.
One of the fundamental things in obstetrics is not to
think the thing is over when the baby is bom, but the
doctor has to watch the mother during the puerperium
and at the end of the puerperium to examine her to
see what has happened. It is at that time that we can
detect retroflexion and cure the majority of such cases
by means of a pessary, but the best gynecologist in the
world when he sees that woman five years later cannot
cure 3% by the pessary. Finally, in regard to Dr.
Bradley's remarks, I congratulate him on his results,
but cannot confirm what he says about the blood pres-
sure. The average pregnant woman has about the
same blood pressure as the average nonpregnant
woman of the same age. In the former it averages 116
to 120, and when we get a pressure much above that
we begin to look for danger, but very low blood pres-
sures are comparatively exceptional.
THE EFFECT OF THE INFLUENZA
EPIDEMIC ON TUBERCULOSIS*
C. HOWARD MARCY, M.D.
pirrsBUKGH
Many interesting reports have been published
recently on postinfluenzal pulmonary conditions.
The statement, "I have never felt well since I
had the 'flu,' " has become such a common re-
mark in taking medical histories of chest cases
that its significance cannot be passed by without
comment. The frequency of Uiis complaint and
the reports of other men led us to examine our
records at the Tuberculosis League Hospital in
an attempt to determine whether or not our per-
centage of tuberculous infections had increased
since the beginning of the influenza epidemic in
1918.
In this series we have collected 533 cases, the
onset of whose symptoms is referred to an attack
of influenza. An attempt has been made to elimi-
nate cases in which, as we were led to believe
from the history, the so-called attack of "flu"
was probably nothing more or less than a ca-
tarrhal pyrexia of some other type than true epi-
demic influenza. This, of course, was very diffi-
cult and no doubt cases have been erroneously
admitted and excluded from this series because
of the necessity of depending on the patient's
own statement for a diagnosis of his acute in-
fection.
For convenience we have divided the cases
into three groups :
I. Cases having known tuberculosis lesions
either quiescent or active before the epidemic.
'Read before the Section on Medicine of the Medical Society
of tke State of Pennsylvania, Pittsburgh Session, October 6,
i»ao.
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February, 1921
EFFECT OF INFLUENZA— MARCY
297
2. Cases of diagnosed pulmonary tuberculosis
with the history of onset beginning with an at-
tack of influenza.
3. Cases of postinfluenzal nontuberculosis le-
sions and cases simulating tuberculosis which,
after exhaustive study, cannot be definitely diag-
nosed.
The patients having known tuberculosis le-
sions prior to their attack of influenza form a
comparatively small group. We were surprised
to find in compiling these figures that we had
record of but 15 cases which, to our knowledge,
had definite pulmonary tuberculosis before their
influenzal infection. The explanation of this is
not quite clear. The same low percentage has
been reported from a number of places. Arm-
strong,* in his work at Framingham, Mass.,
found that although 12 per cent, of the entire
population of Framingham was infected with
influenza, only 4.0 per cent, of the tuberculous
subjects of the community were infected. Mur-
phy^ in his Survey of Massachusetts' Institu-
tions found the same to be true and stated that
he believed "a low grade of inflammatory prog-
ress of the respiratory tract confers a marked de-
gree of immunity against a frank invasion of in-
fluenza." In a report from the Sandhof Munici-
pal Hospital, Frankfort, Germany, Amelung*
came to the following conclusions: "The inci-
dence of influenza among patients with pulmon-
ary tuberculosis is slight. In a group of 150
cases of pulmonary tuberculosis only fifteen pa-
tients contracted influenza. The course of influ-
enza is milder, especially in cases of slight tuber-
culosis, than in the nontuberculous. The theo-
retical explanation of this action of the two dis-
eases upon each other is that the tuberculous
organism is in a state of constant defense,
whereas the healthy organism succumbs to the
.sudden attack."
From our viewpoint another explanation can
be oflfered. Nearly all of our previously diag-
nosed cases have been, at one time or another,
under institutional treatment for pulmonary
tuberculosis and upon returning to their homes
were either living on outdoor sleeping porches or
in well-ventilated sleeping quarters. Many of
these people probably were not exposed to in-
fection to the same extent as healthy individuals.
An analysis of our 15 positive cases, however,
shows that 3 have died from a reactivation of
their tuberculosis ; 6 showed definitely increased
signs and symptoms of tuberculosis activity ne-
cessitating their return to the hospital for fur-
ther institutional care ; and 6 recovered without
apparent ill effects.
From this small group it would appear that the
influenza has been instrumental in reactivating
the old quiescent lesions or producing a condition
which permitted an increase of activity in 9 of
our 15 cases.
The second group, composed of cases diag-
nosed pulmonary tuberculosis, the onset of which
began with an attack of influenza, gave no his-
tory of tuberculosis prior to their influenza and
the diagnosis has been made for the first time
since their attack. In this series we have 183
cases, or 34.3 per cent, of our total on which we
have been able to make a positive diagnosis of
pulmonary tuberculosis. We have used only
those cases whose history, physical signs, labora-
tory and x-ray findings would justify us in label-
ing them as positively tuberculous.
TABLE
1
DiagnoBla of S8S Cases Appearing at Tuberculosis Clinic with
Pulmonary Symptoms— by Number and Per Cent.
Tuberculous
6 s
g n
»^
•SO
s
J
&" .
s
S»
M 9
•a
i
a
o
ill
©5
hi
tH
S5
»i
c
Number : 533
33I> 183 15
101)
62.9 34.3 2.8
Fifty-three per cent, of these had tubercle
bacilli in their sputum, and forty-seven per cent,
were negative on routine examination.
TABLE i
Table Showing Percentage of Positive Sputum of 183 Cases of
Positive Tuberculosis by Stage of Tuberculosis
Stage
Total
Positive
Sputum
Per Cent.
Total
18S
07
SS.O
77 18
90 «3
16 16
!S.4
Moderately Advanced
Par Advanced
70.0
100.0
Seventy-seven or 42.1 per cent, were in the in-
cipient stage of the disease ; 90 or 49.2 per cent,
were moderately advanced and 16 or 8.7 per
cent, far advanced.
TABLE 8
Claselflcatlon by Stage of
Tuberculosis
183 Cases
Following
Diagnosed as
Influenza
Positive
Stage
1
Number
1
Per Cent.
Total ,
183
77
90
..1 16
100.0
Incipient
Moderately Advanced
Par Advanced
42.1
49.2
8.7
The age groups are shown by the following
tnble :
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298
THE PENNSYLVANIA MEDICAL J^^RNAL February, 1921
TABLE 4
Table Showing Ace Groups of Tuberculosis Oases by Number
and Per Oent.— By Stage ot Q.'ubereulosis
Age Groups
!
1
1 a
1 >
1
'
<
1
t
1 s
2
1
5
•D
«
"m
■a."
»
6
g
g
Inci
Per
a
^
£
Total
Under 10 years
10 to ib years
ZS to 40 years
40 yean and over
No daU
183
100.0
8 4.4
«e 90.1
92
60.8
16
8.7
1
.5
I
42.1
2.71
19.7
16.4
3.8
80 49.2'
2 I.I
2413.2
D5'i)0.0
8 4.4
I .S
I
le! 8.7
1| .s
«< 3.3
7| 8.8
2 I.I
It will be seen that the greatest number of pa-
tients were between 25 and 40 years of age.
Ninety-two out of our total of 183 positive cases
fell into this group. Thirty were incipient, 55
moderately advanced, and 7 far advanced.
for some time, thinking their symptoms were
only benign and temporary. No doubt many of
these cases were positively tuberculous some time
before they came for medical advice.
Pneumonia following influenza appeared to
have some significance as a causative factor. Of
the total number, 22.3 per cent, had pneumonia ;
12.5 per cent, of these were tuberculosis cases
and 9.8 per cent, nontuberculosis cases.
As a matter of comparison we took the rec-
ords of 254 cases appearing at the chest clinic
before the epidemic and found that 26.5 per cent,
of these had been found to have clinical tubercu-
losis. In other words, 26.5 per cent, of our pa-
tients coming for chest examinations under nor-
mal conditions were found to have pulmonary
tuberculosis. Since the influenza epidemic the
percentage has increased to 34.3 per cent, in pa-
tients who attributed the onset of their trouble to
an attack of influenza. This is an increase of
TVJBERCOWSIS ANpPATEOF InFUUENZA 0\r |83 CaS^S DiAGNOSED
Positive TuofRCuiosis foit fin^rTmB after tNFi.UEt(z.A.
ts
MtfM»eR f,0
t 3 ^
JLJ-JL
i 9
IP II It. a M- ts ti n a ij u J.I AX a
M t H*T H S.
Another interesting point is shown by the fol-
lowing graph which represents the length of time
from the attack of influenza to the time when a
diagnosis of tuberculosis was made. It will be
seen that the greatest number of cases were diag-
nosed at the end of three months. The curve
then falls and rises again at the ninth month and
again at the twelfth month.
These figures, of course, can be only rela-
tively correct as many patients gave a history of
postinfluenzal sequellae which they had neglected
7.8 per cent, in our cases of pulmonary tuber-
culosis which we believe to be due to conditions
brought about by influenza.
The cases of postinfluenzal nontuberculous
lesions and those with indefinite signs and symp-
toms simulating tuberculosis from our largest
group. No attempt has been made in this paper
to further separate these cases. There are the
usual nontuberculous pulmonary conditions as
bronchitis, unresolved pneumonia, basal lesions
of various types, bronchiectasis, lung abscess and
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EBRUARY, 1921
POSTINFLUENZAL CHEST— MORGAN
299
number with bronchopulmonary signs which as
;t are undiagnosed. It is to this group of un-
agnosed cases I wish to call special attention,
hese people have been of greatest interest from
diagnostic point of view but from a therapeutic
andpoint have been somewhat unsatisfactory.
It is not difficult to advise patients after we are
ice sure of our diagnosis. Well-known rou-
ties are established for the tuberculous, and
ore or less satisfactory treatments can be given
)r most nontuberculous pulmonary conditions ;
xt for these borderline cases the greatest care
necessary before making a decision. They can-
st be passed by lightly, hoping their symptoms
e temporary, and yet one does not feel justi-
;d in recommending a routine which may be an
inecessary hardship. What percentage of these
;ople will later be found to have clinical tuber-
ilosis is of course unknown. We do know,
)wever, that the successful treatment of pul-
onary tuberculosis depends on an early diag-
jsis and that one of the most important points
an early diagnosis is to know when to suspect
Certainly, judging from the figures given
)ove of cases already found positive following
fiuenza, we have every reason to suspect tuber-
e infection in many of these people. It is es-
:ntial then that our methods be sufficiently
lorough to make the earliest possible diagnosis,
dvice which gives the patient a false sense of
icurity must also be avoided. No doubt such
Ivice is responsible in many instances for the
itient being in an advanced stdge of the disease
;fore discovering his affliction. We are too
ften satisfied with giving symptomatic treat-
lent without careful enough study of existing
athology.
One or two physical examinations in these
oubtful cases is usually not sufficient. Care-
iilly recorded physical findings checked up at
requent subsequent examinations, are necessary,
tereoscopic x-ray plates are of great assistance.
Lccurate temperature, pulse and weight records
ive us valuable information. Repeated exami-
ations of twenty-four hour specimens of spu-
im for tubercle bacilli and, when possible, cul-
iral examinations of washed sputum may help
3 determine the causative agent.
With this data carefully collected, few cases
an go far on their downward course without be-
ig warned of their danger in time to get under
ctive treatment, and less hardship will be
rought to many homes from unnecessary, pro-
3nged absence from work.
REFERENCES
1. Armstrong: "American Journal of Public Health," De-
ember, 1919.
2. Hurphv; "Boston Medical and Surgical Journal," 1919,
:i<XXXI. j66.
3- W. Amelung: Muench. Med. Woch., Nov. 14, 1919.
THE POSTINFLUENZAL CHEST*
A. C. MORGAN, M.D.
PHIIADEUHIA
Following upon the heavy incidence of pneu-
monia and other complications during the "flu"
epidemic of 1918, many patients were very slow
in accomplishing convalescence.
This was particularly noted in the study off a
large number of soldiers who came under our
observation while on duty at the Base Hospital
at Camp Lee. Because of the persistence of evi-
dence of pulmonary pathology and the possibility
of tuberculosis being present, the surgeon-gen-
eral directed that all soldiers convalescent from
the epidemic should be examined with a view of
transfer to a general hospital where the patient
could receive prolonged treatment under suitable
and favorable environment. Most of the cases
were in those who were ambulant patients and
whose general conditions had improved up to a
certain point and yet who lacked restoration to
full health, therefore requiring constant medical
observation.
Since returning to civil life we have found
much the same class of patients comprising a
large number of individuals who have been
studied from the same viewpoint.
The persistence of physical signs that indi-
cated severe pathology caused considerable diffi-
culty in the study of these cases as to the dis-
crimination between a real postpneumonia pa-
thology and the implantation or activation of a
pulmonary tuberculosis.
In order to attempt a proper classification of
the cases, we have borne in mind the following
fundamental principles. The primary and chief
pathology of the lungs in pulmonary tuberculosis
is always located in an apex and is unilateral at
the onset. The pathologic process proceeds di-
rectly downward and outward by continuity of
structure. In the usual case of tuberculosis the
point of maximal pathology and physical signs
will continue to be manifest in the upper portion
of the chest.
In the ordinary case of lobar pneumonia, es-
pecially of the type encountered prior to 1918,
the usual pathology is located at the base of the
lungs, more frequently on the right side, and
after resolution has set in the area involved
shows a tendency to decrease rather than to in-
crease in size. If the pneumonia had been uni-
lateral at the onset, then no physical signs of
pathology incident to the pneumonic process
would be manifest on the opposite side.
It must be remembered and emphasized that in
*Read before the Section on Medicine of the Medical Society
of the State of Pennsylvania, Pittsburgh Session, October 6,
1920.
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300
THE PENNSYLVANIA MEDICAL JOURNAL
February, 1921
the pneumonia accompanying the "flu" in 1918,
the pathology was that of a generalized, wide-
spread, active, inflammatory pulmonary edema,
with areas of pneumonia more or less widely dis-
tributed over all five lobes of the lungs.
Many persons recovering from this severe
condition are now subjects of pathology that may
be .intra- or extramural. In this instance, local-
ized areas of unresolved pneumonia or of adhe-
sion formation may be scattered over various
portions of the chest, showing a predilection for
localization just within and under the scapula,
at times below the supraspinous line, or just be-
low the lower border of the scapula. There have
been some cases of localized empyema or of ad-
hesion formation discovered in the Axillary
spaces.
We have found in a large number of post-
pneumonic patients that the physical signs in the
upper chest seldom extended beyond the upper
border of the scapula, whereas in tuberculosis
apical signs are the rule.
The points of contrast therefrom should em-
phasize :
1. The primary implantation of tuberculosis
at an apex, with its tendency to progress down-
ward and outward by continuity of structure
with no normal tissue intervening.
2. That pneumonia ordinarily shows its maxi-
mal pathology during the height of or soon after
the disease has run its course, without tendency
to become progressive.
3. Postinfluenzal pneumonia has a tendency to
manifest generalized areas of pathology, fre-
quently bilateral, and usually with intervening
portions of apparently normaJ lung.
The clinical symptoms in the three conditions
will show some variation. Thus in tuberculosis,
weakness, pallor, loss of weight, more or less
continued fever, cough, expectoration and night
sweats are common.
In the ordinary postpneumonic stage, the ac-
tive symptoms rapidly subside and show a ten-
dency to disappear, with prompt recovery in the
majority of instances without much difficulty.
In many of the postinfluenzal pneumonia
cases the patient was slower in regaining health,
it being noted that general body weakness, psy-
chasthenia, shortness of breath, and fatigue on
only slight exertion, with a cough that persisted
for a long time but with scant or no expectora-
tion were the outstanding features. The pain in
the latter type is usually described by the patient
as a heavy substernal soreness, or weight and op-
pression, rather than an actual sharp pain, such
as one notes in the usual pleuritic involvement.
Following pneumonia, if a localized empyema
still persisted, the patient would then show the
clinical signs of suppuration, and he was usually
able to indicate the probable location of the trou-
ble by telling of the sense of weight or of tender-
ness in certain portions of the chest. Where the
patient has an accumulation of fluid that exerts
pressure on the diaphragm, he will frequently
describe the following experience: On settling
for a nap, or for sleep at night, just about the
time of entering upon a comfortable sleep he will
get wide awake because of a sense of suffocation
and fulness, or even of actual pain, which induces
marked nervousness and a fear of going to sleep.
In all probability the process that causes this
.symptom-complex is analogous to that which re-
sults in the "night cry" of the patient with cox-
algia. During waking moments the respiratory
muscles are in a state of tonic spasm. During
sleep relaxation of these muscles takes place and
catches the affected parts "off guard" and per-
mits dragging downward of the diaphragm by
the weight of the fluid.
Interference with the movement of the dia-
phragm by reason of pleuritic adhesions is quite
a common finding, the patients usually complain-
ing of a girdle weight or pressure, or sometimes
of actual pain or soreness along the lower costal
margins.
In several cases of adherent pericardium to
the diaphragm or the right pleura, we have no-
ticed a peculiar tugging upon auscultation that
seemed to impress upon the ear distinct evidence
of a heart trying to work against resistance.
These cases were confirmed by x-ray. These
patients frequently complained of faintness on
exertion and of a sense of discomfort in the pre-
cordium when turning in bed, probably because
of increase of tension on the adhesions.
Where there has been extensive pleuroperi-
cardial adhesion the patient will show a dyspnea
out of proportion to the apparent physical signs
or x-ray findings. This will persist until such
time that the heart will take on hypertrophy to
meet the extra work forced on it. In the case
of a physician now under observation, who had
ten weeks of serious illness from influenzal
pneumonia the heart was greatly widened, by
percussion and fluoroscope tracings. After a
course of modified Schott gymnastic treat-
ment, frequent rest periods in the daytime and
small doses of digitalis at bedtime it was found
that the heart lessened in width, increased in
muscle sound and the dyspnea has lessened
greatly, with promise of continued improvement.
In case of severe diaphragmatic adhesion, with
the natural decrease in function that results, the
patient will present many features of mechanical
obstruction to venous circulation, such as passive
congestion of the lungs, liver and stomach, so
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February, 1921 INFLUENZA AND TUBERCULOSIS— DISCUSSION
301
that gastrointestinal catarrh with its train of
symptoms will form a part of the picture. The
keynote to treatment in such instances will log-
ically concern itself with careful watch of the
heart and lungs, rather than to the alimentary
tract alone. These patients also show fatigue
and dyspnea on even slight exertion and in later
years the likelihood of cardiac dilation will be
directly related to the permanent effects of the
pneumonia pathology.
The chest of a person who has suffered a se-
vere attack of "flu" without the incidence of
pneumonia will usually reveal in the x-ray study,
a prominence of the hilus and peribronchial
glands that differs entirely from that which
usually accompanies tuberculosis. In some pa-
tients, examination eighteen months after clini-
cal recovery showed this condition still persist-
ing. It is altogether probable that reflex irrita-
tion from subacute inflammation and enlarge-
ment of these glands will account for the per-
sistence of the dry cough that has been found to
continue for many weeks and months following
clinical recovery.
As to the increased frequency of tuberculosis
in the postinfluenzal ca.ses our records have not
yet been tabulated but the impression is that
there has not been a marked increase along this
line. At the Philadelphia General Hospital the
tuberculosis wards were decimated during the
epidemic, especially affecting those patients who
had been heavy alcohol addicts.
The medicolegal phase of these cases is of
great importance. The matter of insurance is a
vital one, as most insurance companies will de-
cline to pay the full amount or in some cases will
refuse tq pay any insurance in a case of tubercu-
losis but do not hesitate about paying for pneu-
monia.
While these patients, particularly military sub-
jects, should be treated in a sanitarium, they
should not be placed promiscuously among ac-
tively tuberculous patients.
Should the need of operation arise the choice
of anesthetic would be determined by the chest
conditions still present. A physician operated
upon for cholecystitis, within a year following
recovery from influenzal pneumonia, developed
extensive empyema which required two separate
openings of the right chest because of excessive
and dense adhesions of the pleura which made
two separate reservoirs of pus. He eventually
recovered.
The contemplation of marriage by an actively
tuberculous subject should be seriously consid-
ered or abandoned, whereas the nontuberculous
postpneumonic person could safely undertake
marriage, being bound only by his capacity to
earn a livelihood, and not by fear of infection.
In the matter of employment, the tuberculous
patient should properly be debarred from certain
indoor employments, not becau.se of lessening his
own chances of recovery but for the greater rea-
son that he may infect his fellow workers. The
postpneumonic patient is not a potential carrier
and can mingle with people in general.
The ultimate prognosis of the postinfluenzal
chest will have regard to the ability of the heart
to take on hypertrophy sufficient to overcome the
added burden incident to pulmonary fibrosis,
whether it takes on the form of chronic inter-
stitial pneumonia or bronchiectasis, or adhesions
develop such as will result in great mechanical
interference with the pulmonary circulation. In
the event of a previous endocardial affection, or
one acquired during the illness, the burden
thrown on the heart might be too much and the
normal cardiac reserve would become exhausted,
thereby causing the patient to become partially
or totally invalided for life. In all events it can
be safely assumed that if such permanent pa-
thofogic change remains the likelihood is that the
patient's expectation of duration of life will be
shortened.
In order to establish the presence of a local-
ized empyema or dense adhesion of pleura we
have found the following procedure to be of
practical aid: have the patient stripped to the
waist, in a well lighted room. Use a soft crayon
pencil in drawing crescentic lines two inches
apart, starting on each side of the spine and run-
ning them well into the axillae, continuing down
to the lumbar area. The limited movement of a
small localized area of the chest can easily be ap-
preciated by watching the excursion of the lines.
By drawing two or three vertical lines on each
side of the chest a "closeup" of the affected area
can thus be outlined and will aid in the interpre-
tation of the other physical signs noted over this
portion of the chest.
(Living models are used to demonstrate the
above points.)
2028 Chestnut Street.
DISCUSSION
OF PAPERS OF DOCTORS MARCV AND MORGAN
Dr. George Morris Piersol (Philadelphia) : I was
much interested in listening to Dr. Marcy's statistics.
Last year as reports began to come in from various tu-
berculosis clinics, the impression one obtained was that
following influenza there had not been any noteworthy
increase in the cases of tuberculosis. Furthermore,
that individuals who already had tuberculosis, had
for the most part, not been seriously disturbed by at-
tacks of influenza, and that the mortality of influenza
had not been particularly high in the tuberculous,
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THE PENNSYLVANIA MEDICAL JOURNAL
February, 1921
This increase of 7.8% given by Dr. Marcy is rather
contrary to this heretofore prevalent idea.
There seems to be no doubt that the greatest diffi-
culty in the diagnosis of these postinfluenzal pulmon-
ary conditions is to separate them from tuberculosis.
In spite of this 7.8% increase in the number of tuber-
culous cases that have been found, I believe more have
been called tuberculosis that were not, than vice versa.
In this Connection it must be admitted that much harm
may be done by branding patients as tuberculous when
they are not.
When one stops to consider the pathology of cases
of influenzal pneumonia, it is not surprising that many
of the residual lesions are confused with tuberculosis.
In a general way the lesions most readily confused are
the deep seated residua that may be very persistent
about the roots of the lungs and the bronchiectases
that frequently follow influenzal pneumonia. After
the epidemic of 1889-90 bronchiectasis was commonly
observed following influenza. At that time the pa-
thology of influenzal pneumonia was carefully studied
by Dr. Stengel, who pointed out the frequency of post-
influenzal bronchiectasis. In the last two years we
have again seen more bronchiectasis than in the pre-
ceding decade. The explanation lies in the fact that
in the recent type of pneumonia associated with influ-
enza, there is a very violent bronchitis and peribron-
chitis which tends to weaken and distort the bronchial
walls thereby giving rise to conditions that favor the
development of bronchiectasis. •
The point brought out by Dr. Morgan that these non-
tuberculous postinfluenzal lesions are nearly always at
the bases rather than at the apices, is an important
diagnostic difference to be remembered in differentiat-
ing them from tuberculosis. If you are looking for
the certain classic evidence of consolidation in the pul-
monary complications of influenza, you are doomed to
disappointment, for commonly no such obtrusive signs
occur. As a rule the lung involvement shows itself
only as slight impairment of resonance, feeble breath-
ing, and showers of fine, moist rales.
- Another very important postinfluenzal lesion is inter-
lobar or encapsulated empyema. I think Dr. Landis
will bear me out that at no time have so many such
cases been seen as recently, following the great epi-
demic of influenza, cases that have been too often
called unresolved pneumonia. I am beginning to
doubt whether unresolved pneumonia ever exists, so
many cases alleged to be of such a character have been
demonstrated to be interlobar empyemata. I am very
strongly inclined to the opinion that heretofore we
have failed generally to recognize such empyemata.
Certainly since this last epidemic they have been sur-
prisingly common. Interlobar empyema is a lesion
which should be constantly suspected if it is to be
promptly recognized.
In making the diagnosis of pulmonary lesions which
develop after influenza, whether they are in the pleura
or in the lung parenchyma, especially when differen-
tiating them from tuberculosis, every point must be
taken into account. If you depend only on the x-rays
you are going to have difliculty, because these x-ray
pictures are by no means always diagnostic. Many
lesions give an appearance that looks for ail the world
like tuberculosis but is not. The whole clinical pic-
ture, a careful history of the patient, whether or not
tuberculosis existed before influenza, ought to be
taken into account ; the presence or absence of emaci-
ation and fever ought also be considered, as well as
the physical signs and their location; and finally the
laboratory examinations are important, particularly
the repeated examination of the sputum for tubercle
bacilli. Anyone who is satisfied with single or occa-
sional negative sputa, is liable to run into serious error.
For instance, in organizations like the army, where it
was necessary to study large groups of men and where
ail facilities were available, we frequently could not
determine definitely whether a patient did or did not
have tuberculosis tintil twelve or fifteen successive
sputum examinations had been made. It should be
emphasized that repeated sputum examinations, as well
as x-ray studies and physical signs are essential to
properly differentiate postinfluenzal residua from tu-
berculosis. I believe that the person who is willing to
make the diagnosis of tuberculosis following influenza
without knowing whether or not the patient has a pre-
vious tubercular history, or without finding tubercle
bacilli in the sputum, is liable to do the patient a seri-
ous injustice which will often result in more harm
than good.
Dr. Henry R. M. Landis (Philadelphia): It was
only after postmortem experience that we began to
learn that many loculated empyemas occur in very defi-
nite, fixed places. I should say that in fully three-
quarters of the cases I saw during and following the
influenza epidemic, there would be a mass of physical
signs without any direct evidence as to where the pus
was. As a rule it could be surmised that it would be
about the angle of the scapula on one side or the other,
and it is just at this point that the septum dividing the
upper and lower lobes occurs.
There is one sequel that has not been mentioned at
ail, and which has occurred in a fair proportion of
these cases, when the pus occurred between the base
of the lung and the diaphragm, the diaphragm fre-
quently became fixed, leading to a very considerable
amount of shortness of breath, which would persist
for a matter of many months. The diaphragm and its
relation to diseases of the chest have been studied en-
tirely too insufficiently. A fluoroscopic examination of
individuals who have had empyema will often show
fixation of the diaphragm on one side or the other.
This sequel happens particularly in postinfluenzal
cases where pus has become loculated in the angle be-
tween the chest wall and the diaphragm, the diaphragm
being fixed at this point, and restricting the capacity
of the lower lobe on that side.
Dr. a. J. Simpson (Chester) : It appears to be a
logical deduction that following any diseases in which
the respiratory effects are most evident, as in influenza,
there would naturally be an increase in the pulmonary
affections such as tuberculosis. With that in mind we
were warned by tuberculosis societies, the journals
and in every possible way to look out for this phase.
The results, however, did not bear up the original
contention. As Dr. Piersol has remarked, the work
done in Massachusetts, particularly I think during the
early part of 1919, and reported by Hawes and others,
was interesting and had we followed that entirely we
would come to the conclusion that there would be no
increase in tuberculosis whatever, and influenza would
have no effect. They emphasized the possible relative
immunity in these tubercular cases especially to influ-
enza. I do not think that many adherents to
that theory will be found to-day. I think possibly that
relative immunity was more a result of the care that
they exercised and the restrictions thrown about them.
Since then we have had collections of data throughout
the country at different sanitoria so at this time there
is a somewhat different light thrown on the subject.
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February, 1921
SURGERY OF ABDOMEN— HAMMOND
303
The final analysis comes down in all these instances,
as to whether the tuberculosis existed prior to the
influenza, whether the tuberculosis was aggravated by
the influenza, or whether the tuberculosis was defi-
nitely diagnosed after the influenza and not before.
The consensus of opinion now seems to be that tuber-
culosis was aggravated by the influenza, but the per
cent, of increase where there was negative history be-
fore does not come up to what we were led to expect,
and it seems to have been more of an aggravation
of the condition by the onset of influenza than of new
cases coming up following the epidemic. So it makes
one halt and think, rather than make a diagnosis of
tuberculosis where there is purely a basal pathology
and no apical involvement and no organism after re-
peated examinations.
We should emphasize repeated examinations of
sputum before diagnosis. In our private practice we
should make not less than six or eight examinations
of sputum before we are satisfied they are or are not
tubercular cases. To sentence an individual to a life
in a sanitarium thinking that he is tubercular, with
purely basal symptoms and without the physical signs
of apical involvement, also without positive laboratory
findings, I think is a mistake.
Dr. John W. Boyce (Pittsburgh) : My experience,
as far as it goes, is in accord with what has been said.
I agree with Dr. Morgan that the most diagnostic
thing about a tuberculous lesion is its preference for
the apex while the lesions of influenzal infection show
an almost equally strong tendency to group round the
lower end of the trachea and primary bronchi. Never-
theless, like Dr. Piersol, I am constantly driven to the
sputum examination. In fact my practice at the pres-
ent time is to repeat sputum examinations frequently.
When acid fasts are found I diagnose t-b., but until
then I leave myself just as many loopholes as the pa-
tient will stand for.
We are blaming all our present troubles in diagnos-
ing t-b. on the flu. If t-b. can be excluded then we
say it is postflu infection. It is important to remember
that it was in June, 1918, that the surgeon-general was
compelled to issue an order that no soldier should be
sent to a t-b. hospital until the sputum had been found
positive. This order was necessary for the special
hospitals were packed solid with what the surgeon-
general's office was calling streptococcus bronchitis,
though in most of them the physical signs gave evi-
dence that there was more than a mere mucous mem-
brane involvement. In other words, four months be-
fore the flu epidemic there was a very prevalent sub-
acute and chronic lung infection with which we were
not familiar and which (except for the negative
sputum) imitated t-b. so closely that experienced men
were calling it t-b. even after ward study. In particu-
lar this infection is capable of causing hemoptysis.
Five years ago if a patient came into the office saying
he had spat blood it was a ten to one shot the cause
was t-b. This is not true at the present time. More
than half the current cases of hemoptysis are due to
something else.
Db. Joseph Sailer (Philadelphia): I hadn't ex-
pected to speak on these papers, interesting as they are.
The question of physical diagnosis is of course very
important For very nearly a hundred years the study
of physical signs of lungs has been pursued, and I
think it is fair to say that during the war when we
had so much pneumonia, we all realized that the sub-
ject was by no means exhausted.
It was at that time a difficult matter to diagnose
empyema, particularly to localize the collection of pus
close to the spinal column on the right and on the left
side, and the signs, as Dr. Piersol remarked, were
very different from those described in textbooks as
characteristic.
The most difficult feature, I think, was to localize
some of the abscesses subsequent to influenza. In the
majority of these cases the empyemas were walled off
and loculated and the discovery of the pus required
the greatest ingenuity. Every case was carefully
x-rayed and the plates shown to the group of men en-
gaged in the medical wards; the man in charge read
his clinical notes and all of us studied the plates.
Often it suggested further examination and yet in
spite of this, sometimes we failed at first. All of
tliese cases to which Dr. Morgan refers are of value,
but I think Dr. Morgan will agree that there are no
definite rules of physical diagnosis at the present time.
Each case requires a particular and careful special
study of its own.
CONCERNING ACUTE TRAUMATIC
SURGERY OF THE ABDOMEN*
LEVI JAY HAMMOND, M.D.
PHILADELPHIA
Every injury to the abdomen, however slight
it may appear at the time, should be seriously
considered and treated as though known to be
gp-ave, for unexpected symptoms may arise and
death ensue from apparently slight blows. On
the other hand, injuries apparently severe may
be neither attended nor followed by serious re-
sults. In the interest of the patients then, we
must be suspicious of the worst when injuries to
this region occur.
It is not difficult to understand the gravity of
injuries to the abdomen when we recall the
abundance of hollow viscera, solid organs, blood
vessels and nerves, many of which are in close
proximity to its walls. The passage of a weight
over it, compressing forces, blows or kicks are
the usual causes of injuries to and ruptures of
the abdominal organs and these may occur with-
out any trace whatever of injury to the surface.
A blow below the belt, in pugilistic parlance, may
cause instant and severe shock arresting the
heart's action, and death may ensue without even
a trace of surface evidence.
The discussion in this paper is limited to in-
juries to the abdominal viscera without perfora-
tion of the abdominal walls and those associated
with penetrating wounds of the abdomen.
These injuries, whether penetrating or nonpene-
trating, vary according Jo the nature of the in-
flicting body and the manner of their occurrence.
The punctured are the most common; the in-
cised are the simplest and most favorable; the
'Read before the Section on Surgery of the Medical Society
of the State of Pennsylvania, Pittsburgh Session, October $,
1920.
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304
THE PENNSYLVANIA MEDICAl^
;%
NAL
February, 1921
lacerated and contused Jire the most tedious in
recovery, and the most prone to be followed
by suppuration and sloughing; while gunshot
wounds are the most fatal.
About ten per cent, of the serious injuries af-
fecting the body are to the abdominal viscera.
The surface of the abdomen, because of its elas-
ticity and yielding, may escape serious effect
from a sudden smart blow that will contuse or
rupture the organs within. This is especially true
of such solid organs as the liver, spleen, kidney —
the pancreas rarely because of its protected posi-
tion. The stomach, urinary bladder, gall blad-
der, each or any if distended with fluid may be
ruptured by a blow or fall that would not injure
the intestines unless the force of the blow is di-
retced so as to press them against the bodies of
the vertebrae or the bones of the pelvis. Com-
plete rupture through all the coats of the stom-
ach at the cardiac extremity is attended by more
serious shock, collapse and sudden deaths than in
complete rupture at the pyloric extremity or in
rupture of any region of the small intestines.
INJURIES TO THE VISCERA WITHOUT PENETRA-
TION OF THE WAI,I,
The immediate and serious effect of these con-
cealed injuries is hemorrhage and rupture of the
hollow viscera with discharge of infectious ma-
terial into the cavity of the peritoneum. Severe
and prolonged shock may immediately follow in
the absence of hemorrhage, but if prolonged, and
ansemia increases, with growing weakness of
pulse and restlessness, hemorrhage should be sus-
pected; because symptoms of pain, rigidity of
the abdominal muscles, nausea, vomiting and hic-
cough (which suggests peritonitis from escape of
intestinal contents) are not present early, as they
do not come on until at least twelve hours later.
When the intestine is not torn through but con-
tused, the .symptoms of peritonitis are still longer
delayed until the gangrenous slough resulting
from the contusion completes the perforation.
During this interval the patient may be compara-
tively comfortable. If the perforation from
necrosis is still longer delayed (from seven to
nine days) circumcised adhesions may close off
the injured parts so that after perforation does
take place the intestinal contents will not dis-
charge into the general peritoneal cavity but into
a protected pouch.
It is more difficult to decide upon the actual
extent of injury to the viscera without wounds
of the abdominal walls than when such exist. If,
however, the degree of .'-hock is great and the
general condition does not improve, and the in-
jury of other parts of the body will not explain
the lack of improvement, it must be assumed that
there is grave intraabdominal injury. The diag-
nosis of internal hemorrhage is not difficult to
make but it is impossible to say from what organ
the blood comes unless it is revealed by the char-
acter of the injury. Median laparotomy, if the
condition of the patient warrants such a step, is
the only sure means of ascertaining this fact and
controlling the bleeding, and the more quickly
it is performed and the torn vessels ligated, the
more favorable will be the result. If from a
wounded liver, hemorrhage is best arrested by
tamponing, as sutures will seldom suffice because
of the absence of elastic tissue and the great
friability of the organ. A badly torn spleen had
better be removed.
The blood supply of the abdominal viscera and
organs is abundant. The vessels are poorly pro-
tected and if they are torn, alarming hemorrhage
promptly ensues. Wounds of the great vessels
(the aorta and vena cava) are, as a rule, fatal, the
patient perishing before help can be secured, and
bleeding from the epigastric, intercostal, lumbar
and circumflex iliac arteries will prove equally
fatal unless hemorrhage is promptly arrested.
The blood supply of the viscera, omentum and
mesentery is so great that they could not escape
injury in a wound of these organs and seldom is
there found injury to vessels without serious in-
volvement of the organs. The pressure exerted
by the abdominal walls and through them of the
contained viscera is often sufficient to check hem-
orrhage from these small vessels though it can-
not be relied upon to secure the same results
when the larger vessels have been torn. The
rapidity and amount of hemorrhage depends
therefore on the size of the vessel wounded and
the degree of abdominal resistance.
The most misleading of the visceral injuries
are those where a grave lesion exists, yet shock is
transient and followed by a period of compara-
tive ease. Such a patient should be closely ob-
served and the abdomen promptly opened if
vomiting of bile or blood-stained material, muscle
rigidity, especially of the recti, and irregular dis-
tension develop. To disregard these signs and
symptoms for later and more positive evidence
of peritonitis allows the most favorable oppor-
tunity for" operation and repair of the injury to
pass.
PUNCTURED WOUNDS OF THE ABDOMEN
In traumatic perforations of the viscera there
is this advantage : the ruptured organ is usually
healthy and the perforation is more or less closed
by muscular contraction and inversion of the
mucous lining. In rare instances this contraction
is sufficient to prevent the escape of infectious
material into the abdominal cavity. This is es-
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February, 1921
SURGERY OF ABDOMEN— DISCUSSION
305
pecially true in wounds of the small intestine —
less so in those of the large — ^and the danger of
infection from the escaped material is decidedly
less from the small than from the large intestine.
Next to the danger from . infection, is hemor-
rhage. In punctured wounds of the wall, the
most important question is to determine the ex-
tent of involvement of the organs, for a punc-
tured wound may exist without such complica-
tion, especially when the inflicting force is made
with a blunt object. Penetrating injuries of the
epigastrium are less frequently accompanied by
injuries of the organs than are those of the lower
abdomen.
It is one thing to consider simple penetrating
wounds of the abdomen without protrusion or
injury of the viscera, and quite another when the
viscera protrudes and is injured, or protrudes
without injury. The severity of the symptoms
cannot always be measured by the extent of the
injury or the early apparent gravity of the case.
Some persons suffer much more severely and
reaction in them is much longer delayed than in
others. Then, too, punctured wounds in certain
regions, such as the lumbar and hypogastric, may
inflict serious injury to the kidney and bladder
without penetrating the peritoneal cavity. In
neither of these instances need results prove
fatal, and recovery may be complete unless in the
instance of the kidney the tubular structure has
been seriously affected. There is, on the whole,
nothing necessarily dangerous in any simple
penetrating wound — ^the seriousness depending
entirely on the accompanying injuries to the or-
gans and viscera of the abdomen.
Gunshot wounds which are of a contused and
lacerated nature, when not immediately fatal, are
to be considered entirely as other penetrating
wounds of the abdomen. Shock is occasionally
very intense, even when no viscera has been in-
jured, though it is seldom that the viscera escape
when the wound is through the front of the ab-
domen. A certainty as to the extent of the in-
jury cannot be arrived at always from the ap-
parent course of the bullet, nor is shock or func-
tional derangement of the viscera (as vomiting
or muscle rigidity) evidence of visceral penetra-
tion, and without protrusion of viscera or escape
of their contents no proof of the extent or se-
verity of the injury can be established without
exploratory incision, which is the safest pro-
cedure to follow when there are symptoms of
continuing hemorrhage. Probing is dangerous.
Shock is delusive. The kidneys, the colon, the
bladder and other extraperitoneal organs may be
injured in this way without the peritoneum be-
ing opened, and give rise, as does hemorrhage
from fractured spine or pelvis, to intestinal pa-
ralysis that may simulate perforated injuries of
the intestines.
Of our last twelve serious intraabdominal in-
juries seven were from bullet wounds, and I
have noted especially in wounds of the bladder
and the bile ducts that escape of their contents
when from a healthy bladder or healthy bile duct
resulted merely in local plastic peritonitis when
incision with drainage and repair of the parts
could be immediately carried out, showing that
neither the bile nor the urine from healthy or-
gans is early more than irritating to the peri-
toneiun. This may equally be said of blood clots
but in none of them is this true when the escape
of these fluids is from unhealthy organs or if
permitted to long remain in the peritoneal cavity.
Early operation is the safest principle to fol-
low, even though the abdomen is at times need-
lessly opened, for the risk thus taken is less on
the whole than the danger that results from con-
tinuing hemorrhage or escaping of infected ma-
terial into the cavity of the peritoneum.
Shock is so diflicult to distinguish from hem-
orrhage that, if other factors, especially the rate
and volume of the pulse, will permit it, there
should be no delay in operation in any severe in-
tra-abdominal injury. Leucocytosis in hemor-
rhage is not, as claimed by some, a reliable factor.
There can be no hard and fast rule to guide
operative procedure since no two wounds will re-
sult in precisely the same character or extent of
injury. Of grave importance is the arrest of
hemorrhJEige, suturing of ruptured organs or
viscera, and the establishment of drainage, and
this last should be as limited as the individual re-
quirement demands because packing may in-
crease and prolong shock. If the condition of
the patient will at all permit of operative inter-
ference, promptness of its performance consist-
ent with thoroughness will save many more lives
than will treatment by the "let alone'" method.
We should not yield to the "delusions of hope"
in such instances even though it is claimed that
some patients have recoyered from punctured
wounds of the abdomen without operation.
DISCUSSION
Dr. John O. Bower (Wyncote) : I agree with Dr.
Hammond in that every case of abdominal injury
should be considered a surgical one potentially. I
have had a different experience, however, with the
leucocyte count in practical diagnosis. In every emer-
gency case that came into the Samaritan Hospital in
the past ten years a leucocyte count has been made
immediately. In every instance where internal bleed-
ing was present the amount of hemorrhage was com-
mensurate with the degree of leucocytosis. There
was only one case in which a leucocytosis was found
in which operation was not done and that was in a
ruptured spleen. The patient was treated expectantly
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306
THE PENNSYLVANIA MEDICAL J^^^UaL February, 1921
for 48 hours. At the end of 4hat' time he was given a
bottle of citrate by mistake and within an hour his ab-
domen was filled with blood.
In a ruptured hollow viscera we do not depend upon
the letlcoyte count because it would mean delay. We
rety entirely upon abdominal rigidity. This alone we
consider sufficient evidence for exploratory lapa-
rotomy.
Our experience has been that there is an advantage
in operating on these cases with spinal anesthesia.
One of the reasons for its infrequent use is, I believe,
that surgeons are not generally familiar with the tech-
nique of administration, or the family physician had
read of more deaths titan he has seen administrations.
One of its advantages is that it is quickly given.
Usually in the average emergency case a green . resi-
dent gives the ether and you have a tight abdomen in
which to work. The second advantage is that it re-
laxes the abdomen and you can operate in a much
larger field ; the third is that it diminishes hemorrhage
by lowering the blood pressure; the fourth that it
paralyzes the sphincter and frequently a bowel move-
ment results.
It is a decided aid in the treatment of combined
perforation of the lung and abdominal viscera due
to gunshot wounds.
We have a case of this kind in the hospital at the
present time where the bullet entered the eighth inter-
space in the posterior axillary line, perforated ' the
upper pole of the right kidney and the right lobe of
the liver. On examination there was evidence of in-
ternal hemorrhage; spinal anesthesia was given and
while his blood pressure, systolic, fell from no mm.
to 75 mm. after the injection, his condition throughout
the operation was much better than one would expect
after such a loss of blood. The irritating effects of
ether with resultant coughing and struggling would
have been a' decided disadvantage in such a case. The
patient made an uneventful recovery.
The very young react well to spinal anesthesia. I
recently operated on a case of a child four years old
with a ruptured liver using stovaine intradurally. The
recovery was uneventful.
Dr. Samuel D. Shull (Chambersburg) : I feel
there is but little that I can add to the excellent f>aper
by Dr. Hammond, but it is a fact that traumatic in-
juries of the abdomen produce conditions that are
more difficult to diagnose than almost any other con-
dition we find in surgery, and among the injuries the
penetrating wounds are the ones that require most at-
tention because we are apt to have perforation of al-
most any of the viscera. We are more apt to have
hemorrhage because the large blood vessels may be
punctured, and we are more apt to have greater shock
and peritonitis developing. I believe in treating pene-
trating wounds of the abdomen quickly. An operation
should be done immediately if the patient can be got-
ten into the hospital at once. The quicker the abdomen
can be opened the less great weakness we will have. I
mean to say that the chances for the recovery of the
patient are better with a rapid operation. Blows and
contusions of the abdomen can be studied a little while
longer than the penetrating wounds. They do a great
deal of damage and rupture the peritoneum and yet
sometimes do not do any damage to the viscera.
Some claim that we should immediately administer
morphia hypodermically in injuries to the abdomen. It
is a fact that morphin will splint the intestinal tract or
splint the viscera and stop peristalsis and in case of
rupture we will not have scattering of the fecal con-
tents, consequently less chance of peritonitis ; but I
believe if given too early it will mislead us in our
diagnosis. It changes the expression of anxiety, it
relaxes the abdominal rigidity and in other words it
misleads us very markedly. I have in mind one case
of a boy brought idto a hospital who had been shot
with a i2-gauge shotgun at close distance from the
gun and the abdomen was covered with perforations
from No. 6 shot. In consultation the man who was
with me declared that the shot did not penetrate the
peritoneum. The boy was dying, his pulse was weak
and rapid, the ansemja was marked and all the indi-
cations of shock were present as he was dying from
shock. We had no chance to do anything because he
died half an hour after he entered the hospital. Post-
mortem showed that almost every organ in the abdo-
men was penetrated and shredded with shot. It rather
made plain to me that even though the wound of en-
trance is not very marked, on the inside there may be
great damage done.
Dr. William L. Estes (So. Bethlehem) : These
cases of injuries to the abdomen interest me very
much. I have seen a great many of them, usually acci-
dents occurring in industrial establishments. I want to
emphasize the importance of making early determina-
tions and opening the abdomen at an early stage when
it is necessary. There is no doubt what ought to be
done in a penetrating wound of the abdomen if below
the epigastrium. Whether caused from gunshot or
entrance of a bolt, spike or whatnot, there is always
more or less injury to the contents of the abdomen.
There will certainly be hemorrhage and frequently
multiple perforations of the viscera.
Another class, namely, contusions of the abdomen,
has given me a great deal of difficulty in diagnosing
and knowing what to do early enough to do the effec-
tual thing. In contusions of the abdomen there may
be absolutely no indication of ecchymosis or anything
to lead one to suspect that there was serious injury
within the abdomen, where in many cases there have
been serious lacerations of the viscera. I have found
in the observation of a large series of cases that leuco-
cytosis varies very much. Sometimes it gives one an
idea and sometimes it gives one absolutely none. I
have made it a rule in my cases, to have a leucocyte
count made almost immediately. Where there is a
good deal of hemorrhage there is a relative diminution
of the red corpuscles and increase of the white. In
some cases there is an almost immediate increase in
the leucocytosis, but it varies so that I have learned
almost entirely to disregard it. I have found the
viscera most commonly affected in these contusion
wounds: first, the liver; second, the spleen. In these
cases there is always severe hemorrhage, such a quan-
tity of blood being poured out that the patient will not
recover without opening the. abdomen and evacuating
the blood. Then I have found of the hollow viscera,
the intestinal tract, that the large intestine is never
torn. I have never found except by direct injury that
a large intestine has been injured. The small intestine
is commonly injured just where it is fixed, near where
the mesentery is attached and especially at the begin-
ning of the jejunum just where it passes Treitsch's
ligament. I always look for the injury there, and if
I do not find it there, I nearly always find it near the
attachment of the greater mesentery, and lastly in the
mesentery or the omentum when there is no laceration
apparent of the small intestine. I would counsel every-
one who has to deal with these injuries to watch care-
fully for persistent statis of the intestines, and if thete
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GASTRIC AND DUODENAL ULCER— ESTES
307
is vomiting, persistent distention of the abdomen, and
signs of shock I should always advise that the abdo-
men be opened without delay.
Dr. Hugh E. McGuibb (Pittsburgh) : In discussing
Dr. Hammond's paper I wish to say a word in regard
to the use of morphine in abdominal injuries. I have
a rule in the South Side Hospital that no man is to re-
ceive morphine who is suffering from an abdominal
injury until the diagnosis- is made, for just the moment
you give such a patient morphine all symptoms of the
injury and condition following disappear. In many
cases you will only have a rigidity of the abdominal
muscles, absolutely no external signs of injury, but a
lessened peristalsis at the seat of injury, and if you
give the patient morphine in such a case these few
symptoms will entirely disappear. When a patient
enters the hospital suffering from an abdominal injury
he is put to b«d and if his temperature goes above lOO
with a slight rigidity, lessened peristalsis and no other
symptoms we open the abdomen. My experience has
been that in cases where you wait until you get the
textbook signs of perforation (vomiting and disten-
sion), these cases, when operated upon nearly all die.
If possible I try to operate within the first six hours
after the injury, and in these cases the abdomen' can
be smeared with fecal matter from the ruptured bowel
and you will not have peritonitis develop.
In the last ten years I have operated upon quite a
number of cases with ruptured bowel and have only
operated upon one case with the above symptoms and
did not find a perforation. This case also had a frac-
ture at the base of the skull which masked the ab-
dominal condition.
Dr. John P. Griffith (Pittsburgh) : I am quite
sure this paper of Dr. Hammond's has been a very
important one, particularly for surgeons in this dis-
trict as well as other industrial centers. The impor-
tant thing is the early recognition of intra-abdominal
injury and prompt intervention. Being aware of the
importance of early operation in these cases, we in-
■ struct our interns to carefully examine the abdomen
in all traumatic cases admitted to the hospital. The
two invariable signs present are: first, diminution or
absence of peristalsis ; second, tenderness at or near
the traumatized area. I think in my surgical work the
one sign, tenderness, elicited properly has been the
greatest factor in early recognition of the acute abdo-
men. It is true that rigidity is usually present, but
early in these cases, particularly in cases of extreme
shock, you may find a flaccid abdomen. Tenderness
however is always present; you simply cannot have a
traumatized peritoneum without tenderness. Often we
receive these traumatic abdomens within four to six
hours from the time of the injury. We have talked
so much about these cases that physicians in the out-
lying districts when suspicious of an intra-abdominal
injury immediately send them to the hospitals. In
cases of hemorrhage without a ruptured viscus you
may have almost identical symptoms within the first
six hours. The tenderness is more likely to be diffuse
however, and peristalsis may be entirely absent. These
cases are operated immediately. We may find no ac-
tive bleeding but I feel safe in that I have done the
best thing"for the patient and can go home and sleep
with a clear conscience. If we wait hours, or until
the next day, in this class of case we find at times a
ruptured viscus with slow leakage in addition to hem-
orrhage. The hemorrhage diffusing over the peri-
toneal cavity produces a cessation of peristalsis which
accounts for the slow dissemination of contents in this
type of case. To emphasize tl;e value I place upon
tenderness in these cases I will site the following case.
A colored man came in to the Mercy Hospital eight
years ago with the history of a blow on the abdomen.
Examination revealed no external evidence of violence
which is the rule in these cases. It is like breaking an
egg in a bag without injuring the bag. This man
presented a flat abdomen, no rigidity, a complete ces-
sation of peristalsis and an area of tenderness pretty
well circumscribed to the right of the umbilicus. I
decided to open the abdomen on the one sign of ten-
derness. I found the terminal ileum completely sev-
ered, with practically no leakage. I explain this case
by the associated traumatic ileus.
Dr. Richard J. Behan (Pittsburgh) : One factor in
traumatism of the abdomen is cessation of abdominal
respiration. I have examined many cases of abdomi-
nal injuries, and that is one of the first things that we
notice is absent. It comes on as quickly as does the
'rigidity of the abdominal muscles.
Dr. L. J. Hammond (closing) : I have nothing fur-
ther to add, other than to express my pleasure, and to
assure those who have taken part in the discussion that
I have profited by listening to the discussion.
EARLY DIAGNOSIS OF PERFORATED
GASTRIC OR DUODENAL ULCER*
WILLIAM L. ESTES, JR.
SOUTH BETHLEHEM
It has long been emphasized that the success-
ful treatment of perforation of a gastric or duo-
denal ulcer depends upon early surgical interven-
tion. In the first few hours following perfora-
tion, especially of the duodenum, the fluid poured
out into the peritoneal cavity is relatively sterile,
and the peritonitis produced is largely chemical.
In the later stages, bacterial infection occurs and
a suppurative peritonitis results. In the first
twelve hours, operation offers the patient a fairly
certain cure. Operation later than twelve hours
after perforation, or when bacterial peritonitis
has begun, may be too late to save life. The
recognition of a perforated ulcer early, there-
fore, is obviously imperative, so that the patient
may receive the full benefit of surgery..
It is fortunate that, if seen at this early stage,
there is a most striking clinical picture, not easily
forgotten when once recognized, which stamps
perforation of an ulcer quite definitely. Certain
features of this accident have been well heralded,
but there are others, that have been less well em-
phasized, which have been especially prominent
in our series of cases, making it seem worth
while, in spite of numerous predecessors in this
field, to direct attention to this subject once
again.
Moynihan, as well as Peck, has suggested
'Read before the Section on Surgery o( the Medical Society
of the State of Penn>ylvania, Pittsburgh Session, October 5,
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THE PENNSYLVANIA MEDICAL JOURNAL February, 1921
that perforated ulcers may be divided, roughly,
into three groups:
1. Acute perforation with considerable im-
mediate leakage.
2. Chronic ulcers which leak from time to
time, causing local exudate or abscess only.
3. Chronic perforated ulcers, protected by in-
flammatory adhesions, which never have any
considerable leakage at any one time.
Ulcers of the anterior surface of the stomach
and duodenum, and the lesser curvature of the
stomach, are likely to have considerable immedi-
ate leakage. Ulcers of the posterior wall usually
fall into one of the last two groups. Eliot has
observed that the posterior ulcers form but one-
fifth of all perforations.
The diagnosis of perforation may be made
from: i. History — symptoms. 2. Examination
— signs.
History. — The predominant and characteristic
symptom and complaint is pain of sudden onset,
— ^intensely severe and agonizing. There is prob-
ably no other acute abdominal lesion in which
the pain is so great. It is usually localized in
the epigastrium,— occasionally in the right or left
abdomen. At onset, the patient may actually
have a sensation as though something had "burst
inside." There is apparently no constant rela-
tion to meals, though perforation may occur an
hour or two after a large meal. In a few cases
in our series it followed a moderate exertion,
but, in the majority of instances, the pain began
in the early morning hours. It is usually con-
stant and continuous and in cases in which mor-
phia had been given, very little, if any, relief had
been obtained. Exceptionally, the pain is parox-
ysmal, with excruciating exacerbations, im-
planted upon a dull steady ache. The interval be-
tween the severe spasms varies greatly, — often
several hours. In these cases of intermittency,
it is likely that some effort by omental or other
adhesions has been made to plug the opening,
and leakage, and extending peritoneal irritation
and involvement has been temporarily controlled
or checked.
Very rarely there may be a premonitory mild
discomfort in the epigastrium for several hours
or even days before the acute pain of perforation
occurs.
In the greater number of our series, previous
periods of dyspepsia — sour eructations, epigas-
tric pain and discomfort a few hours after meals,
relief by food — ^had been experienced, indicating
the ulcer had existed for some time. Moynihan
argues that the usual perforation is in a chronic
' ulcer and that an acute ulcer with perforation is
exceedingly rare. Most observers concur in this
belief though in every series of perforated ulcers
reported there is a group in which no symptoms
of previous indigestion could be elicited ; in Sul-
livan's series, however, there was but one such
case.
Vomiting is inconstant, unimportant, but
usually present. There is no specific character
to the vomitus.
Examination. — A glance at the patient is suf-
ficient to realize that he is suffering agony. He
has an anxious fearful expression; his thighs
may be flexed on the abdomen ; he holds himself
rigidly and moves but little, as any movement in-
creases the pain; his respiration is entirely
thoracic ; his abdomen is scaphoid to the point of
retraction, especially in the upper half, often pro-
ducing a transverse line or furrow completely
across the abdomen, one to two cc. above the
umbilicus, usually through one of the transverse
lines representing the tendinous intersections or
divisions of the rectus muscle. This appearance
of the abdomen is most characteristic, and is one
of the distinguishing features of a perforated
ulcer.
With this retraction, there is extreme, board-
like rigidity, and exquisite tenderness of the en-
tire abdomen, especially marked in the epigas-
trium. Some observers have even asserted that
the site of the ulcer may be detected by a point
of maximum tenderness in the epigastrium or in
the right hypochrondrium. In our series, no
such distinguishing point could be accurately de-
termined.
Another feature for remark is that, for so se-
rious an abdominal lesion, there is but little evi-
dence of shock. The pulse is usually of good
volume, seldom accelerated, often almost bound-
ing in quality. Immediately upon perforation,
there may be a brief interval of collapse. Cer-
tain deaths from "acute indigestion" have been
ascribed to a severe fulminating type of perfora-
tion. However, in the typical perforation, there
is apparently very "rapid recovery from the initial
effect of the perforation, and practically a nor-
mal pulse may persist until the terminal stages.
Though it is well to have a leucocyte count in
every acute abdomen, there are no characteristic
findings in perforated ulcer. There is usually a
leucocytosis — in our series between 14-18,000 —
but one of Deaver's cases showed only 7,000.
The polymorphonuclear count is usually between
75 and 80%.
Discussion. — The severe pain and marked ri-
gidity associated with perforated ulcer have been
quite generally noted. Moynihan, Eliot, and
Scully have called attention to retraction of the
abdomen. Dr. John Deaver, as long ago as 1913,
observed that, in perforated ulcer, "the abdomen
is first retracted and a transverse depression is
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February, 1921
GASTRO-ENTEROSTOMY— FOSS
309
seen at the level of the umbilicus." Recently,
William and Hebblethwaite have reported a
transverse line across the retracted abdomen as
a sign of perforted "digestive ulcer." In our
.series of cases, since 191 5, we have been struck
by the high incidence of abnormal retraction
with a transverse depression above the umbilicus
— nine out of twelve. This is particularly
stressed because of the striking, and, when once
seen, unforgetable appearance of the abdomen
which is never so emphasized in any other acute
abdominal lesion.
For those who are constantly seeing acute ab-
dominal lesions, this emphasis is not so necessary
— the unique characteristics of perforated ulcer
are well known to them — but, for the casual ob-
server, the recognition of this alxlomen may
serve to distinguish it from other suspected le-
sions— notably gallstone colic ; for this latter, a
temporizing, surgical policy may be considered,
when, in perforated ulcer, immediate surgery is
demanded.
It is to be remarked that the above character-
istic picture concerns perforation with free leak-
age, and little eflFort on the part of omental or
other adhesions to arrest the process. There are
a certain few cases of perforation, especially of
duodenal ulcer, which are quite atypical, whether
due to the formation of protective adhesions or
not, in which the diagnosis is easily confused
with other acute abdominal conditions — espe-
cially appendicitis. Often, after transitory symp-
toms of right upper abdominal lesion, the pain,
rigidity, and tenderness become located in the
right iliac fossa and the true condition may only
be revealed at operation. Walton Martin has re-
cently shown that, in this doubtful type of case,
perforation may be recognized by a radiogram
of the abdomen, which will reveal gas along the
lower surface of the diaphragm, especially be-
tween the diaphragm and the liver. Field also
has asserted that, in many of these cases, evi-
dence of gas in the peritoneal cavity may be ob-
tained by an area of tympany in the right lower
axilla, over the liver, with the patient lying on
the left side. The same area may be quite dull
to percussion with the patient prone on his back ;
the change in percussion, he ascribes to the gas
mounting to the higher level on change of posi-
tion. I have had no experience with this pro-:
cedure. Both these observations may be of
value in culling out cases of perforated ulcer
from a puzzling "right abdomen" in which the
need for immediate surgery or the localization
of the lesion may not be clear.
Conclusion. — Early diagnosis of perforation
of a gastric or duodenal ulcer can be made in the
vast majority of instances by the severe, .sudden
pain of onset, history of previous indigestion,
boardlike abdominal rigidity, and marked retrac-
tion of the upper abdomen, sufficient to cause a
transverse line just above the level of the um-
bilicus.
In atypical cases, radiogram of the abdomen
for the detection of gas along the diaphragmatic
line, and a shifting tympany over the liver in the
lower axilla may serve to identify a perforated
"digestive ulcer."
BIBLIOGRAPHY GASTRIC ULCER
I.
2.
3-
4.
5-
220.
6.
7-
8.
.4:
10.
191 3,
1 1.
Vo).
13.
13.
■ 9i6,
14
15
Annals of Surgei^, 1917,
_<9i3.. Vol. 1x1, p. 75 (July'ia).
Vol. Ixvi. p. 72.
Alexander:
Deaver: Jr. A. M. A., . .
Edinburgh Med. Jr.: December, 1914, p. '461."
Eliot: Annals Surgery, Vol. Iv, p. 594.
Field: Boston Med. and Surg. Jr., 1918, Vol. clxxviii, p.
Gibson: Surg. Gr. and Obst., Vol. xxii, p. 393.
Hebblethwaite: Brit. Med. Jr., 1918, Vol. i, p. 259.
Martin, W.: Annals of Surgery, (Quoted by Alexander).
Moynihan: Abd. Operations, Saunders and Co., 1914, p.
Moynihan: Duodenal Ulcer, W. B. Saunders and Co.,
p. 220.
Richardson: Trans. South, Surg. Asso., Phila., 1917,
XXX, p. 252.
Scully: Am. Jr. Med. Sciences, 1918, Vol. civ, p. 874.
Sullivan: Transactions, Am. Med. Asso., (Surg. Section)
p. 216.
Willan: Brit. Med. Jr., 1918, Vol. i, p. 142.
Wood: Edin. Med. Jr., 1918, N. S., Vol. xx, pp. 258-369.
GASTRO-ENTEROSTOMY— A CONSID-
ERATION OF THE OCCASIONAL
DISAPPOINTMENTS THAT
FOLLOW*
HAROLD L. FOSS, M.D.
DANVIUE
Gastro-enterostomy was introduced into sur-
gery by Wolfler, who, in 1881, at the suggestion
of Nicoladini, performed the operation success-
fully for the first time. Used in cases of pyloric
obstruction as a paliative procedure, the opera-
tion was accompanied by a high mortality and
it was not for many years that much confidence
was placed in it. Forty years ago the operation,
looked upon as a new and daring example of
surgical gymnastics, was performed by only the
most skilled of surgeons and even in their hands,
prior to 1885, the mortality averaged over 65%.
Imperative as a last resort in stenosis and per-
foration, the great field of usefulness of the
operation in other conditions was at the time
scarcely realized.
Robert Wier of New York, in his masterly
presidential address before the American Sur-
gical Association in 1890, first called attention
to the surgical possibilities of duodenal ulcer. In
the light of our present knowledge it is amazing
that its frequency was not appreciated earlier.
The failure of the great continental pathologists,
at whose disposal was a wealth of necropsy ma-
*Read before the Section on Surgery of the Medical Society
of the State of Pennsylvania, Pittsburgh Session, October s.
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THE PENNSYLVANIA MEDICAL JOURNAL
February, 1921
terial, to realize its great incidence, and the equal
failure of our own American teachers to recog-
nize the relative incidence of gastric to duodenal
nicer, is inexplicable in modern pathology. The
surgeon himself has contributed to medical
knowledge the fact that duodenal ulcer is far
from a rarity, being in reality one of the most
common organic lesions producing gastric symp-
toms, being three times more frequent than gas-
tric ulcer. This furnishes an excellent example
of the significance of Deaver's "pathology in-
vivo."
The first considerable series of cases of duo-
denal ulcer was presented in 1904 by the Mayos
who, at that time, were able to report but 54 pa-
tients. To-day several hundred cases of duo-
denal ulcer are operated on at Rochester each
year and gastroenterostomy has become one of
the most frequent of abdominal operations and
one of the most satisfactory of surgical pro-
cedures.
Occasionally, however, the surgeon is per-
turbed by certain untoward symptoms following
the operation and, in rare instances, is com-
pelled to face complete failure. The coming
home to us at last of these facts has resulted, of
late, in much having been written of the disap-
pointments following the operation. To explain
the occurrence of vicious circle, gastrojejunal
and jejunal ulcer and other unexpected compli-
cations following gastroenterostomy, a world of
hypotheses has been brought forth. In the con-
sideration of the subject the gastroenterologist
and internist have been well to the fore with sug-
gestions of much value, but the best y/itness has
been the surgeon, for his has been the privilege
of reopening the abdomen and of seeing exactly
what has taken place in the case of the patient
who still suffers following the performance of
gastroenterostomy. In the majority of instances
it has been shown that, when recurrent symp-
toms follow the operation and when an ulcer has
been definitely demonstrated, there are evidences
of secondary organic trouble, chiefly adhesions
and newly formed ulcers near the site of anasta-
mosis, and occasionally obstruction with the pro-
duction of a vicious circle.
Our attention during the past few years has
been drawn particularly to the subject of second-
ary ulcers located in the vicinity of the stoma
and usually developing within six to twelve
months following the original operation. These
lesions are gastrojejunal or jejunal, the first be-
ing far the more common, as atte.sted by Mayo.
Secondary ulcers after gastroenterostomy
were common, following the anterior operation,
and were frequently known to perforate the
colon producing gastrocolonic fistulae, or even to
penetrate the liver or through the skin. Second-
ary ulcers occurred following the Y type of
gastroenterostomy but this operation, as well as
the anterior approximation, have fortunately be-
come obsolete. Wright considers secondary je-
junal ulcer as due chiefly to the inability of
the mucosa to withstand the digestive ac-
tion of the gastric juice, this being favored
by traumatism at the site of the anastamosis.
Wright and Patterson have pointed out that
the ability of the intestinal mucosa to with-
stand gastric digestion seems to decrease from
the pylorus downward although the impor-
tance of the role of acid digestion ini the pro-
duction of these conditions is seriously ques-
tioned by Smithies, Pemberton and others. Pem-
berton very logically holds that secondary ulcers
may be due not so much to gastric digestion or
to mechanical irritation as to that inexplicable
condition within the intestinal tract which
brought about the production of the original
ulcer and for which the primary operation was
performed. An extraordinary • sensitization of
the duodenal and jejunal mucosa to the action of
certain streptococci, which may have their origin
in a tonsillar crypt, dental abscess, diseased gall
bladder or appendix, may account for the sec-
ondary lesion as well as it seems to account for
the primary one.
During the past few years there has been a
definite trend of opinion towards attributing sec-
ondary ulcers to the use of continuous, non-
absorbable suture material such as linen, silk or
Pagenstecher thread. This theory is supported
by Wright, Moynihan, Mayo, Terry, Coflfey, and
Eusterman, who have written recently on the
subject. In 142 cases studied by Wright 13 un-
questionably were due to the use of nonabsorb-
able sutures. In 14 cases of the 142 a Murphy
button or bobbin was used. As an etiological
factor, the latter requires but slight considera-
tion at this time, for the employment of such
devices has practically disappeared.
The use of catgut for the inner layer and non-
absorbable material for the outer does not seem
to obviate the possibility of secondary ulceration,
for the animal experiments of Wilkie have
proved that external sutures of nonabsorbable
material may readily work their way into the
lumen of the intestinal canal.
A case is reported by Woolsey in which catgut
was used for the outer layer and linen for the
inner, and two years later a long thread was
found hanging in the loop beside the gastro-
enterostomy opening. Tool, reports linen used
for the outer layer in two cases, both being re-
operated on within six months. In each an ulcer
was found on the jejunal side of the anastamosis
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GASTRO-ENTEROSTOMY— FOSS
311
with, in the one case a thread, and in the other a
knot at the bottom of the ulcer. I, personally,
have seen several cases in which continuous linen
was used for the outer layer and catgut inter-
nally, where at the secondary operation, an ulcer
was found, in whose center hung a long loop of
thread encrusted with salts, very obviously the
chief cause of irritation. If a nonabsorbable
suture remains encysted it is a potential danger
merely ; if it becomes loosened and partially <:ast
off secondary ulcer will probably be produced.
Terry believes that the principal factor in the
production of secondary ulcer is the diversion of
acid chyme into a part of the intestine which has
less neutralizing power than the duodenum, plus
the irritation resulting especially from retained
sutures. On the whole this is the explanation
most universally accepted at the present time. It
has long been known that some of the best re-
sults follow gastroenterostomy done for com-
plete pyloric stenosis and that secondary ulcers
following such operations are rare. It is pos-
sible that the undiluted duodenal contents with
their high degree of alkalinity are in a better
position to protect the jejunal mucosa at the
stoma than thev are if the alkalinitv has been re-
duced by the passage of a portion of gastric
juice through the pylorus as is the case when the
stenosis is not complete.
Eusterman of the Mayo Clinic recently has
completed an exhaustive study of the cases
of failure followmg gastroenterostomy which
have appeared at Rochester. He states that two-
thirds of the disappointments occur in cases in
which an operation was perforrfied in the ab-
sence of a definite lesion. At the Mayo Clinic
nearly 400 gastroenterostomies performed else-
where have been undone. Such evidence of ex-
tensive unnecessary surgery is a serious com-
mentary on our modem progress, yet it is being
indulged in, not only by the ambitious tyro but
by those in the operating rooms of some of our
best hospitals. A duodenal ulcer can usually be
.seen across the room. What is not so visible,
is usually not an ulcer, and a gastroenteros-
tomy performed in the latter event is often a
needless operation destined to harass the patient
later and ultimately to again bring him to the
operating table. In 3,700 gastroenterostomies
for benign ulcer performed by the surgeons of
the Mayo Clinic, gastrojejunal ulcer was the
cause of further surgery in 47 cases or in less
than 1.3% — a fact greatly significant in support
of the opinion that complications rarely follow
properly applied technique.
Eusterman feels that secondary ulcer is largely
due to technical error or to mechanical defect in
the performance of the operation and that the
causative factor in at least one-third of all the
cases studied by him was probably retained non-
absorbable suture material. It would seem that
symptoms occurring within the first twelve
months are due more frequently to secondary
gastrojejunal ulcers, although other possibilities
are to be considered, such as reactivation o^ the
original partially healed ulcer, the formation of a
new ulcer, or malignant degeneration in a gas-
tric ulcer. The lack of thoroughness during an
operation, such as neglect to remove a disease<l
gall bladder or appendix is a frequent cause of
disappointment following gastroenterostomy.
In a recent communication, Moynihan consid-
ers the "capricious" results occasionally follow-
ing gastroenterostomy and lays stress on techni-
cal error as the chief cause of disappointment.
Among the errors enumerated are: first, ante-
rior apposition with long jejunal loop resulting
in regurgitant vomiting; second, obstruction of
the efferent jejunum by kinking or by adhesions
with resulting vomiting; third, leaving a raw
surface on the jejunum close to the stoma with
adhesions following, causing obstruction of the
proximal bowel ; fourth, too small an opening.
Moynihan believes the stoma should not be less
than 2j4 inches in length, a point that has been
frequently stressed by other surgeons. Mayo in-
sists on the large stoma, while Schwyzer holds
that the opening should be sufficiently large to
admit the tips of four fingers. In his anastamosis
Moynihan uses the finest catgut, believing with
the majority that linen and silk are responsible
for many of the bad results and particularly for
the production of ulcer. He insists that the mar-
gin of the opening in the mesocolon be sutured
to the stomach, a point on which Mayo always
lays stress, arrangmg his anastamosis so that the
stomach "funnels" well into the greater perito-
neal cavity. I have had occasion recently to
operate on a patient upon whom a gastroenter-
ostomy had been previously performed and in
whom the stomach had contracted far into the
lesser cavity drawing the jejunum after it and
so producing obstruction. Much has been writ-
ten on pyloric blocking but W. J. Mayo states,
"we have not found that patients in whom the
pylorus was blocked have in any way had results
superior to those in whom it was not blocked fol-
lowing simple gastroenterostomy."
We, as surgeons, have never been too well sat-
isfied with all the details of gastroenterostomy
and have been willing to condemn ourselves by
attributing may of the ensuing disappointments
to technical errors. Accepting mechanical de-
fects in the operation ss provocative of trouble
there has, consequently, been forthcoming a ho.st
of suggestions as to the means of improving or
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THE PENNSYLVANIA MEDICAL JOURNAL
February, 1921
of perfecting the operation. Many of them are
of definite value, some arc ingenious but imprac-
ticable, while the majority are altogether so fan-
tastic and so unsurgical as to be thoroughly
worthless.
Even to-day there is no great uniformity about
(he technique; no one type of instrument or
method has universal popularity. One surgeon
will proceed with a pair of Lane gastro-en'eros-
tomy forceps and silk, or a pair of Kocher re-
section forceps and linen thread; another will
prefer the Linnertz, or perhaps the Roosevelt,
with catgut exclusively; others will use the
Thomas intestinal clamp or the Moynihan ;
whereas Murphy used no clamp whatever, but
performed the operation with the aid of a rec-
tangular button. Surgeons such as Stewart and
Morris will employ no mechanical device as an
aid. As a general thing, the operation can be
more nearly perfectly performed with the as-
sistance of some device which will satisfactorily
control hemorrhage and the flow of the gastric
and intestinal contents. There was such a mul-
tiplicity of devices in the field that it seemed to
me that the addition of still another would do no
harm, wherefore I evolved a clamp of my own
and recently presented it.
On the subject of technique, there are some
delightful differences of opinion. Smith and
Patterson, who seem to stand pretty well alone,
believe that the inner sutures may be of silk, or
linen or of what not and that the assumption
that they act as irritants is groundless. Another
surgeon refers to the attaching of the jejunal
loop in the isoperistaltic sense, a technical point
in the operation over which much controversy
has been waged, although the consensus of opin-
ion so places it. However, Moynihan believes
that it makes little difference whether the jejunal
loop is directed to the right or to the left, and I
recall that the late E. H. Beckman of the Mayo
Clinic would never follo\* the usual rule, always
turning his jejunum in the other direction and
defending his position in the matter .with much
asperity. Whether he was justified or not I can-
not say but his results were always as satisfac-
tory as those of his colleagues.
Metbeth, who worked with Hartman on dogs,
believes that the opening should be large, and that
its most favorable site is on the most dependent
portion of the stomach near the pyloric end.
Ehrlich attributes the late return of symptoms
after gastroenterostomy to the excessive influx
of bile into the stomach and, therefore, suggests
the addition of an enteroanastamosis. In this
connection he advises constriction of the efferent
limb of the jejunum by a strip of fascia between
the gastroenterostomy and the enteroanastamosis.
a complicated step and manifestly unnecessary
as a routine procedure. Vulliet has brought forth
an operation which in point of complexity excels
even that of Ehrlich. Left mobilization of the
duodenum is advocated, with the bringing of the
pyloric end of the stomach or duodenum around
and suturing it to the left aspect of the efferent
loop. This, as well as Ehrlich's operation, is in-
tricate and impractical and illustrates the occa-
sional tendency of continental surgeons to "im-
prove" simple surgical procedures by making
them as complex as possible.
SUMMARY
I. Gastro-enterostomy, though one of the most
valuable of operations and, in the point of re-
sults, the most satisfactory treatment for duo-
denal ulcer, is occasionally followed by disap-
pointment.
II. Such disappointment is often the direct re-
sult of faulty technique or of mechanical defect
in the operation.
III. Among the more common untoward re-
sults are vicious circle, gastrojejunal ulcer, reac-
tiyation of the original ulcer, the production of
new ulcer and malignant degeneration in a gas-
tric ulcer already established.
IV. Of the mechanical defects or technical er-
rors the most common are to be found in the
use of the Murphy button, bobbin or a similar
device ; the formation of a long jejunal loop ; the
employment of the Roux or Y technique; the
employment of such unnecessarily complex pro-
cedures as that of Ehrlich or of Vulliet ; the use
of the anterior operation ; the failure to properly
locate the stoma ; the failure to make an opening
of sufficient size; the use of nonabsorbable
suture, especially if the suture material be con-
tinuous ; failure to properly funnel the stomach
through the transverse mesocolon ; infection
during the operation, with the production of
dense adhesions resulting in angulation of the
jejunal loop ; the performance of a gastroilos-
tomy; failure to combine careful postoperative
medical treatment with the surgical treatment.
V. Many failures are due to the fact that gas-
troenterostomy has been performed in the ab-
sence of a definite lesion or to a lack of thor-
oughness at the time of the operation, such as the
neglect to remove dental infections, a diseased
gall bladder or a diseased appendix.
VI. The most satisfactory operation is the one
W. J. Mayo devised several years ago and which
is now slightly modified so as to be performed
entirely with catgut.
REFERENCES
1. Bevan, A. D. : Vicious Circle Following Gastro-enter-
ostomy. Surg. Clin., Chicago, 1918, ii, 11 19.
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GASTRIC ULCER, ETC.— DISCUSSION
313
1. Coffey, R. C: Gastro-enterostomy Still the Treatateut for
Duodenal Ulcer. Ann. Surg., 1920, Ixjci, 303.
3. Ehrlich, F. : Gastroenterostomie und Heilung des Magen-
ausgangseschwurs resp. der Magenstenosis. Deutsche Med.
Wochenschr., 1920, xlvi, 170.
4. Eusterman, G. B.: A Clinical Study of 83 Gastrojejunal
Ulcers; Diagnosis Verifijed at Operation. Not yet published.
5. Foss, H. L. : A Gastro-enterostoQiy Clamp Simplified and
Improved. Ann. Surg., May, 1920.
6. Hutchinson, R.: Disappointments After Gastro-enter-
ostomy. Brit. M. J., 1919, i, 535.
7. Mayo, W. J. Chronic Duodenal Ulcer, J. A. M. A., lois,
Ixiv, 3036.
8. Metviet, G.: Remarques sur le Fonctionnement des
Bouches de Gastro-entirostomie, Presse, Med., 1920, xxviii, 75.
9. Morris, Robert T.: Posterior Gastro-enterostomy. Inter-
nat J. Sur^., 1919, xxxii, i.
10. Moynihan, Sir B.: Disappointments After Gastro-en-
terostomy. Brit. M. J., 1919, i, 33.
„."• Moynihan, Sir B.: Diagnosis and Treatment of Gastric
Ulcer. Bnt. M. J., 1019, ii 76s.
12. Paterson, H. T.: The Surgery of the Stomach, New
York, 19 1 4.
13. Schwyzer, A. Some Techn-'cal Points in Gastro-enter-
ostomy and Gastroplication. Tr. West. Surg. & Gynec. Ass.,
■ 9>8, xxviii, 323.
14. Soresi: L'esclusione del piloro per mezzo di bandellette
elastiche. Clm. Chirurg., 191 7, xxv, 386.
IS- Stewart, F. T.r A Method of Gastro-enterostomy, Tr.
Am. Surg. Ass., 1917, xxxv, 462.
16. Terry, Wallace I.: Ulcer of Jejunum Following gastro-
jejuno3tom;r. T. A. M. A-. 1920, XXlV, 349.
17. Vulhet, H.: Le "Circle Vitiosus" Apris la Gastro-en-
terostomie et les Moyens d'y Remedier, La Mobilisation de
lAnse Duodeno-jejunale. Rev. Med. de la Suisse Rom., 1918,
xxviu, 67^.
18. Wright, G.: Secondary Jejunal and Gastro-jejunal Ul-
ceration. Bnt. J. Surg., 1918-19, vi. 390.
DISCUSSION
OF PAPERS OF DRS. ESTBS AND FOSS
Dr. Charles H. Frazier (Philadelphia) : Dr. Foss
has covered this subject very thoroughly and very
completely and I know of no one who has had a larger
opportunity for direct observation at the operating
table than he, as a one-time assistant of W. J. Mayo.
As Sir Berkeley Moynihan is the master mind in duo-
denal ulcer on the other side of the Atlantic, so Wil-
liam J. Mayo is the master mind on this. I was par-
ticularly interested in Dr. Foss' reference to secondary
ulcers. I do not think it becomes the surgeon to enter
too deeply into a discussion of the etiology of ulcer.
This is one of the sad chapters in the history of ulcer,
to other phases of which an American surgeon has
made so many brilliant contributions. We know so
little about the etiology of primary ulcer that I do
not think we are going to get very far in speculating
as to the etiology of the secondary variety. All we
can do now is to eliminate those factors which we
suspect play some part in ulcer formation and the
most important of these is nonabsorbable suture ma-
terial. There are, it seems to me, very definite and
substantial reasons for ruling out silk or linen in the
construction of the artificial stoma. But I have never
been aroused by the discussion (and there has been
so much of it in literature from time to time) as to
the exact direction of the artificial stoma, whether
vertical, oblique to right or left, etc. I do not believe,
upon inspection of a case two or more years after
operation, that either you or I could tell what the
original direction of the stoma had been. As time
goes on, certain physical factors, such as peristalsis,
gravity, etc., may very materially alter the relation-
ship of the ligatures of the stomach and in the end
it would be impossible to say what was the particular
hobby of the surgeon as to direction at the original
operation. In guarding against secondary ulcer there
is something to be said in favor of dietary regula-
tions, a phase of the subject entirely neglected in
most surgical clinics. We know so little about the
etiology of ulcer that we can't speak very dogmati-
cally either as to the use of drugs or diets in the post-
operative period. At the same time, it seems to me,
common sense dictates that immediately after a gas-
tro-enterostomy with the ulcer still unhealed, the
patient should not be permitted to resume at once the
diet of a person with a perfectly normal stomach.
Yet this is what happens in most cases. The patient
leaves the hospital without specific instructions and
often pays the penalty of dietary indiscretions. It is
to the patient's advantage for a considerable period,
six months to a year, after the operation, to take
alkalies as he did before the operation and to take
six small rather than three large meals a day. As
to the technic of gastro-enterostomy we are all agreed,
I take it, on these essentials ; the no loop operation,
the use of catgut for suture material throughout, the
site of the stoma to the right- of the Hartman-
Mickulicz line, as to the propriety of establishing an
artificial opening, whether the ulcer is excised or not,
We may disagree on what to do with ulcer itself ;
personally I favor excision of the duodenal ulcer or
ulcers on the anterior walls (for sometimes there are
more than one). I do not approve of artificial clo-
sure of the pylorus. I advocate total excision of
saddle-back ulcers of the stomach (pylorectomy) and
excision of the large indurated ulcer. I favor the Bal-
four plan of dealing with ulcers of the lesser curva-
ture near the cardia. In general with the views ex-
pressed by Dr. Foss I am in entire accord. He knows
the subject of ulcer from A to Z and we have much to
learn from his paper.
Dr. Robert T. Miller (Pittsburgh) : The paper of
Dr. Estes seems to me particularly timely. These
cases about which he spoke, practically all of them, die
without treatment. Mayo Robson estimated that of
those patients who came to operation twelve hours
after perforation one-third died within 24 hours ; one-
third died in 48 hours and of those who came after
48 hours practically 100% died. It is obvious that
early diagnosis is essential. The only criticism I
would make of Dr. Estes' paper is that it was read in
the wrong section. The difficulty is not with the sur-
geon, the difficulty lies with the man who first sees
the case, who temporizes, uses a little morphia and a
hot water bag, letting the family down easy. The
surgeon operates as soon as he sees it. He must have
the case early if he is to do very much good. In re-
gard to symptoms in differential diagnosis ; the picture
of acute perforative peritonitis is rather a typical one.
The differential diagtiosis as to the point of origin is
sometimes very difficult. I have had 7 of these cases
and have saved 4 of them, and yet in 3 instances have
operated, supposing that J was approaching an
acute appendix, only to find that there was perfora-
tion of the duodenum. Notwithstanding awkward
handling 4 were saved, and notwithstanding the fact
that not one of them came to the operating table
within 12 hours of time of perforation. The most
important thing is to get in, find the source of infec-
tion and get out, whether the trouble concerns ap-
pendix, gall bladder or what not.
We used to hear some years ago of the diagnosis
of preperforative stage of typhoid ulcer and perhaps
by analogy of duodenum and stomach. The pictfre
was so difficult to recognize that it was soon dropped,
which seems to me reasonably good proof that we
never under any circumstances diagnose a perfora-
tion. We never would diagnose them did they not
cause peritonitis.
In reference to the points Dr. Estes brought out in
regard to leukocytosis, they run rather parallel to points
he emphasized. The particular point he brought out of
configuration of the anterior abdominal wall we fail
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THE PENNSYLVANIA MEDICAL JOURNAL February, 1921
to recognize as he did. Those people all had periton-
itis, but did not have extreme distention. They had
extreme tenderness, an abdomen which one would
hesitate to pat. As to whether the sign he brought
out can be used as a pathognomonic sign I have had
no experience. His paper served in particular to em-
phasize the thing that is essential, namely, to go after
the early diagnosis in the hands of the man who sees
the case and not to think of this thing as a surgical
problem, h is a problem in internal medicine pri-
marily.
Dr. Donald Guthrie (Sayre) : Dr. Estes speaks of
the eariy history as being a factor in the diagnosis of
perforation of acute ulcer. This of course is true in the
majority of the cases, but I have noted several times in
my work that we find acute septic ulcers which perfor-
ate without warning, and which give no history of early
dyspepsia. Graham, of Rochester, mentioned these cases
years aeo. I have had six of them in my experience
and speak of them for the reason that we cannot al-
ways rely upon the history of chronic indurated ulcer
of the duodenum in order to be sure we deal with per-
forated duodenal ulcer. Some surgeons have strongly
advocated performing gastro-enterostomy at the same
time the perforation of the ulcer is closed. I have
been afraid to resort to gastro-enterostomy in my
patients and as far as I know, none of them who have
had perforations closed, have had any signs of pyloric
obstruction following operation. In the differential
diagnosis, I should like to mention acute hematogen-
ous infection of the right kidney and acute mesenteric
thrombosis. In one case I was on the point of open-
ing a man's abdomen for what I thought was an acute
IJerforated ulcer when the laboratory report of blood
In the urine made me change my diagnosis and the
patient was found to be suffering from acute hema-
togenous infection of the right kidney. In another
case, I operated upon a patient for what I thought was
a perforated duodenal ulcer and found early mesen-
teric thrombosis before the stage of gangrene.
I have nothing to add about the technique of gas-
tro-enterostomy which has been so splendidly reviewed
by Dr. Foss, but to emphasize as he has .the import-
ance of the position and size of the stoma and the
use of nonabsorbable suture throughout.
Dr. Frazier's suggestion for prolonged after care I
think is excellent. The surgeon when he completes
his work is often satisfied that the end result is satis-
lactory, if he hears nothing further from the patient,
when, in reality, many of our patieiits have trouble
following operation that we hear nothinir of. It
seems to me in no other class of patients should the
surgeon cooperate more closely and for a longer
period of time with the internist, than with these ulcer
cases.
Ulcers of the jejunum mav perhaps be prevented by
giving these patients large heavv aoses of alkalies im-
mediately after operation and continuing them for
many months, at the same time regulating their diets
under the direction of well-informed medical men.
Dr. J. Stewart Rodman (Philadelphia): Both of
these papers are on moot questions in gastric surgery
and for the most part everything has been said that
can be said. There are a few points, however, that
do occur to one and I should like to emphasize them
in this discussion. I can a^ree with Dr. Estes in the
main about the diagnosis of perforative gastric ulcer.
I think as a general rule it is fairly easy. There are
a few points about which I do not perhaps agree with
him entirely. One is the question of shock. No one
1 suppose sees a large number of these cases. I have
seen ten altogether. Dr. Estes says he was rather
impressed with the absence of shock. I recall one
case in which there was entire absence of shock and
that was the only one in the series. This was a sol-
dier who walked to his tent two hours after perfora-
tion, his pain continued and he came to the hospital
one hour later. He made a good recovery. The rest
presented rather severe shock. I recall one case in
which the shock was so severe when the hospital was
reached 2 hours after perforation that it was impos-
sible to do anything. The patient was in extremis and
died an hour and a half to two hours after admission
to the hospital. I ag^in have been more impressed by
the point brought out by Dr. Griffith, of Pittsburgh,
in regard to the silent abdomen, than I have in one of
Dr. Estes' symptoms, namely retraction of the abdo-
men. I believe whenever we have a perforation of a
hollow viscus we will invariably get a loss of peri-
stalsis and that is an almost infallible dagnostic sign,
coupled with other symptoms which we will get in
these cases. I agree heartily with Dr. Guthrie that
diet is extremely important following operation. I
expected Dr. Estes to say something of the treat-
ment of these cases, but realize time would not per-
mit. As far as one can lay down a rule I believe it
is better not to do a gastro-enterostomy in these cases.
.■\s far as Eh-. Foss's paper is concerned I believe
there is a good deal being said about the failures of
gastro-enterostomy and it is interesting to hear Dr.
Foss recount his experience because I know he has
had considerable experience in abdominal surgery.
Gastro-enterostomy was first proposed as a palliative
procedure and it has remained that for gastric ulcer
up until the present time and always will. It is a
curative procedure as far as duodenal ulcer is con-
cerned, but unless it is combined with destruction of
the ulcer in gastric ulcer it is certainly nothing but a
palliative procedure. Balfour has given us the most
effective means of dealing with gastric ulcers along
the lesser curvature.
In igoo my father first brought out the principle of
excision of ulcers of the pylorus to prevent principally
the development of malignant disease. I still firmly
believe in that principle. I believe at times it is ex-
ceedingly difficult to do it and in these cases, which
I think are the exception, one had better not attempt
it. I think as a general rule it can be done. It was
interesting to find out from i2 surgeons that the dif-
ference in mortality in doing pylorcctomies for ulcers
were only 8.$ and $.6% for the gastro-enterostomies.
Surely that little difference in the mortality will not
be made up by the danger of hemorrhage, perforation
and malignant degeneration. I am well aware that
it is now rather the fashion to say that cancer does
not develop upon an ulcer base. I am not enough of
a pathologist to say it does. Ewing says that perhaps
only 5% of cancers of the stomach will develop on an
ulcer base. The weight of the evidence is still very
much on the other side, however. Pathology, coupled
with clinical evidence makes me believe that in deal-
ing with gastric ulcers we had better, whenever pos-
sible, get rid of the ulcers.
Dr. W. Wavne Babcock (Philadelphia) : This stimu-
lating paper brings up that very interesting question
as to the cause of gastric ulcer, a cause that probably
gives the clue to those secondary ulcers that occur
around the stoma after a gastro-enterostomy. Why is
it that some gastro-enterostomies are followed by ulcer
and not others ? And why is it when you do a gastro-
duodenostomy, no ulcer follows, while after a gastro-
jejunostomy you get two to six per cent, of jejunal
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GASTRIC ULCER, ETC.— DISCUSSION
315
ulcers? Why is it that ulcers are more common after
the Roux operation, while after the long loop anterior
gastro-enterostomy even a larger percentage of ulcers
follow? The factor that stands out is that the closer
you place the stoma to the ampulla of Vater, the
point where the bile and pancreatic juice are poured
into the intestine, the better protection you have
against a secondary intestinal ulcer. If these' 'secre-
tions protect the duodenum from ulcer then we should
find that the duodenum ulcerates when the bile and
pancreatic juices are diverted to other parts of the
intestinal tract. This is precisely what experimental
evidence shows us. In eight cases in which the biliary
and pancreatic ducts were made to empty into a lower
portion of the bowel, in seven ulceration of the duo-
denum rapidly followed. Peptic ulcers have their
incidence in those portions of the intestinal tract
which are least protected from the gastric juice by the
bile. We do not find them in the second part of the
duodenum. We rarely find them in the jejunum and
likewise in the stomach they occur in areas where
there is the least reflux of bile and pancreatic juice.
When a gastro-enterostomy is done, it cures about 85%,
of duodenal ulcers. When the ulcer is in the stomach
and especially when high on the lesser curvature, we
find the percentage of cures by gastro-enterostomy
drops to about 35%. This and other evidence points
to the fact that we have in the bile and pancreatic
juice the normal resisting and protecting substances
for the stomach and upper intestines. In other words,
these liquids normally antidote the acid chyme. This
being the case, it would seem rather foolish not to
use the bile to prevent or to heal peptic ulcers.
The thought was so stimulating that about a year
ago we stopped doing gastro-enterostomy for ulcer
and instead have taken the gall bladder and so anas-
tomosed it that the bile continuously bathes the ulcer
bearing area. If the ulcer were in the stomach, then
we excised the ulcer and implanted the gall bladder
in the orifice that was left, or if it were not con-
venient to excise the ulcer, we made the anastomosis
in the ulcer bearing area or did what we have termed,
a cholecysto-ulcerostomy. We have done what Dr.
Guthrie does for his patients, but instead of feeding
an artificial alkali, -we pour into the affected part of
the stomach a normal alkali for the rest of his life.
After operation, the gall bladder shrinks to a small
duct running from the notch in the liver to the point
of anastomosis. In several x-ray studies we have
found no bismuth regurgitating into the gall blad-
der. In some 200 cases of anastomosis to the stomach
or duodenum for gall bladder disease or ulcer, the
evidence is that at least during the first two years
secondary complications are rare and the patients
usually live very comfortably with the bile running
into the new area. So far as we can see, patients
usually rapidly improve and get along just as well as
they do after gastro-enterostomy, indeed, I think
rather better. I present to you this simple operation
which you can do under local anesthesia, which gives
no danger of a secondary jejunal ulcer, and which
is done on very accessible organs for trial as the
means of healing ulcers and preventing ulcers after
anastomotic operations on the stomach. For example,
after a coatsleeve resection, we have made the anas-
tomosis so that the suture line would be continuously
bathed by the bile to facilitate healing and prevent
ulceration. The operation does not abolish, although
it does reduce, the gastric acidity.
Dr. Moses Behrend (Philadelphia) : These two
liapers are of great merit and they deserve the discus-
sion that they are receiving. Dr. Estes naturally has
said nothing about the treatment of ruptured ulcer.
Recently I have irrigated these cases with gallons of
salt solution or sterile water. Years ago we did that
and then the pendulum swung the other way, and irri-
gation was not advised ; but at the present time I
irrigate with just as good results as those I did not
irrigate.
It has been our custom to do gastro-enterostomy in
every case of perforation. Recently we tried the
operative procedure of not doing a gastro-enterostomy.
The results were just as good, but the time is still
too short to compare those cases in which we did a
gastro-enterostomy and those in which we did not do
it. It seems it makes little difference what method
we use ; if we have a proper technic the cases will get
well. I do not believe that a nonabsorbable material
is responsible for the gastrojejunal ulcer. One of our
surgeons has recently reported in his clinic where a
gastro-enterostomy was done with absorbable ma-
terial throughout in two cases. They opened up in
two to four weeks, and in one of these cases the
surgeon operated and found stomach and intestinal
contents in the abdomen. It looks plausible that it
may be due to the use of absorbable material. There-
fore r feel that it may be a little bit dangerous to use
catgut throughout the entire operation of gastroenter-
ostomy.
Dr. John O. Bower (Wyncote) : Several years ago,
while studying these cases we discovered what has
since proved to be a pathognomonic symptom of acute
perforation of the stomach and duodenum; that is
induced vomiting. We found that patients did not
vomit after acute perforation unless given something
by mouth, when they immediately vomited, — undoubt-
edly nature's attempt to prevent leakage into the peri-
toneal cavity.
A study of the progress of these cases is interesting.
In 1912 Gustave Petren reported a study of the post-
operative progress of one hundred and forty-five cases
of acute perforation in which suture of the perforation
with drainage and gastro-enterostomy were done in
about equal number. The results were about the
same. He also reported that the patients who gave a
history of having had severe ulcer symptoms prior
to operation were not benefited by either of the oper-
ative procedures mentioned.
Apropos of what Dr. Babcock has said regarding
cholecystogastrostomy, I should like to report a case
of acute perforation of duodenum, chronic ulcer,
anterior wall, in a man 48 years of age in whom the
gall bladder was anastomosed to the duodenum at the
site of perforation. Four months after operation this
patient had gained in weight and had returned to
work.
Dr. Emory G. Alexander (Philadelphia) : It has
been our experience at the Episcopal Hospital, where
we have had in the neighborhood of 50 cases of per-
forative duodenal ulcer within the last ten years, to
have found in the great majority of these cases that
they give a definite history of previous stomach
trouble. I might say almost invariably you get this
history. Frequently if you question the patient at the
time of the first examination they are generally suffer-
ing and are unable to collect themselves sufficiently to
give you accurate data on this subject, but if you will
visit them a day or so after the operation and question
them closely you will find that they will tell you that
they have had stomach trouble, and probably they
will say that they have had it for years. The symp-
toms and signs we lay the greatest stress on, are the
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THE PENNSYLVANIA MEDICAL JOURNAL
February, 1921
sudden onset and marked rigidity of the right upper
rectus; absence of liver dullness I have always
thought of some value. The majority of surgeons,
however, do not believe this sign to be of any marked
value because you do not have the normal liver dull-
ness in that patient. The great majority of these
patients do not show any marked deg^ree of shock.
We have found that within the first 12 hours, in fact
I can stretch it to within the first i8 hours, on taking
cultures taken from the site of perforation (the upper
and lower abdomen), the bacteriological report re-
turned from the laboratory is almost invariably "no
growth." So if you are able to operate on these
patients within the first 18 hours nearly every one
should recover. I have had 12 cases of perforated
duodenal ulcer with i death from subdiaphragmatic
abscess.
I disagree with Dr. Miller in regard to the differ-
ential diagnosis; it is not entirely a medical subject.
I have done a great deal of the emergency work at the
Episcopal Hospital and to be called to the hospital at
two or three o'clock in the morning, and after exami-
nation of a patient to say whether or not a perforated
duodenal ulcer is present is not always an easy mat-
ter. Last summer we had a case of thoracic aneurysm
just above the cardia in which the patient entered the
hospital with all the symptoms of perforated duo-
denal ulcer. Lead colic, gastric crises in tabes and
subdiaphragmatic pleurisy may sometimes be quite
difficult "to differentiate from a perforated ulcer. A
few years ago I reported a series of cases of perfor-
ated duodenal ulcer before the Philadelphia Academy
of Surgery. I followed up the end results of quite a
number of these cases, some had a closure of the
opening and a gastro-enterostomy, and others only
a simple closure and no gastro-enterostomy. I was
unable to determine by questioning, those which had
had a gastro-enterostomy and those which had not.
Therefore, my belief is that a gastro-enterostomy is
not necessary in acute perforated duodenal ulcer so far
as the end result is concerned. There are indications
for an immediate gastro-enterostomy, the main one of
which is when the duodenum is more or less occluded
by the closure of the ulcer. Postoperatively, the
gastro-enterostomy patients do better than thqse on
which a simple closure was performed. The gastro-
enterostomy does not add to the mortality in these
cases.
Dr. WiuiAM L. EsTES, Jr. (closing) : It should be
remarked, with regard to retraction of the abdomen,
that upon no one factor or symptom should especial
stress be laid in any condition. It was not the object
of this paper to emphasize this symptom over and
above others but to call attention to its early pres-
ence in perforation of gastric or duodenal ulcer. Like-
wise, retraction of the abdomen does not occur
exclusively in acute perforated ulcer. I have seen a
case of high intestinal obstruction, due to adhesions
following appendectomy, which showed retraction of
the abdomen. The absence of liver dullness should
not be confused with the change in percussion note
over the liver upon change of position of the body,
reported by Scully. I do not believe that absence of
liver dullness is of much value. The change in per-
cussion noted by Sculley was mentioned for what it
may be worth. There will always be, it seems to me,
a battle to obtain a history of previous digestive dis-
turbance in certain of these cases. Unquestionably,
there are rare instances of perforation without
previous symptoms of ulcer. I believe Dr. Guthrie's
high number is unique. In our cases, seen anywhere
from six to twenty-four hours after perforation, there
certainly has been very little shock. It must be borne
in mind that toward the end of twenty-four hours
after perforation, there are symptoms and signs quite
different from these early signs that have been de-
scribed, signs commonly associated with a general
peritonitis, and with which this paper is not con-
cerned. There is, in all probability, a rare type of
acute perforation which dies in shock — ^the fulminat-
ing type — ^and which may be of that group often classi-
fied by practitioners as "acute indigestion." The
question of treatment I did not mention. The better
part' of wisdom is to get in and get out as rapidly as
possible. If the perforation is near the pylorus, and
obstruction thereto has been caused, or is likely,
through closing of the perforation, gastro-enterostomy
would be advisable.
Dr. Howard L. Foss (closing) : I think the points
brought out in the discussion by Dr. Frazier and
Dr. Guthrie when they emphasized the importance of
postoperative care in cases of duodenal ulcer treated
by gastro-enterostomy are most valuable. Dr. Rod-
man refers to the possibility of ulcer preceding car-
cinoma. Wilson and McCarty have shown that at
least 70% oF gastric carcinoma forms on an ulcer
base. Dr. Babcock's operation seems to be based on
logical reasoning but I believe the anastamosis would
be difficult to perform especially if the ulcer be situated
high on the lesser curvature. Gastro-enterostomy if
properly performed; and the fundamental theme of
my paper is the importance of establishing a uniform
technic; seems, however, to be sufficiently satisfac-
tory in the treatment of duodenal ulcer. The im-
provement in symptoms is immediate and permanent
and until something distinctly better has been found
surgeons will hesitate before discarding it. Dr.
Behrend does not believe that nonabsorbable material
is responsible for the production of gastrojejunal
ulcer. I believe it has been pretty well established by
Wright, Coffey, Terry, Moynihan and Mayo that silk
or linen frequently produce secondary ulcer and that
such complications are exceedingly rare when catgut
is used. I have seen many cases of secondary ulcer
in which have been found long pieces of silk thread
encrusted with salts hanging in the bed of the new
lesion and very evidently the cause of irritation.
Eusterman's researches on postoperative ulcers fol-
lowing gastro-enterostomy show that at least 30%
have been due to retained nonabsorbable sutures.
The chief points I desired to make are, that gastro-
enterostomy is a thoroughly established surgical pro-
cedure in the treatment of ulcer, but that to secure
results the operation must be properly performed and
that nothing but unsatisfactory results will be ob-
tained when the operation is performed in the ab-
sence of a definite ulcer.
GASTRIC SYMPTOMS FROM A
SURGICAL VIEWPOINT
A. WIESE HAMMER, M.D.
PHILADELPHIA
Surgeon to the American Hospital for Diseases of the
Stomach; Instructor in Anatomy, Graduate School
of Medicine, University of Pennsylvania,
Polyclinic Section: Surgeon to the
Pennsylvania Railroad.
The symptomatology of gastro-intestinal dis-
eases is usually regarded as the special province
of the medical practitioner ; too often, however,
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February, 1921
GASTRIC SYMPTOMS— HAMMER
317
the fact is overlooked that many of the entities
in this domain fall under the category of surgi-
cal intervention and, in not a few instances, life
has been sacrificed through the neglect of this
precaution and saved, in other instances,
through surgical operation.
Of one thing the medical practitioner should
be made fully cognizant and it is this : a stom-
achic affection, or one of the intestinal canal
that offers resistance to the intelligent treatment
by a skilled physician, demands the consulting
opinion of one versed in the field of surgery;
the unfortunate criticism that is incontrovertible
and that is too often brought forward, is that
the patient's life might have been spared had a
surgical opinion been sought.
The division of the abdomen into the nine
classical regions should always be kept clearly
in mind and, hand-in-hand with this familiar
mapping of the surface, naturally follows the
facts gained by inspection. Thus, immobility
of the abdomen is indicative of incipient peri-
tonitis, irregular breathing in diaphragmatic
peritonitis, fixed and bulging ribs in subphrenic
abscess, the enormous bulging of the whole ab-
domen in marked stomachic dilatation, and the
visible peristalsis from left to right in obstruc-
tion at the pylorus, are merely a few of the
important diagnostic points revealed by abdomi-
nal inspection.
Palpation may reveal rigid recti muscles, the
result of incipient peritonitis; pyloris or duo-
denal ulcer results in a fixing of the right rectus
muscle, while fixation of the left rectus is indica-
tive of ulcer at the cardiac end of the stomach.
Spasm of the pylorus elicits a sensation of
hardness to the palpating fingers which soon dis-
appears, to quickly reappear. Bimanual palpa-
tion with dne hand in the lumbar region, the
other over the abdomen often detects a movable
kidney, a pathological gallbladder, a movable
tumor, etc.
Much valuable data may be obtained by per-
cussion. The abdomen is normally tympanitic,
save for the note elicited from the splenic and
hepatic dullness. By percussion the size and
shape of the stomach may be ascertained with
much accuracy and, in this way, dilatation of
that viscus, hour-glass deformity and gastropto-
sis may be readily demonstrated. Percussion
is also of use in determining the presence of
fluid in the peritoneum, and in subphrenic
abscess, by indicating the extent to which the
liver is depressed, and by the production of a
hyper-resonant note, if the abscess contain air
and fluid ; the percussion note being dull, with
the gravitation of fluid as the patient turns upon
the affected side.
Ausculation is a corroborative measure for re-
vealing the succussion splash incident to gastric
dilation ; while the gurgling sound heard in the
cavity of a subphrenic abscess containing fluid,
or in mapping out the area of gastric resonance,
establishes at once this adjunct to diagnosis.
This cursory summary of physical diagnosis
as an aid to surgical recognition of gastric af-
fections, needs be supplemented by mention of
the instrumental aids indispensable to the intelli-
gent surgeon. These instrumental aids include :
bougies for the recognition of stricture; the
employment of the x-rays, especially for the
study of the size of the stomach ; the presence
of foreign bodies ; the situation of the pylorus,
the determination of the hyperacidity of the
stomach, by the employment of bismuth sub-
nitrate encased in an animal substance, observ-
ing the time required for the digestion of the
covering and the consequential diffusion of the
bismuth salt ; the use of apparatus for the trans-
illumination of the stomach; the employment
of gastric lavage; the use of the test meal, etc.
Among the painful diseases of the stomach
we mention: ulcer, less frequently cancer,
erosions in general, gastritis, gastroptosis, gas-
trectasis, neuroses, gastralgia, etc. In most
cases a patient suffering with a stomachic af-
fection, comes to the physician and offers a
history of distress or pain first felt in the epi-
gastrium, very infrequently behind the lower
sternum and between the scapulae.
Again, pain is often complained of in the
hypochondriac region, right or left, or in the
posterior lumbar region; while attacks of gas-
tralgia may involve pain over the whole abdo-
men, so that it behooves the careful investigator
to consider a little in detail those gastric af-
fections that are likely to cause pain, and that
claim the attention of the surgeon for their al-
leviation and cure.
In this connection it is interesting to note
briefly a complex condition that causes many
and varied symptoms and is a part of that
peculiar congenital or acquired condition usual-
ly called visceroptosis, of which gastroptosis is
an integral factor.
Thirty-five years ago, Glenard, of Lyons,
offered an illuminating study of this condition
that he encountered in 400 cases in a total of
1,300, in which the peritoneal folds or the liga-
ments supporting many of the viscera are lax
and loosened, allowing the sagging and dis-
placement of various organs, including at times
the stomach, liver, kidney, etc. With such a
prolapse, as of the stomach, the pyloric end is
low down, so that while the lower border is
below the umbilicus, the smaller curvature and
the pylorus are correspondingly depressed, the
organ as a whole assuming a decidedly vertical
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THE PENxNSYLVANIA MEDICAL JOURNAL
February, 1921
position. There are varying symptoms, the
patient becomes thin, pale, lacks all ambition,
complains of various gastric affections, includ-
ing many vague symptoms, among the more
common of these being : excessive flatulence,
diarrhoea, alternating with constipation, mucous
"colic," gastric neuroses, dragging pain, weak-
ness in the back, and many of the symptoms of
neurasthenia or hysteria, that are seized upon
by exploiters of patent medicines to frighten the
unwary, all of these may contribute to form the
clinical picture. When the usual medical meas-
ures such as lavage, the administration of tonics
and mechanical support are unavailing, resort
may be made to gastropexy, or by the method of
Beyea,* which is shortening the suspensory
ligaments of the stomach, by means of a series
of ligatures passed through the gastrohepatic
omentum. This operation does not impair the
normal functioning of the stomach and there is
no attachment to the abdominal wall. Bier**
has successfully performed his own modifica-
tion of Beyea's operation several times with
asserted good results, attaching the pyloric end
and the lesser curvature of the stomach to the
capsule of the liver.
Congenital hypertrophic stenosis of the py-
lorus, usually quickly ends in death from starva-
tion, unless the infant is operated upon. The
symptoms may appear a few days or weeks after
birth. There is dilatation of the stomach, the
presence of a tumor and visible peristalsis. The
condition must be differentiated from spasm of
the pylorus. The operation indicated may be
pylorodiosis (stretching of the pylorus), pyloro-
plasty or any other method of establishing a
free opening of the pylorus.
Pylorectomy, although practiced by some sur-
geons, is unnecessarily severe and is not to
be recommended. Gastro-enterostomy is the
favorite procedure with many operators, they
claiming that it is less liable to be followed by
relapse than is pyloroplasty. Pylorodiosis,
stretching the pylorus, or Loreta's operation, is
more or less uncertain, and may result in exten-
sive laceration of the pylorus and sixbsequent
contraction of the scar. My own view is favor-
able to pyloroplasty.
That rare affection designated as gastric vol-
vulus, of which a few cases have been reported,
have yielded happy results by the Beyea method
of treatment, as in gastroptosis.
The typical symptoms of gastric volvulus are
sudden pain and collapse, with inability to belch
or vomit ; a majority of the cases reported were
found in association with diaphragmatic hernia;
•Beyea, American Journal of the Medical Sciences, June,
1899.
••Bier, Oeutach. Zeitschrift. Chir. Bd. Ivi, 1900, p. 374.
some instances are known of the diagnosis of
this affection as gastric neuroses. If surgery
is not availed of early in the case, death is sure
to follow. By many authorities, gastric volvu-
lus is believed to be more than possible in "^le-
nard's disease, because of the altered anatomic
relations of the prolapsed stomach and the likeli-
hood of its twisting on its axis.
The dull oppressive pain of gastric ulcer is
too well known to need elaboration. The time
of pain in relation to the kind of food and the
interval of distress between food ingestion and
the advent of the. paroxysm, need be carefully
considered. Pain is most likely to be felt in the
epigastrium or the patient refers it to the level
of the tenth dorsal vertebrae. When the ten-
derness is limited to the epigastrium, the symp-
tom is one of paramount importance. Hemate-
mesis is present in half the cases of ulcer and
I'.yperchlorhydria is an ever present symptom.
Too often is the case diagnosed as chronic in-
digestion, until life is a hopeless burden or per-
foration ■ may occur and adhesions, abscesses
into neighboring organs or cicatricial contrac-
tion of the pylorus result in hour-glass contrac-
tion of the viscus; or, as is not uncommon, a
fatal peritonitis may end a long neglected case.
If the ulcer-bearing area is limited, excision of
the affected part is often practiced. If the ulcer
be situated at the pylorus, and the latter be
thickened and free from adhesions, removal of
the ulcerated pylorus is to be advised.
With these exceptions, however, the choice of
operation is gastro-enterostomy, and the con-
sensus of opinion of operators is that this choice
is best defended by the facts that the food cur-
rent is little interfered with, that the stomach is
allowed its physiological rest and that the hyper-
chlorhydria is relieved. As duodenal ulcers
often coexist, the operation of gastro-enterosto-
my is thus doubly applicable. W. J. Mayo* re-
ported 307 cases of gastrojejunostomies of non-
malignant cases with a mortality of six per
cent. ; that in the last eighty -one cases of the
series he had but one death ; and that in a subse-
quent series of cases involving 109 gastrojeju-
nostomies, for ulcer of the stomach, only one
patient succumbed.
A few words as to the medical treatment of
gastric cancer. In these instances therapeutics
play an impossible role. All that can be done
by these means is to sustain the fast waning
strength of the patient, ease the suffering and
secure sleep, and the only value of medical treat-
ment is in those cases where the patient refuses
operation or where the disease has progressed
too far for surgical interference.
•Mayo, W. J., Annals of Surgery, Nov. 1915.
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319
As early as 1839, Cruveilhier discussed the
possibility of ulcerous transformation into can-
cer; since that time investigators have made a
searching inquiry into the subject with the re-
sult that it has been conclusively proved thai
carcinoma of the stomach is prone to follow
gastric ulcer, when that ulcer is in the pyloric
region and thus unduly exposed to mechanical
irritation.
Again, such a transformation may occur r •
a result of the edges of the ulcer being exposed
to the mechanical irritation caused by the churn-
ing of the stomachic contents during the process
of digestion. Thus, long continued gastric dis-
turbances, at times not recognized as an ulcer,
but called "chronic dyspeptic" symptoms,
"catarrh" of the stomach, etc., all too often are
responsible for the invasion of carcinomatous
disease. While ordinarily the invading malady
announces its oncoming by eructation after
food, anorexia, nausea, vomiting (which may
only be occasional), constipation and pain; the
symptoms may be even fewer or, perhaps, en-
tirely latent until the disease has far progressed.
In more than eighty per cent, of cases, a palpa-
ble tumor is indicative of the far progress and
the near fatal termination of the disease. In a
brief exposition, such as this, it is only neces-
sary to mention that of the various surgical
procedures practiced. We mention : simple ex-
ploratory incision, which determines whether
interference is justified or not ; gastrectomy
(partial or complete), gastro-enterostomy, gas-
trostomy, and jejunostomy.
To attempt even to outline in tabulated form
the various gastric maladies that are well within
the domain of the surgeon, would be to inscribe
a pretentious mon<^raph, full of detail, and ex-
hibiting throughout the need very often of sur-
gical consultation, in what appears to be, at
first glance, the special work of the intelligent
physician. The recital of mere symptoms is
never scientific medicine; the whole abdomen
must be searchingly examined, and when treat-
ment through the agency of therapeutic meas-
ures fails in its purpose, a surgeon well skilled
in his work should offer his opinion.
SELECTIONS
"SOME PROBLEMS ENCOUNTERED IN AT-
TEMPTING TO APPLY INSURANCE
METHODS TO THE SICKNESS
HAZARD"*
E. MacD. Stanton, M.D., F.A.C.S.
Schenectady, N. Y.
In the United States less than 3^ per cent, of sick-
ness costs are covered by insurance. This is the reo
•Read before the Medical Society of the County of Wash-
ington, at Hudson Falls, N. V., October 5, 1920.
ord as it stands after ii.ore than fifty years of normal
opportunity for development. The advocates of
Compulsory Health Insurance would have us believe
that the more than g6'/i per cent, deficiency should be
made good by the mandate of the law. At first glance
some of their arguments seem at least partially plau-
sible. However, when after more than fifty years of
free opportunity for development an insurance pla:'
shows a record of less than 3^ per cent, accomplish-
ment and more than 96^ per cent, failure of accom-
plishment then there must be something wrong with
the plan. I believe that it will be well worth the time
at our disposal to study some of the reasons for this
failure.
The chief reasons for the failure are I believe, not
difficult to ascertain. A study of those forms of in-
surance which have become almost universal in their
application, such for instance as fire, life, marine and
auto liability insurance shows us that all of these
forms of insurance comply with certain fundamental
requirements. First, the events insured against are
of relatively infrequent occurrence, and, Second, the
events when they do occur are serious and as a rule
beyond the ability of the insured to meet their conse-
quences successfully without the aid of the insurance.
A community of three or four thousand houses loses
on an average only one or two each year by fire. Be-
tween the ages of twenty and forty the chances of
death per individual per year are only about one in a
hundred. Compared with the number of ships that
sail the seas shipwrecks are very rare. Considering
the number ot automobiles in operation accidents with
serious personal injury plus liability are relatively in-
frequent. On the other hand the losses caused by
these events when they do occur may be very great,
and far beyond the normal ability of the insured to
meet without the aid of the insurance.
The mere fact that certain events when they do
occur are liable to cause more or less hardship or that
the expenses incurred by them are more or less irregu-
larly distributed is not in itself proof that the insur-
ance method can be successfully applied. Everyone
knows and recognizes the advantages of fire insurance
and yet I have never heard anyone advocate that the
average property owner should attempt to cover by
the insurance method the expenses incident to the
ordinary wear and tear -on his property. Probably
every man who owns his home carries fire insurance,
and yet, I do not suppose that a single one has ever
even thought of carrying insurance against the oc-
casional necessity of having to paint his house. There
are some very definite reasons why house-repairs in-
surance has never been developed. In the first place
the necessity for such repairs is of frequent occur-
rence and insurance covering them would require an
enormous account of detail in its management necessi-
tating correspondingly high overhead costs. In the
second place 'the expenses when they do occur are
not beyond the ability of the house owner to meet by
other means less wasteful and expensive than the in-
surance method.
The moment we begin to study the problems of
sickness insurance we find that when we attempt to
cover by the insurance method the ordinary run of
short duration illnesses we are confronted with an
insurance proposition of the house-repairs or house-
painting type. Minor repairs are of almost yearly
occurrence and so are minor illnesses. The average
house needs repainting about once in five years and
the average individual suffers a short duration, in-
capacitating illness about once in five years. Tru» it
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February, 1921
is that the incidence of sickness is not evenly dis-
tributed, but as I will show you later, the uneven
distribution of sickness has mostly to do with the hard-
hitting, long duration illness which I believe consti-
tute the insurable portion of the sickness problem.
To illustrate still further the vast difference be-
tween fire insurance and sickness insurance of the
short duration illness type let us compare the relative
costs of the two. In fire insurance the ratio between
cost and protection is for the average risk about $i
premium per annum for $300 worth of protection.
In the case of favorable risks the $1 premium per
annum will purchase as high as $600 worth of protec-
tion. The ordinary short-duration illness type of sick-
ness insurance is from fifty to one hundred or even
more times as costly as fire insurance. One of the
best of the short duration type sickness insurance poli-
cies ever offered is that of the General Electric Mutual
Benefit Association of the Schenectady (N. Y.)
Works. During the six years ending with 1919 the
ratio between premium and protection in this asso-
ciation was $1 premium per annum for an average
protection of $4.84. Even this insurance cost the
holder more than sixty times as much as did their
fire insurance. Most other sickness insurance policies
which I have studied are even more expensive.
When one can insure a $6,000 house against loss by
fire at a cost of $20 per year, there is no question of
the advisability of carrying the insurance. On the
other hand, if it were to cost $1,500 per year to insure
a $6,000 building then almost no one would carry fire
insurance. This is, however, almost the exact ratio
between cost and protection as it obtains in the short
duration illness type of sickness insurance.
The reasons for the low insurance value of the short
duration illness type of sickness insurance are not
difficult to ascertain. The economic value of insurance
decreases as the occurrence against which the insur-
ance is carried becomes more frequent and the distribu-
tion more uniform. For illustration suppose that each
individual could count upon being sick once a year for
an approximately uniform length of time. Then it
would be the height of folly to attempt to carry yearly
term sickness insurance because from the very nature
of things the returns from this insurance could only
be the amount of the premium paid less the overhead
costs of conducting the business. It is because the
common run of short duration illnesses are of relative-
ly frequent occurrence and have a relatively uniform
distribution that they do not lend themselves readily
for solution by the insurance method. Out of a group
of 1,000 individuals approximately 400 will suffer
some form of illness during the year. About 200
members of this group will have one or more weeks
of disability due to illness, but of these only about
sixty will suffer more than four weeks' disability and
only about twenty will suffer more than ten weeks'
disability. In the case of the twenty suffering the
more than ten weeks' illness and of the sixty suffering
more than four weeks' illness there is no question of
the desirability of sickness insurance but to attempt
to include along with them the 200 or 300 cases of
minor nondisabling illnesses or even the 140 cases of
short duration disabling illnesses is bound to result in
an attempt to accomplish something which does not
conform with the first fundamental requirements of
a successful insurance proposition.
The remarkable uniformity of the distribution of
the short duration illnesses is nowhere better shown
than by the data obtained by the United States Depart-
ment of Labor statistics. A study by this department
of the cost of living in 1,214 workingmen's families in
several different localities showed that although 99J
per cent, of these families had sickness expenses dur-
ing the year the costs were so uniformly divided that
while the average cost for medical care was $44.64 per
family per year, only 3.47 per cent, of the families had
medical expenses amounting to more than $150 during
the year. These figdres would lead us to believe that
their expenses for medical and dental care were more
uniformly distributed than were their house painting
bills. Certainly they were more uniform than were
their expenses for motorcycles and Fords.
I believe that every member of the medical profes-
sion should keep clearly in mind the true meaning of
this data furnished by the U. S. Department of Labor
Statistics. These figures show with unnxistakable
clearness that as far as the ordinary run of illnesses
are concerned there is no more reason for the doctor's
bills being paid through an insurance fund than there
is for paying the grocery bills by means of grocery
insurance. The longer time credits extended for the
payment of medical services as compared with the
grocery bills more than compensates for the slight
irregularity in the family distribution of the medical
bills.
There are very good economic reasons why neither
the grocers nor the physicians should be handicapped
by the losses due to the attempt to apply insurance
where insurance methods are not properly applicable.
Grocery insurance would mean that a large part of the
funds spent for the family food supply would go not
to pay the grocer and the producer of the foods but to
support the overhead costs of conducting the neces-
sarily very expensive grocery-insurance business.
Likewise when doctors' bills are paid from insurance
funds much of the money spent for medical expenses
goes not for medical attendance but for the overhead
costs of conducting this highly complicated form of
insurance. In New York State it costs more than
forty cents to distribute each dollar in benefits under
the relatively simple provisions of the Workmen's
Compensation Act. In the case of workmen's com-
pensation this expense is justifiable because of the
necessity of charging to industry the costs of the in-
juries caused by industry. No like reason exists for
burdening ordinary illnesses with similar overhead
costs.
In the foregoing paragraphs I have outlined very
briefly some of the reasons why sickness insurance of
the ordinary short duration illness type has remained
a weak sister in the insurance family. In the first
place this form of insurance is too expensive. In the
second place the short duration illnesses are not as a
rule a calamity and that there are a certain propor-
tion of illness which extend far beyond the reason-
able ability of the inflicted individual, or family, to
meet successfully without the aid of insurance.
The advocates of Compulsory Health Insurance tell
us that out of 1,000 individuals about one half of the
total cost of all the sickness of the entire group falls
upon about twenty-one individuals. This is approxi-
mately the truth and constitutes a strong argument
for a properly developed sickness insurance but it is
no argument at all for the type of pseudo insurance
proposed by the A. A. for L. L. This is because after
using the twenty-one unfortunate individuals for pur-
poses of argument the Compulsory Health Insurance
scheme calmly abandons these unfortunates a few
weeks after they enter the hard luck sta^e of their
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February, 1921
SELECTIONS
321
illness. While I am absolutely opposed to the house
repairs type of sickness insurance which is exemplified
in its most extreme type in the so called insurance
scheme proposed by the American Association for
Labor Legislation, I nevertheless believe that the in-
surance method could be applied so as to give pro-
tection against the losses caused by the longer duration
illnesses.
Take for instance the case of tuberculosis, doomed
to a sickness not of days but of months, what a won-
derful social and economic help it would be if each
case of tuberculosis were insured by an insurance plan
paying two-thirds wages beginning two or four weeks
after the onset of the illness and extending not for
three months or six months as proposed in the Com-
pulsory Health Insurance scheme but until recovery
or death. This would be real insurance the economic
and social value of which must be self evident to every
physician.
In order to test the possibilities of developing a type
of sickness insurance covering the longer duration
illnesses, I decided to make the attempt to obtain this
type of insurance for myself. I was more successful
than I had anticipated and for purposes of illustra-
tion I will tell you what I have done in the matter of
insuring myself against the possibility of loss by
sickness. Take for instance the ordinary sicknes»
and accident policy offered by any of the standard
companies. These policies pay a stipulated weekly
indemnity for fifty-two weeks of illness. There are
also certain allowances for doctors' bills, surgical oper-
ations, etc. This was not at all the type of protection
that I needed. In the first place all of us can finance
the first few months of any sickness which we may
have. We can collect the old bills due us, or sell a
car, or borrow some money. In the second place this
insurance stops at the end of a year which is just
about the time that most of us would feel the pinch of
a real long, duration illness. In the third place this
form of insurance is almost prohibitively expensive.
A policy giving $500 per month protection for fifty-
two weeks' illness would have cost me approximately
$300 per year premium.
I figured that a sickness insurance policy giving the
kind of protection that I really needed should pro-
tect me beginning six months after the onset of any
illness and continuing not a few months or a year, but
until recovery or death. I applied for such a policy
and after some correspondence with the head office of
one of the large companies received a special policy
paying $400 per month for any disability due to acci-
dent or illness the payments beginning six months
after the onset of the disability and continuing until
recovery or death. The premium for this policy was
only $62 per year or about one-fourth the cost of an
-ordinary short duration illness policy. Later this com-
pany got out a standard policy with the benefit pay-
ments beginning three months after the onset of the
disability and extending until recovery or death. This
policy is not cancelable and the yearly premium at my
age was $79 per year for a policy paying $500 per
month for disability due to any cause. I believe that
the premium for new applicants has been raised
slightly during the last few months, but several com-
panies are now issuing this type of insurance to se-
lected risks at a rate of about $18 per year premium for
each $100 per month protection against disability, the
payments for disability beginning three months after
the onset of the illness and extending until recovery
or death.
It is not the purpose of this paper to advertise any
form of sickness insurance policy. What I do want
to do is to call your attention to what I believe to be
some of the fundamental weaknesses of the type of
so called health insurance proposed by the advocates
of Compulsory Health Insurance and to indicate what
I believe should be the lines of progress if sickness
insurance is some day to take its place as an important
factor in solving the problem of the hardships pro-
duced by sickness.
The medical profession has been time and time again
asked to suggest really constructive changes in the
scheme as proposed. The first amendment which I would
offer to any health insurance scheme be it voluntary or
compulsory would be to eliminate all provisions for
fund-paid medical services. The medical profession of
this country knows that the employed wage-earner is
abundantly able to pay the ordinary expenses for
medical care. It makes no difference whether he can
or can not, neither the patient or the physician can
possibly be benefited by adding the additional handi-
cap of overhead expenses ; fraud and red tape known
to be inseparable from any scheme of fund-paid medi-
cal services. A few years ago, when the Compulsory
Health Insurance agitation first began, we did not have
at our disposal the statistical data to prove what we
all knew in a general way to be the real truth in regard
to the impracticability of paying doctors' bills out of
insurance funds. To-day, thanks to the rapidly ac-
cumulating data on the subject, there is, I believe,
abundant data to prove to any fair-minded person that
the insurance method is not the best method by which
to pay the doctors' bills in the ordinary run of illnesses.
As a second fundamental change in the scheme as
proposed I would eliminate from the insurance plan
all those nondisabling and short duration disabling ill-
nesses which by no stretch of the imagination can be
considered to represent financial disasters which can
be bom readily by the individual or the family group.
The plan of so called insurance proposed by the Com-
pulsory Health Insurance advocates, actually special-
izes in this type of illnesses, yet to include them means
that we must neglect the long duration illnesses which
most need the insurance, and, what is equally bad it
means that a large proportion of the funds must be
inevitably wasted because of the premium placed on
the over emphasis of minor ailments. The waiting
period should be at least two weeks and in many cases
a waiting period of foui w*eks might be even better,
or a waiting period of two weeks, then two weeks of
half-rate payments and full benefit payments after
the fourth week.
As a third fundamental change I would continue the
benefits not for twenty-six weeks as proposed by the
Compulsory Health Insurance advocates, but until
recovery or death. The studies of the Illinois Com-
mission show that the twenty-six weeks' insurance
would eliminate only a very small proportion of the
poverty caused by illness. The long duration illness
insurance would eliminate almost all of the poverty
due to sickness. As I have already shown the elimina-
tion of the short duration illnesses and the fund-paid
medical services from the insurance scheme would
make it readily possible to extend the period of pro-
tection so as to include the long duration illnesses until
recovery or death.
That the great commercial insurance companies are
beginning to recognize the necessity of the longer
duration as compared with the shorter duration sick-
ness insurance is shown not only by the. type of long
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THE PENNSYLVANIA MEDICAL JOURNAL
February, 1921
duration illness policy issued to selected risks which I
have already described, but also by the group policy
now issued by several companies fo" factory em-
ployees. The policy provides weekly benefits upon
proof of total incapacity resulting from sickness or
accidental injury. No benefit is payable under the
policy for the first seven days of incapacity, nor for
the first four weeks of insurance. The benefits are
divided into three periods. During the first period of
twenty-six weeks full benefit is paid ; during the sec-
ond period of 234 weeks, or four and one-half years,
one-half benefit ; and during the third period, run-
ning to age sixty-five, one-quarter benefit. In order
to discourage malingering, the weekly benefit, includ-
ing any other existing insurance or benefits, is limited
to two-thirds of the average earnings for six months
prior to incapacity. Special provisions are made for
the amount of benefit to be paid in various cases of
recurrence of incapacity. The policy is nonpartici-
pating.
It will be noted that in this policy they have en-
tirely discarded the idea of paying the doctors out of
the insurance fund and that in place of this contract
medical service they give four and one-half years of
one-half benefit and after this period one-quarter
benefit to age sixty-five. Although I would myself
recommend a two weeks' waiting period and a much
longer period of full benefit payments, I do heartily
approve of the general principal of the group policy
as described above and I believe that the medical pro-
fession can heartily endorse such insurance which is
based on a model fitting American conditions and
which is totally different from the European pauper
labor model of so called health insurance proposed by
the American Association for Labor Legislation.
EPILEPSY A SYMPTOM OF SPLANCHNOP-
TOSIS*
Charles A. L. Reed, M.D.
Cincinnati, Ohio
The fact that chronic convulsive toxemia, usually
called epilepsy, is constantly associated with displace-
ments of the abdominal organs has now been demon-
strated in 810 consecutive cases m my own hands.
This demonstration has consisted of, first, the clinical
nistory and, second, the physical examination of the
patient; third, the serial x-ray study, and, finally, in
the vast majority of instances, the surgical exploration
of the abdominal cavity. This record, showing the
additional and significant fact that the visceral condi-
tion is always antecedent to and associated with the
convulsion phenomena, as shown by the earlier de-
velopment of constipation, and the absence of both
hereditary factors and extra-abdominal lesions, forces
the conclusion that so-called epilepsy occurs only as a
symptom of splanchnoptosis. This conclusion is fur-
ther confirmed not only by my own observation but
by the daily observation of every general practitioner
to the effect that epilepsy is always associated with
constipation ; that the epilepsy is worse when the con-
stipation is worse; and that the most effective, ready
at-hand relief from seizures is offered by laxatives.
It was this fact, confirmed by surgical experience, that
prompted me to write my first article on the subject
under the title of "Constipation and Epilepsy" (i)
•Abstract of paiier read before the Southern Surgical Asso-
ciation, Hot SpriiiKs. Va., December i6, 19^0.
and upon which I based my second article entitled
"The Probable Cause and Logical Treatment of Epi-
lepsy." (2) My later experience recorded in subse-
quent reports, (3) has shown that constipation while
antecedent to and associated with the seizures in these
cases is, like the seizures themselves, a symptom of
splanchnoptosis. The mere fact that many people who
have splanchnoptosis do not have so-called epilepsy
does not and cannot in the least invalidate the ob-
served and here recorded fact that eight hundred and
ten people who did have epilepsy likewise had splanch-
noptosis and that the development of the splanchnop-
tosis was antecedent to the epilepsy. The explanation
of this difference, which will doubtless sometime be
furnished through biochemic research, is something
with which I have no concern in this connection. I
am simply interested at this time in_ the basic fact,
namely, that epilepsy is always associated with and is
therefore a symptom of splanchnoptosis.
The basic fact, here affirmed, is susceptible of veri-
fication at the hands of every practitioner who sees
these cases and especially by every institution now
acting in a custodial capacity to large groups of these
unfortunates. To begin with, the cases must be ex-
amined— really examined. This means that a thorough
history must be taken. Then the patient must be
stripped. The physical inventory should be carefully
'made, front and back, from head to foot. Special
search should be made for possible focit of infection,
not as a primary but as ancillary factors in the case.
The abdomen should be gone over, first, with the
patient on his back; next, with him erect. A very
little practice with abdominal percussion will enable
the physician to detect the gastric note, the cecal note,
the transverse-colonic note, sometimes the sigmoidal
note. With the patient on his back, these notes will
generally be found approximately in their normal posi-
tions, with the possible exception of the cecal note
which in these cases will always be found low in the
right lower quadrant, sometimes as low as Poupart's
ligament. Now stand the patients up and it will be
found that all of these notes, these separate areas of
resonance, will have become obscured, more or less
blended, by gravitation into the lower zone of the
abdomen. The only note that 'does not thus migrate
downward is that of the cardia which, however, is
generally farther around to the left and toward the
back. In other words, the viscera will have dropped.
This examination is all very easy — and very, very im-
portant.
Then all cases, especially in the present status of
the whole question, should be given an x-ray study.
When this study is done right it is very clarifying;
when done wrong it is very misleading. It is done
approximately right when the following rules are ob-
served: (l) The patient should be free from all
laxatives or enemas for at least twenty-four hours
before taking the'barium me^l ; (2) the barium meal
should be taken at 9 o'clock in the morning; (3) the
first picture, to show the stomach and beginning duo-
denal transit, should be taken ten minutes later — with
the patient upright; (4) the second picture, to show
conditions at the ileo-cecal juncture, should be taken
at 3 o'clock in the afternoon — with the patient prone:
(S) the third picture, to show the condition and posi-
tion of the colon, should be taken at 9 o'clock the next
morning — with the patient upright. These pictures
are essential ; others (after ingestion) to show (a)
completed transit or (b) relative positions of colon
prone and standing; or (after enema) to show (c)
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SELECTIONS
323
redundancy or not of the sigmoid; (d) ileo-cecal
competency or not; or (e) other conditions, may be
taken or not according to the indications of the indi-
vidual case. Of course decensus of the liver and
kidneys is not shown by the x-ray but may be de-
tected by careful palpation in different positions.
The ease with which all of this can be done, and the
importance of the facts thus elicited, make such ex-
aminations of these cases an imperative duty not only
for individual practitioners but for institutions. I can
not resist this opportunity to insist more especially
upon the duties of institutions in the premises.
(i) All institutions for epileptics should be pro-
vided with a well-equipped, competent and liberally
supported roentgenologic service.
(2) There should be a roentgenologic survey of the
entire epileptic population of all public institutions
for the purpose of determining the condition of the
abdominal viscera.
(3) The diagnosis should be individualized in each
case with reference, first, to visceral causative factors ;
and, second, to available treatment with the object and
understanding that the treatment in all cases should be
directed to overcoming such visceral conditions either
by medical and hygienic treatment or, when necessary,
by surgical restitution of the parts.
The same rules apply, with possibly greater force,
to all hospitals for the insane, — but that is another
story.
(1) Cincinnati Lancet Clinic, July as, 1914.
(2) Journal American Medical Assn., March 27, 1915.
(3) Ibid. January 29, 1916; September 20, 1916.
THE PUBLIC AND THE CANCER PROBLEM
WILLIAM H. CAMERON, M.D.
PITTSBURGH
The reluctance of the medical profession to counte-
nance an open discussion of medical problems is due
for the most part to a realization of the fact that the
laws of .medical science are empirical and their inter-
pretations are many and varied. The laws of exact
sciences, such as mathematics, physics and chemistry,
permit of the drawing of definite conclusions, whereas
in medical scieoce exactness cannot be attained tmtil
almost insuperaole difficulties have been surmounted.
Even in this enlightened age there are not many con-
clusions which can be accepted without qualification.
For this reason I wish to call your attention to the
simple word "cure," as applied to the result of treat-
ment of disease — more specially as applied to the result
of treatment of cancer — as being an example of a
medical term frequently used and just as frequently
misunderstood.
We know the cause, course, prevention and result
of a number of diseases and are able, in comparatively
few instances, to properly apply the word "cure" or
"cured" to the final outcome of the disease.
Knowing the "cause" of a disease points the way to
"prevention" and "prevention" is, of course, the great
desideratum. Such a result will, however, never be
obtained unless the law governing the prevention of a
particular disease has the complete backing of all the
people.
Knowing the "course" of a disease, even without a
knowledge of the "cause" permits us in other cases to
control the final result, and thus we are able to apply
the terra "preventable" or "curable."
Most diseases are self-limited, the natural "result"
being a return to the normal. In such cases the term
"cured" is proper and credit for the cure is given
where it belongs — to nature. It is this class of cases
that give existence and maintenance to so many
pseudo-cures.
Frequently the natural laws of a self-limited disease
are transgressed and the "result" is death or a compli-
cated recovery. If the art of medicine or the practice
of surgery triumphs over these unnatural laws and a
complete recovery is had, credit is again given where
it belongs — to scientific medicine. Furthermore, it is
in the handling of such cases that distinguishes the
scientific physician from those who attempt to practice
the healing art without profound and continued study
of anatomy, physiology, histology, bacteriology, pa-
thology and rational therapeutics.
AgaiA, some diseases progress to death, and there
is no known way to alter or control this "result." The
term "cure" or "curable" as applied to this group has
no place. Gradually, however, we are learning to shift
cases from this group to the above mentioned class,
and, in such cases, we are only justified in saying
"curable" if we apply the term with certain restric-
tions. In other words, if a group of similar cases
under a certain line of treatment shows a certain per-
centage of "cures" and these cases stay cured for a
certain period of time (five to ten years) we are jus-
tified in applying the term "curable."
It is said that one woman in eight and one man in
fourteen dies of cancer, and cancer belongs to that
group of cases in which we may use the word "cura-
ble" within certain limits. We do not know the exact
cause of cancer, but by observing the "course" of the
individual types, we may, under certain circumstances
control the result.
I stated that we do not know the exact cause, and
this fact makes "prevention" a difficult task, and a pos-
sible "cure" for all types an uncertain factor.
Is it bactericidal ? Is it misplaced and outlawed foetal
cells? Is it some organic or inorganic implantation in
the tissue, or is it the extraction of these substances
from the tissue? Is it starved normal cells taking on,
for some reason, new and uncontrolled growth? All
theories, but all pointing to the fact — the important fact,
as far as a possible "cure" is concerned — that cancer in
its beginning is a local condition. Now if this disease
in its inception is purely local, when could a possible
"cure" "'cure'"?
Constant irritation to a part seems to be an exciting
cause, at least it is a factor in the extension of the
disease. Therefore, if you have a small mole that
you are constantly picking or cutting while shaving,
if smoking keeps your lip or your tongue constantly
irritated, if you are in the habit of constantly swallow-
ing hot liquids, give some thought while you are doing
it, to the fact that avoiding constant irritation is the
only thing we know as to cancer prevention. Again,
if you have a small lump on your person, or a small
ulcer in your skin or on the lining of your mouth or
throat, or a tender spot on your bony framework, why
temporize if it does not heal under ordinary treatment
and in a short time? Remember that one woman in
eight and one man in fourteen pass the time — the only
time in their disease — when we may have applied the
term "curable" to their condition.
Our present curative agents are surgery, radium and
the x-ray, and with these agents we can only obtain a
"cure" in cases where we can apply these agents early
and direct; therefore, this fact decreases the percent-
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THE PENNSYLVANIA MEDICAL JOURNAL
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age of possible cures. You also recall that I made a
distinction between men or women who practice the
healing art. With a condition like cancer or suspected
cancer, you cannot afford to make a distinction — you
must go to the scientific man.
You delay because you do not like surgery and its
mutilation. Since we have radium, surgery, is not al-
ways necessary, and this will obviate some of this
fear; but again, you must not, if you desire to be in
the "curable" class, temporize, for it is only the scien-
tific man who knows when and in what group of cases
to use radium alone, or surgery alone, or surgery and
radium, and to further supplement either surgery or
radium with expert x-ray treatments. When speaking
of surgery I include the various methods of removing
the local lesion with heat.
At the present time, the agents I have mentioned,
used alone or in combination, according to the indi-
vidual case, are the only ones accepted by scientific
men as being possible, and their proper use give us the
authority to apply the word "curable" when the disease
is local, accessible and of a certain type.
NoT«. — The presentation of the cancer problem in this way
was suggested after some seven or eight years* experience in
personally talking to the public and in listening; to many med-
ical and lay discussions on the subject. In usmg this form I
believe I obtain a much better understanding of the subject by
lay audiences.
PERNICIOUS ANEMIA: A STUDY OF ONE
HUNDRED AND FORTY-EIGHT CASES
James G. Carr, M.D.,
Chicago, III.
The study embraces a total of 148 cases discharged
from the Cook County Hospital under the diagnosis
of pernicious anemia, which may be divided into two
main groups : ( i ) those in which the diagnosis was
purely clinical, and (2) those in which the diagnosis
was confirmed or corrected at autopsy. There were
22 of these latter. Of the other cases, 126 in number,
112 may be accepted, on the basis of the clinical study,
as pernicious anemia; another group of 14 cases is
made up of those which were discharged, with a ques-
tion as to the diagnosis. Of the 112 cases accepted as
clinically pernicious anemia, 26 will be discussed as a
separate group, since they presented, as a major mani-
festation, the important group of symptoms denoting
involvement of the spinal cord. There are, therefore,
86 cases left to be studied as cases typical of pernicious
anemia.
In reviewing the results of this study, we find :
1. The clinical complex known as pernicious anemia
presents certain characteristic blood findings, par-
ticularly the high color-index, the presence of many
large erythrocytes and of nucleated red cells, espe-
cially lymphocytosis ; and clinical symptoms, though
secondary in importance from the standpoint of diag-
nosis, are yet distinct and definite. The progressive
weakness, the gastric disturbances; the dyspnea, pal-
lor, the cardiac findings and the edema of the feet are
the most typical and constant findings.
2. Though pernicious anemia has its own character-
istic diagnostic findings these may be simulated closely
by anemias resulting from various diseases; in fact,
the blood picture of pernicious anemia may be pre-
sented exactly as the result of some definite septic
toxic or malignant condition. The diagnosis should
rest not on the blood findings alone nor on the blood
findings and symptomatology, but on these two fea-
tures in the absence of any discoverable cause for the
anemia.
3. The disease is more common in males and is
most frequent in the fourth and fifth decades of life.
4. The cardiac symptoms and physical findings (the
murmurs and the dilation of the heart) are so con-
stant as to be looked upon as among the most common
symptoms of the disease. Anatomically valvular dis-
ease is not a part of pernicious anemia; the cardiac
findings are the result of myocardial weakness and
relative insufficiency. Ascites and anasarca are not
symptoms of pernicious anemia though there is a pos-
sibility that they may result from cardiac incompe-
tency, this event is so unusual that their presence de-
mands explanation.
5. The systolic blood-pressure is almost never above
normal but tends to be below the lower limit of
normal; the diastolic pressure is disproportionately
low and the pulse-pressure is high.
6. The urine is usually of a fairly low specific grav-
ity, rather increased in quantity, and rarely contains
albumin. The presence of albumin is not to be ac-
cepted as a usual finding in pernicious anemia; its
presence with casts means nephritis, which may be the
cause of the anemia rather than the effect.
7. Pernicious anemia is characterized by an irregular
temperature, which is not often above loi ; there are
often recessions to normal of variable duration.
8. Achylia gastrica is so much the rule that pres-
ence of free HCL may justifiably raise a doubt as to
the diagnosis.
9. The Wassermann reaction occurs infrequently in
pernicious anemia. In 46 cases there was a percentage
incidence of 6.5; the general run of cases in a large
charity hospital would probably show a higher per-
centage. It is possible that certain changes in the
blood incident to the disease interfere with the re-
action.
ID. The gradual decrease in the leukocyte count,
especially in the relative and absolute number of poly-
morphonuclears, is of serious prognostic import. The
diagnosis of pernicious anemia should be made with
the utmost reserve in the presence of a leukocytosis.
11. The negative spinal fluid tests in the presence of
well-established cord disease point to %.toxic degenera-
tive process in the cord rather than an inflammatory
process. Disease of the cord, with pernicious anemia,
usually means an involvement of the lateral and pos-
terior columns, a combined cord lesion. The presence
of evidences of cord disease is of unfavorable prog-
nostic import; the prognosis in these cases is grave,
out of proportion to the blood findings as compared
to the cases not so complicated. These patients are
less likely to live long enough to develop advanced
grades of anemia.
12. Transfusion of blood will not cure but will often
prolong the patient's life. The severe reactions which
occurred in this series were likely the result of im-
perfect technic ; the procedure has really been de-
veloped from its inception in the years covered by this
study; transfusions are now being done with a much
lower percentage of reaction. Yet the experiences
noted here may have a valuable lesson for us. The
transfusion of citrated blood is a simple procedure but
not a harmless one. Before the operation is under-
taken the bloods of donor and patient must be demon-
strated to be compatible by an acceptable and approved
technic.
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MEDICAL COLLEGES OF PENNSYLVANIA
325
THE MEDICAL COLLEGES OF
PENNSYLVANIA
UNIVERSITY OF PENNSYLVANIA
THE PROBLEM OF GRADUATE MED-
ICAL EDUCATION, WITH SPECIAL
REFERENCE TO PENNSYL-
VANIA*
GEORGE H. MEEKER, Sc.D.
Dean of the Graduate School of Medicine, University of
Pennsylvania
To many it may at first blush appear that the
subject of graduate medical education is of mo-
ment to physicians only — and then merely to
such physicians as may impart or receive such
education. As a matter of fact, there is no citi-
zen to whom the subject is not of significant
personal importance. Given an adequate sys-
tem of graduate medical education, everyone
will surely reap the benefits which will accrue as
physicians in general are enabled to resort peri-
odically to graduate medical educational centers
to see and practice, under master clinicians, the
progressive things in medicine.
Again, the whole public should come to real-
ize clearly that no single physician can possibly
be an expert in all departments of medicine as
it exists to-day. The fields of practical medicine
are now so differentiated and each field is so
highly developed, that any typical family, sooner
or later, is rather certain to be in need of the
services of at least thirteen different kinds of
medical practitioners, as follows :
A. General.
1. The General Practitioner. The "family doc-
tor," who is the first to be consulted for all
types of medical services. His services us-
ually suffice; but, as the need arises, he
refers his patients to appropriate specialists
— such being available in points of time,
distance and expense.
B. Medicine and its specialties (no major sur-
gical procedures).
2. The Internist. Grave, obscure, complex and
chronic maladies of adults, not involving
circumstances noted under other captions.
3. The Pediairist. Internist whose patients are
children.
4. The Neurologist (and Psychiatrist). Nervous
and mental diseases.
5. The Dermatologist (and Syphilologist). Skin
diseases and lues.
6. The Roentgenologist. Medical applications of
x-rays and allied forms of radiant energy.
C. Surgery and its specilaties (all important
surgical procedures; but also including
any other procedures appropriate in each
of the special fields).
•By inviution, read before the l^ckawanna County Medical
Society, Scranton, Pa., Jan. i8, 1921.
7. The Surgeon. All operative procedures not
implied under other captions.
8. The Gynecologist (and Obstetrician). Female
pelvic conditions and abnormal labor.
9. The Orthopedist. Deformities.
10. The Urologist. Venereal diseases; and uro-
genital conditions not implied under other
captions.
11. The Ophthalmologist. Eyes and accessory
structures.
12. The Otolaryngologist. Ears, nose and throat
and accessory structures.
D. Complementary (to the work of all clini-
cians).
13. The Pathologist (Clinical Laboratorian).
Clinical laboratory reports upon patients;
and preparation and administration of cer-
tain diagnostic and therapeutic biologic
agents.
The main purpose of undergraduate medical
education is to produce physicians who shall be
well qualified to begin general practice; the
parallel purpose of graduate medical education
is to qualify physicians to begin special prac-
tice ; a further aim of graduate medical educa-
tion is to afford general and special practitioners
varied opportimities to study, periodically, under
master specialists, the progressive things in
medicine; and all efficient medical educational
organizations, have the aim in common to stim-
ulate, foster and direct medical research.
As the result of years of devoted efforts and
at great expense, undergraduate medical educa-
tion in America has been brought to a basis of
efficiency in all of the leading schools of medi-
cine. Admirable standards for medical educa-
tion and licensure have been clearly defined;
and the necessary educational and legal ma-
chinery for realizing these standards has been
provided.
As a national matter, the highly important
problem of graduate medical education is just
beginning to be seriously attacked. The prob-
lem has remained in abeyance, pending that time
when evolution in medical education should
force it to the front and compel its prompt solu-
tion. Such time has now arrived ; and the chief
forces actively attacking the problem are the
American Medical Association, a number of
universities having "Class A" medical schools,
many special medical societies, and the great
philanthropic foundations. We may reasonably
expect that within the decade 1920-1930 com-
petent graduate schools of medicine will have
arisen in most of the larger American medical
centers; and that authoritative standards of
special medical education and practice will be
morally, and perhaps in some states, legally,
dominant.
Before proceeding further with the problem,
some additional facts serving to widen our view
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THE PENNSYLVANIA MEDICAL JOURNAL February, 1921
of medical specialization should be held in mind.
The list of kinds of specialists which is given
above is neither rigid nor complete. It mentions
only clinicians, whereas there is another and
very important class of specialists whose field is
the medical sciences. Representative examples
are: anatomist, physiologist, pathologist, bio-
chemist, hygienist, pharmacologist. The labors
of this type of medical men are at the founda-
tion of all medical education, research and prog-
ress. Again, it is not now possible to present
a really complete and precise list of the kinds of
medical specialists because the departmentaliza-
tion and respective terminology are indefinite
and unofficial ; and many new terms, variants,
compounds and secondaries often appear. Il-
lustrative examples, by no means exhaustive,
are : gastro-entcrologist, physiotherapeutist,
electrotherapeutist, climatologist, industrial
physician, neuropathologist, bacteriologist, se-
rologist, sanitarian, epidemiologist, oral surgeon,
rhinologist, proctologist. The whole trend is
steadily toward higher specialization in both the
medical sciences and in clinical practice.
It thus appears that one who has completed
his undergraduate medical education, who has
had at least one year's supervised medical
experience as a hospital intern, and who has be-
come licensed to practice medicine, must there-
after elect which one of, say thirty separate
opportunities for public service as a physician,
shall be his life work. The majority will elect
general practice, and usually because it offers
the readiest livelihood; the others will elect to
specialize; and many who begin with general
practice will specialize finally. The importance,
in the premises, of high grade graduate schools
of medicine is obvious.
It may be said at once that there is to-day no
complete graduate school of medicine. Until
very recently, no really serious efforts were
made to found such schools, which is not sur-
prising in view of the inherent difficulties.
There has been no lack of appreciation of the
great necessity and importance for such schools ;
but the task of creating them is a staggering one
— involving heavy expenditures ; the formation
of large organizations of teachers, hospitals,
laboratories, libraries and museums; and new
and intricate problems of standardization and
administration. There can be no doubt, how-
ever, that we are now on the eve of real solu-
tions of the problem ; and great graduate schools
of medicine are in the making in a number of
leading medical centers.
The first school of medicine in America was
founded in the University of Pennsylvania in
1765. Ever since then, Philadelphia has been a
noted medical center; and the school of medi-
cine in "Franklin's University" has ever been a
leader. It is most fitting, therefore, that the
University of Pennsylvania should have become
a pioneer in graduate medical education, by
opening in the fall of 1920 the first fairly com-
prehensive group of systematic graduate courses
in medicine to be offered in the United States.
The history of the school, and a description of
the educational details, appear in the current
"Bulletin" of the school and need no restate-
ment here. The school has attracted much na-
tional and even international interest within
medical and university circles; and through
various newspapers it has. been brought to the
attention of the general public. While only in
its beginnings, and by no means complete, it is
doing a work which is notable and of a magni-
tude which should be widely understood.
To the new school, in its initial session, phy-
sicians have come as students from twenty-five
of the States of the Union and from a half-
score of foreign lands, in number equal to that
of the average class in the best undergraduate
schools of medicine. Its teachers of all grades
total two hundred and sixty-five. Of these, at
least one hundred are medical men of wide ex-
perience and reputation in their respective
departments ; the others are their capable asso-
ciates and assistants. Practically all of the clin-
ical teachers serve without salaries. The story
of the unselfish and enthusiastic cooperation of
Philadelphia's great men of medicine in this
movement is an epic. It tells more surely than
words, their deep appreciation of the importance
of the project to the whole public ; to medical
education ; and to the medical prestige of the
city, state and nation.
The financial assets of the school total about
two and one-quarter millions of dollars, of
which more than one million dollars is in pro-
ductive funds, and the remainder is invested in
plant and equipment. The yearly expenses ex-
ceed four hundred thousand dollars ; and, alas,
the attendant deficit is more than one hundred
thousand dollars.
Beyond doubt, when competent graduate
schools of medicine shall have arisen in America
and shall have become reasonably well de-
veloped, it will be found that they are not to
resemble each other so closely as the standard
"Class A" undergraduate schools of medicine
resemble each other. Each graduate school of
medicine will, or should, avail itself of those
favorable local conditions peculiar to it. Tliis
point has been fully appreciated by the Uni-
versity of Pennsylvania. The educational pro-
gram of its Graduate School of Medicine is
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PITTSBURGH ACADEMY OF MEDICINE
327
made possible by the facts that the factors es-
sential to the program exist in Philadelphia;
and that the university has been enabled to util-
ize a sufficiency of these factors in effective
combination.
These Philadelphia factors are: The Uni-
versity, with its old and prominent undergrad-
uate medical school, which initiates, fosters at^d
guides this additional school; within the Uni-
versity the Central Organization of the Grad-
uate School of Medicine which has graduate
medical education as its sole business and do-
main; a great American metropolis with fine
medical traditions, numerous hospitals, clinics,
clinicians, laboratories, libraries, museums and
medical societies; and an atmosphere of active
medical specialization, education and research.
The Central Organization consists of a large
group of leading Philadelphia clinicians, med-
ical educators and investigators, constituting
the faculty of the Graduate School of Medicine ;
together with the former Medico-Chirurgical
and Polyclinic institutions, which have aban-
doned their earlier types of medical education,
and are now devoted wholly to the work of the
Graduate School of Medicine. The relation-
ships between this Central Organization and the
other factors above mentioned arise mainly
through the members of the faculty of the
Graduate School of Medicine in their further
capacities as members of the staffs of the vari-
ous medical organizations of the city.
Students in the Graduate School of Medicine
are .suitably qualified physicians, who become,
substantially, clinical or research assistants and
understudies of the members of the faculty in
medical activities throughout the citv-
The effective amalgamation of so many of its
medical facilities has been made possible be-
cause of the exceptional potentiality for soli-
darity in medical education which maintains in
Philadelphia. This solidarity should be evident
from what has already been said; but is em-
phasized when we note that the members of the
faculty of the Graduate School of Medicine are
already utilizing varied facilities in about thirty
of Philadelphia's prominent medical institutions
as aids in teaching their "student physicians" —
while yet only at the beginnings of this broad
Philadelphia — university project.
All things considered, it is peculiarly appro-
priate that a graduate school of medicine should
have been founded in Philadelphia ; under the
aegis of the University of Pennsylvania ; in the
period immediately succeeding the great war;
and in consonance with the prevalent American
spirit for progress and independence in a de-
partment of medical education which previously
flourished only in Teutonic lands. If it be ac-
corded reasonable moral and financial support
by the profession, the state, philanthropic foun-
dations, wealthy benefactors and the general
public, graduate medical education in the Uni-
versity of Pennsylvania will be enabled to make
fully effective its special and ample opportuni-
ties for real success in the field — thereby ensur-
ing to Pennsylvania a leading position in this
new national movement for the normal expan-
sion of medical education. It is impossible for
the university to bear the whole burden. Will
Pennsylvania and Pennsylvanians deny to the
university that need of material aid without
which this really great project must languish ?
Note. — The attention of our readers is called to the
editorial in this number under title of "Graduate
Medical Teaching." — Editor.
PITTSBURGH ACADEMY OF
MEDICINE
ABSTRACTS
SYPHILIS OF THE LIVER
Dr. J. A. LicHTY
Of the internal viscera, the nver is the most fre-
quently involved in syphilis, and yet, in the ordinary
run of post mortem cases it is rare to find the evidence
of permanent syphilitic disorder. Aside from the
nervous system, there is probably no organ in the
body, in which the interpretation of the invasion of
syphilis is so misunderstood as is that of the liver.
It is most inspiring to observe the clearness of clini-
cal and pathological descriptions which mark the
early history of this disease. In this consideration,
one is impressed by the statement made by Dr. F. D.
Mallory when he says, "In some organs the late stages
of certain lesions have received more attention than
the beginning of these lesions. The emphasis has
been placed on the wrong end of the process." This
statement is particularly true of the inflammatory
changes of the liver, and in the central nervous sys-
tem. It is not my intention, therefore, to discuss so
fully what is already known to all of you, the pathology
of tertiary syphilis of the liver, as it is to discuss the
early clinical manifestations of syhpilis of the liver.
There is at present in the course of organization at
St. Andrew, Scotland, a school of postgraduate medi-
cine which will put to the test the ideas set forth by
Sir James McKenzie in his article in Oxford Mcdi-
cmf .entitled "The Future of Medicipe," In this article
the wiriter insis.ts that there is a stage in disease imme-
diately preceding that of physical signs and far earlier
than that of pathological change which, until now has
not received due consideration. He calls it, "the
stage of subjective sensation." Among the first of
these he mentions pain and berates the profession for
knowing so little and for being apparently concerned
much less about the proper interpretation of pani.
He next speaks of exhaustion, of giddiness, of faint-
ness, of palpitation, nausea, heartburn and breathless-
ness, and insists- that in our present organization of
hospitals and medical schools we pay the least atten-
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328
THE PENNSYLVANIA MEDICAL JOURNAL February, 1921
tion to that stage of the disease in which most can be
done by way of treatment. He calls attention to the
fact that the dispensary, where the early signs of
disease and the most hopeful cases are likely to be
seen is manned by the least experienced physicians,
that the hospital wards where the easily discovered
stage of disease and the more hopeless cases are
found are looked after by the most experienced phy-
sicians and that over the laboratory where dead tissue
only is studied, the most skilled and scientifically
equipped physicians preside.
In order to determine whether the recent additional
knowledge on syphilis has in any way shown a change
in our clinical and pathological reports I thought it
well to review the autopsies done in the past ten years
by the pathological department of the Medical School
of the University of Pittsburgh.
The total number of autopsies was 992. The total
number of cases of syphilis, that is general syphilis,
was eighty-two. Of these eighteen were found to
present syphilitic cirrhosis of the liver.
At the Philadelphia Hospital, Flexner found eighty-
eight cases of hepatic syphilis among 5,088 autopsies,
and at the Johns Hopkins Hospital, Prof. Welch found
forty-seven cases of syphilis of the liver among 2,300
autopsies, and at the Bellevue Hospital, N. Y., Sym-
mers found 105 cases of syphilis of the liver in 4,480
autopsies.
The symptoms of syphilitic cirrhosis of the liver are
those of the tertiary stage. There may be first, the
picture of that of cirrhosis alone, slight jaundice,
fever, portal obstruction and ascites, or second, there
may be the symptoms of a simple anemia with an en-
larged liver, perhaps irregular, and also an enlarged
spleen, and third, there may be a group of cases with
an enormous enlargement of the liver causing a
prominent bulging in the epigastrium and producing
a great deal of pain and distress. The liver is ir-
regular in contour. And then, also, there may be a
group in which the spleen is enormously enlarged, the
liver only slightly enlarged, with some ascites and
anemia, giving a clinical picture on the one hand like
that of Banti's disease, and on the other hand, like
that of splenic anemia. The diagnosis between an
ordinary syphilis of the liver with an enlarged spleen
and splenic anemia, and Banti's disease is sometimes
quite difiicult. There are those who are of the opinion
that syphilis is the underlying cause in both Banti's
disease and splenic anemia.
CASE I. CONGENITAL SYPHILIS WITH ENLARGED LIVER
AND SPLEEN
The child was three months old and of Greek
parentage. It was well at birth, apparently, but after
ten days there was hemorrhage from the umbilical
cord. This was quite profound and since then the
child had not been so well. It was breast-fed. The
mother was thirty-four years old and had always been
well. She had had nine pregnancies resulting as fol-
lows: Three miscarriages, three still births, three liv-
ing children of whom two are apparently well and the
third was the present patient. The father was well
and denied any venereal disease. The babe was pale
and sallow, weighing fourteen pounds. The abdomen
was prominent The spleen was greatly enlarged, ex-
tending to the median line and dipping down into the
pelvis. The liver was also enlarged, especially up-
ward, the lower edge approached the umbilicus and
presented a rather sharp edge. No ascites was demon-
strable. There was no edema of the lower extremi-
ties and there was no other glandular enlargement.
The blood showed Hemoglobin forty-five per cent.,
R.B.C. 2,100,000 with marked change in size and shape.
W.B.C. 7,650, of which thirty-one per cent, were poly-
morphonuclears, thirty-four large mononuclears and
thirty-one small mononuclears, one eosinophyle, one
mast cell and two transitionals. There were also five
myelocytes, two nucleated reds, and one Turk's irri-
tative cell. A Wasserman of the mothers' blood
showed the cholesterol reaction -|— |-, the lipoid re-
action O. The father's blood was negative through-
out, the reaction being exceptionally clear. From the
clinical findings and from the history of the mother
I was sufficiently convinced of a diagnosis to advise
anti-luetic treatment.
CASE 11. CONGENITAL SYPHILIS WITH A CUMMATA OF
THE LTVER
A boy aged eleven years was referred on account of
a mass in the upper abdomen which was discovered
by the family physician during a rather prolonged, so-
called, bilious attack. These attacks occurred rather
frequently, almost from the time of birth, usually
lasted about two weeks, and were characterized by
nausea and vomiting with slight fever. Between the
attacks the boy was well excepting that he had fre-
quent attacks of epistaxis and had an unaccountable
languor with pains in the joints which had been inter-
preted as being rheumatic. The mother was well.
She had two children, the patient and an older daugh-
ter. Between the two children she had a miscar-
riage. She had not been living with her husband for
the past nine years.
The boy was pale, weighed sixty-eight pounds,
whereas six months ago his weight was eighty pounds.
The post-cervical, inguinal, axillary and epitrochlear
glands were enlarged. The liver was large, extend-
ing from the fourth rib to the umbilicus. A definite
nodule or an irregularity seemed to lie on the anterior
surface of the liver just below the ensiform. This
was quite tender. No ascites were demonstrable.
The spleen was normal. The knee jerks were present
only when reinforced. The blood gave a negative
Wasserman reaction at two different times in two
different laboratories. A Wasserman of the mother's
blood was also negative in the same laboratories.
Fordyce in the A. M. A. Journal, November 20, 1920,
"A negative Wassermann test in the face of positive
clinical manifestation may occur in congenital syphilis."
"Antisyphilistic treatment may be instituted with nega-
tive serology."
A diagnosis of congenital syphilis was made, how-
ever, from the history and the physical findings. Anti-
luetic treatment was instituted and improvement fol-
lowed. The liver diminished in size and there was a
definite gain in weight. The patient returned to the
family physician and it was learned recently that he
died three or four months after leaving the hospital.
Unfortunately no further information could be ob-
tained.
CASE III. CARDI.\C DECOMPENSATION, ALCOHOL NEURITIS,
PURPURA, HEMORHAGICA. CIRRHOSIS OF THE
LIVER, GLYCOSURIA, JAUNDICE, AND DEATH
Married man, aged 42, who consulted me in 1906
on account of a cardiac decompensation which
seemed to have been of recent date. He said that
he had always been well but in 1903 he had had a
severe attack of tonsilitis from which he did not re-
cover fully until he made a sojourn to Hot Springs,
Arkansas. He had a family of three children, who
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February, 1921
PITTSBURGH ACADEMY OF MP:dICINE
329
were well. The wife had not had any miscarriages.
He drank w^jiskey regularly and occasionally lie-
came intoxicated.
The physical examination showed a man weighing
245 pounds. The pulse was rapid, there was a left
sided cardiac hypertrophy and a right sided dilata-
tion. There was also a loud mitral systolic murmur
transmitted to the axilla. The liver was enormously
enlarged and smooth. Ascites was present. After a
few days of rest in bed the patient developed a definite
alcoholic neuritis, which disabled him for the most of
the year. The rest and quiet which this condition
necessitated resulted in his recovering his compensa-
tion and he was apparently perfectly well for two
years, until 1908, when he had an attack of purpura
hemorrhagica, and was seen by the late Dr. John H.
Musser, of Philadelphia, who made a diagnosis of
Laenec's cirrhosis of the liver.
Shortly after this sugar was found in the urine.
The amount of urine was three quarts in twenty-four
hours, S. G. 1025, a trace of albumen, three per cent,
sugar, acetone, no bile or casts. There was no exces-
sive thirst or hunger but a considerable loss in weight.
The glycosuria was easily controlled by a slight change
in the diet.
From 1909 to 1912 the patient was remarkably well.
In August, 1912, after an attack of acute indigestion
which was attributed to eating fish he was deeply
jaundiced and' again had definite cardiac decompen-
sation. The liver was enormously enlarged and pre-
sented an irregular contour. There was ascites and
edema of the legs and effusions into both pleural cavi-
ties. The urine did not show any sugar but was posi-
tive to bile. The blood was normal, the W.B.C. 10,800,
with eighty-five per cent, polymorphonuclears. On
account of the great distension of the abdomen it was
found necessary to do a paracentisis. The patient was
relieved somewhat but later was comatose and died.
An autopsy showed a liver weighing 2,000 grams.
The liver was much shrunken, its surface was finely
and roughly nodular and in places distinctly lobulated.
Between the nodules it had a white fibrous appear-
ance. The nodules were a dark red in color. The
margins of the liver were rounded and nodular in
outline. On section the substance cut with much in-
creased resistance. The cut surface showed numer-
ous large, broad, fibrous bands extending from the
capsule inward into the liver substances. These bands
cut off small pieces of liver substance which formed
dark isolated islands in a background of white fibrous
tissue. Part of the liver substance was free from this
heavy fibrous change, but as the tissue showed con-
siderable fibrosis, which was more diffuse, it was al-
most impossible to pit the liver substance with the
finger. The liver lobules appeared generally darker
and raised above the cut surface. There was a slight
greenish tinge to the organ.
A diagnosis of hepar lobatum-syphilitic cirrhosis of
the liver was made. It might be stated that Wasser-
man tests were not being done at that time, in 1912,
and no history of syphilis was ever obtained by myself
or any of the numerous consultants. There was great
surprise at the findings and after reviewing the course
of the disease it was concluded that not unlikely
syphilitic infection could explain all the varied clini-
cal phenomena which were manifest from time to
time.
Case IV was a young coachman,. 24 years of age,
who consulted me on account of pain and swelling in
the upper abdomen. Upon examination a mass was
found lying below the left costal margin which he
declared followed an exposure to cold while he was
driving a carriage. He said the pain was quite severe,
had come on suddenly, and for a time he was in-
capacitated.
The laboratory tests in this case were all negative.
Wassermans were not being done at that time. It
was decided to do an exploratory operation. On
opening the abdomen a gumma as large as a hen's
egg was found on the anterior surface of the left
lobe of the liver. Its nature was not recognized and
the mass was removed. The patient made a good
recovery from the operation and subsequently, with
anti-luetic treatment, he became entirely well.
The question arising in a review of these cases is
this : were there any clinical manifestations during
the primary and especially during the secondary stage
of the disease which would have led one to suspect
that the liver is to receive the chief brunt of the in-
fection? In our own experience we can say there
were none, but what do clinicians and pathologists
generally, say of the liver and biliary tract in the
secondary stages of syphilis? Adami and McCrae
say it is rare to find permanent syphilitic disorders of
the viscera, but of the viscera the liver is the most
frequently involved. They refer, however, only to
the congenital and the tertiary stage of syphilis.
McCallum says little is known of any secondary
syphilitic lesions in the liver. Osier says in the sec-
ondary stages of the disease, the liver is not always
involved, jaundice may occur coincident with a rash
or with the enlargement of the superficial glands.
Those clinicians who speak of the clinical manifesta-
tions of disturbance of liver or biliary tract in the
secondary stage of syphilis, nearly all refer to oc-
casional occurrences of jaundice, coincident with the
syphilitic rash. ' Some also speak of pain in the region
of the liver, especially in the gall bladder area, and
some speak of enlargement and tenderness, of the
liver.
Among my own series one particular case verifies
this statement.
CASE v. JAUNDICE WITH SECONDARY RASH.
A man aged 33 years consulted me in 1906 com-
plaining of jaundice and also of a peculiar sore on the
chin, which would not heal with ordinary remedies.
This sore had an indurated base and was evidently
the initial lesion. The urine contained bile and the
stools were clay colored. Later the secondary ap-
peared. The liver was enlarged — about one inch below
the costal margin in the midclavicular line. His tem-
perature was 100%. Anti-luetic treatment was insti-
tuted and all the manifestations of syphilis, together
with the jaundice promptly disappeared. Two other
patients have given practically the same history; that
is, jaundice and slight enlargement of the liver.
Wasserman in both cases was positive. Whether
these patients will be more likely to develop syphilis of
the liver than if they had not manifested early symp-
toms of biliary disturbance, is an interesting question.
So far as I can see it can be answered only through
close clinical observation and recording of data pos-
sibly the application of such principles to which Sir
James McKenzie calls our attention.
I have in mind a few patients, probably a half dozen,
in which there were definite symptoms pointing to gall
bladder and duct involvement which were referred to
the surgeon. Two of these were about to be oper-
ated when a positive Wasserman was found and the
operation was postponed. Anti-luetic treatment seemed
to have cured these. Two others were operated for
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THE PENNSYLVANIA MEDICAL JOURNAL
FEBRUARY, 1921
gall bladder trouble and at the operation the gall
bladder could not be found. In these a positive Was-
serman was later developed. It is possible that these
patients, at some time, had a cholecystitis of spi-
rochxtal origin, leading to a destruction of the gall
bladder. In conversation with Dr. Klotz, he told me
of an autopsy which he had performed, I believe, in
Montreal, and in which the gall bladder could not be
found and was evidently destroyed. This was in a
case of syphilis.
It will be seen, without any further discussion, that
very little evidence can be produced to show that the
liver is involved as a rule in the early stages of syphilis.
From the clinical side the evidence is meagre and
questionable. From the pathological side, that is,
from the side of the laboratory, it is even more in-
definite and unsatisfactory. May it not be possible
that our studies on syphilis of the liver by the newer
methods have not been as intensive as they might be,
especially on the clinical side.
Frederick B. Utuey, M.D.,
Secretary.
HARRISBURG ACADEMY OF
MEDICINE
At the anniversary meeting of the Harrisburg
Academy of Medicine on December lo, 1920 —
held in the Hotel Penn-Harris, writh Dr. George
W. Bauder, the retiring President, presiding —
Dr. Walter L. Niles, Dean of the Cornell Medi-
cal College, New York City, read a paper on
"Congenital Fixation of the Duodenum." The
paper was most interesting and instructive and
as the subject is comparatively new it has been
abstraced in detail.
ABSTRACT OF THE PAPER ON "CON-
GENITAL FIXATION OF THE
DUODENUM"
The importance of normal functioning of the
duodenum has but lately been recognized. With
the exception of duodenal ulcer, it has not gen-
erally been regarded as a frequent seat of dis-
ease. Its numerous and complex functions, its
location with respect to adjacent organs, and the
frequency of developmental anomalies in its
vicinity, suggest the ease with which its func-
tions may become disturbed
Normally, it has considerable latitude of mov-
ability, because it has practically no mesentary.
Fixation frequently results from inflammatory
processes in adjacent structures, particularly the
gall bladder, but I have gradually become con-
vinced that it more often results from defects in
development. During a certain period of foetal
life, a portion of the anterior mesogastrium ex-
tends from the duodenum to the liver. Normally
it fades out and becomes lost in the peritoneum
covering the duodenum. Occasionally, however,
it persists as a fold of membrane which extends
from the base of the gall bladder to the peri-
toneum over the pancreas or the superior layer
of the mesocolon, involving the duodenum and
producing fixation of it at an abnormally high
point. Upon assuming the upright position the
effect on the duodenum is similar to hanging a
hollow tube upon a hook, and sometimes results
in quite marked constriction.
I have gradually become convinced that this
condition is a common one, having had twenty-
three such patients operated upon during the
past six years, and having seen over fifty in
which the diagnosis was made, but did not come
to operation. Of my twenty -three operative
cases, nineteen have been females. The greatest
number have been seen in the third decade, but a
review of the symptoms shows that in most
cases the symptoms have begun early in the
second decade. Generally speaking, the older
the patient, the longer the history
The general symptoms are those usually called
"neurasthenia," namely, fatigability, nervous-
ness, headache, insomnia, vaso-motor instabili-
ties, and mental depression. These frequently
overshadow the gastric picture, which is as fol-
lows: Particularly after large meals there is a
sensation of weight, or fullness or pressure, in
the epigastrium. This is usually referred to as
gas, and if belching can be induced, some relief
tollows. Pain is a variable symptom, though
every patient had actual pain at some time or
other, though never very severe! A few have
pain almost every day, but usually it comes on
in occasional severe paroxysms felt in the right
portion of the epigastrium, apd not radiating
up or down. The majority have vomited oc-
casionally, particularly after severe exertion or
fatigue. Constipation is the rule, and severe
chronic colitis is frequent. Examination of the
stools reveals nothing characteristic. The stom-
ach contents usually show hyper-chlorhydria.
Physical examination reveals nothing charac-
teristic. There is usually moderate, sometimes
marked, tenderness in the region of the gall
bladder.
The diagnosis depends upon x-ray examina-
tions, fluroscopy giving more information than
do plates alone. The stomach is usually fish-
hook in type, the pylorus drawn well over to the
right and upward. The junction of the first and
second portions of the duodenum is opposite the
second lumbar vertebra, and absolutely immov-
able, though the pylorus and the distal part of
the second portion of the duodenum may move
considerably. The first portion is generally
somewhat dilated, but the stomach is rarely so.
Gastric retention is unu.sual.
Many patients are relieved by taking a non-
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February, 1921
BUREAU OF MEDICAL EDUCATION
331
irritating diet in small portions frequently re-
peated, wearing an abdominal belt or other sup-
port to elevate the stomach, and strengthening
the abdominal and pelvic muscles. Belladonna
often gives temporary relief. They should al-
ways be given the benefit of a period of medical
care. Patients not relieved thereby should be
operated upon*. This consists in dividing the
band, giving 4 to 6 cm. additional motility of the
duodenum. The raw surfaces should be care-
fully covered over to prevent formation of ad-
hesions.
The results of operation have been uniformly
good. All patients have been relieved of pain,
and the general health has invariably improved.
The shorter the duration of symptoms, the bet-
ter the results.
Frank F. D. Reckord, Reporter.
COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF PUBLIC
INSTRUCTION
BUREAU OF MEDICAL EDUCATION
AND LICENSURE, HARRISBURG
MEMBERS BY APPOINTMENT
John M. Baldy, Pres., 409 Lincoln Bldg., Philadelphia.
William M. Hillegas, Philadelphia.
Irvin D. Metzger, Pittsburgh.
Calvin L. Johnstonbaugh, Bethlehem.
Adolph Koenig, Pittsburgh.
MEMBERS EX-OFFICIO
Thomas E. Finegan, Sec, Dept.' of Pub. Inst., Harris-
burg.
Edward Martin, Harrisburg.
LIST OF QUESTIONS SUBMITTED BY THE
BUREAU OF MEDICAL EDUCATION AND
LICENSURE AT THE JANUARY 11,
1921, EXAMINATIONS
SURGERY — ANATOMY
1. Describe in detail the principles involved in the
Carrel-Dakin treatment of wounds. Point put the es-
sential difference in principle between this method and
the dichloramine T method.
2. State the conditions necessary to be present which
would warrant the amputation of an extremity.
3. How is Pott's fracture produced? What displace-
ments occur and what is their anatomical explanation?
4. What structures are injured in the dislocation of
the shoulder joint? What causes the difficulty in re-
ducing the dislocation?
5. State what in your opinion are the two most seri-
ous possible lesions resulting in the case of a very
severe blow on the head. Indicate the method of the
production of each.
6. Describe the lesion known as (a) carbuncle, (b)
bunion. How would you account for the deformity
known as bunion?
7. State what are the first danger signals of cancer
of (a) the uterus, (b) the stomach, (c) the intestines,
(d) the lip, (e) the female breast
8. Describe the essential elements involved in the
treatment of any severe wound of the soft parts.
9. What are the early symptoms of hip joint dis-
ease? (No credit given for late symptoms.) What
is the anatomical explanation of each of these symp-
toms?
10. State the possible causes of intestinal obstruction
other than organized adhesions which might follow
an abdominal operation within a few days. Indicate
the proper methods of meeting such an emergency.
OBSTETRICS — GYNECOLOGY — CHEMISTRY
1. A woman presents herself to you for a prospec-
tive delivery liut is fearful as to her ability to give
birth to a child: what prenatal examinations would
you adopt in order to reassure her?
2. Name two varieties of vomiting of pregnancy.
Discuss the significance of each one. Give the man-
agement of each.
3. How would you conduct the third stage of labor?
How would you care for the woman for the following
six weeks?
4. Differentiate a face from a breech presentation.
Detail the mechanism of a face delivery.
5. A pregnant woman at any time after the sixth
month consults you for uterine bleeding, (a) What
would be your deduction ? (b) How would you confirm
your opinion, (c) Detail the dangers and management
of such a case.
6. Upon what differential points would you base a
diagnosis of an enlarged uterus containing a uterine
polypus from one containing a foetus?
7. What conditions may follow cervical lacerations
if they are not properly repaired.
8. State the symptoms and findings in a case of
salpingitis. Differentiate it from tubal pregnancy:
from ovarian cyst.
9. What changes may malignant disease produce in
the urine?
10. What is lipase? What is its action and func-
tion? In what pathological conditions is it of im-
portance ?
DIAGNOSIS — SYMPTOMATOLOGY — TOXICOLOGY — MEDICAL
JURISPRUDENCE
_ I. Describe the lesions of acne and name its va-
rieties. Describe the various stages of acne rosacea.
2. What would lead you to suspect and how would
you recognize the development of empyema in a case
of lobar pneumonia ?
3. Describe Vincent's angina. Differeniate it from
stomatitis and from diphtheria.
4. Discuss the significance of acetonuria and of
diaceturia in diabetes melitus.
5. What are the symptoms, physical findings and
differential diagnosis of aortic aneurism ?
6. What are the signs and symptoms of intestinal
perforation in typhoid fever? About what period in
typhoid fever is such a complication most apt to occur?
7. In case of sudden illness characterized by severe
gastrointestinal symptoms, what measures would you
take to ascertain whether it was a case of poisoning?
In case the patient died under such conditions, what
extra measures would you take at once ?
8. State in detail what you understand by "Quaran-
tine" as applied to contagious and reportable diseases.
9. Differentiate abdominal distension due to gas
from ascites. Name three or four frequent causes of
each of these conditions.
10. Differentiate between parotitis (parotiditis) and
one other condition that may resemble it.
MATERIA MEDICA AND THERAPEUTICS, PRACTICE, HYGIENE
AND PREVENTIVE MEDICINE
1. (a) Why is it needful to neutralize arsphenamine
with sodium hydroxide? (b) What is the reason for
supposing that tincture of digitalis is a more efficient
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THE PENNSYLVANIA MEDICAL JOURNAL February, 1921
preparation to combat cardiac failure than digitalin?
What is the objection to writing a prescription for a
case of locomotor ataxia, for example, which would
contain potassium iodide and strychnine sulphate?
2 (a) What is the objection to the administration
of adrenalin by mouth? (b) Why is ergot contra-
indicated in the second stage of labor? (c) What
drug, or drugs may be prescribed with hexamethle-
namine to increase the acidity of the urine and thereby
increase the amount of formaldehyde set free in the
urine ?
3. Prescriptions: (a) An accessory diuretic for a
patient on digitalis medication with compensated mitral
insufficiency, complicated with persistent ascites, (b)
A patient with a pulse deficit of 30 per minute, i. e.,
a radial rate of 70, and an apex rate of 100. (c) A
patient with malaria.
4. (a) What advice would you give to a man, re-
garding marriage, who presents a positive blood-
Wasserman? (b) To a man who yields a positive
gonococcus smear?
5. When a public water supply as delivered to the
consumer contains colon bacilli, what dangers threaten
the community? What measures should be taken to
secure immediate protection? What to secure con-
tinued safety?
6. Outline the dietetic, medicinal and possible sur-
gical treatment of a case of pernicious anemia.
7. Why was cod liver oil empirically selected as the
best fatty remedy in tuberculosis? What other fixed
oils may be used in that disease?
8. Discuss the subject of vitamines in articles of diet.
9. Outline the management of a case of psychoneu-
rosis in a patient of either sex, aged about 35 years.
10. How would you guard against the anesthetic
dangers of (a) cocaine; (b) chloroform; (c) ether;
(d) nitrous oxide gas with oxygen?
PHYSIOLOGY — ^PATHOLOGY — BACTERIOLOGY
1. Describe the physiology of blood pressure, giving
reasons for any marked alteration from the normal.
2. In cerebrospinal fever discuss briefly (a) the
characteristics of the organism, (b) the laboratory
procedures in the study of the disease.
3. What do you understand by immunity? comple-
ment fixation? disease carriers?
4. Describe (a) the physiology of walking; (b) a'
pathological lesion which disturbs the same.
5. Describe the development of a boil. Explain the
prmciple and technic involved in the treatment of
furunculosis by autogenous vaccine.
6. Outline how you would collect and transmit to
a bacteriologist the material which would confirm the
diagnosis in (a) typhoid fever, (b) diphtheria, (c)
tuberculosis, (d) gonorrhea.
7. What laboratory investigations should precede an
appendectomy? a tonsillectomy? Why?
8. Describe the pathology of tubercular caries of
bone.
8. Discuss briefly the digestion of carbohydrates.
Show its relation to diabetes melitus.
10. Outline the laboratory findings which are diag-
nostic of each of the following diseases: (a) Chronic
parenchymatous nephritis. (b) Gastric carcinoma,
(c) Tertiary syphilis, (d) Primary anemia.
Wednesday, January 12, igai, 9 A. M.
PRACTICE — HYGIENE
1. Name some of the special treatment appliances
you would desire to have in your office equipment.
2. Outline treatments which may furnish exercise to
a bed-ridden patient.
3 How would you manage a case of neuritis? of
a paralyzed limb?
4. What is meant by reconstruction treatment?
Give an example.
5. Describe briefly the various types of baths, indi-
cating to what conditions each is applicable.
6. How would you treat a sprained joint? a stiff
joint?
7. Explain how massage aids the functions of the
skin.
8. In your_ management of a case of obesity, outline
your hygienic directions to the patient and explain
your treatment.
9. Explain your management and treatment of a
case of hysteria.
10. What abdominal conditions would be benefited
by massage? In what conditions is it contraindicated ?
ANATOMY AND PHYSIOLOGY
1. Locate and describe the urinary bladder. What is
its function?
2. Describe one of the vertebra and describe its
method of articulation.
3. Give a brief description of the heart.
4. Describe the physiology of vomiting.
5. What is meant by peristalsis? Where is peristal-
tic action found?
6. Name four glands of the human body? Name a
secretion of each. What is the function of each?
7. Describe the patella and tell all you can about it.
8. How long does digestion in the stomach require
for its completion? Name two foods that digest rap-
idly and two foods that digest slowly, in the stomach.
9. Describe the distribution of the sympathetic nerv-
ous system.
10. Describe connective tissue. What is its func-
tion?
PRACTICE — HYGIENE — PATHOLOGY
1. Explain what is meant by these terms: aseptic,
antiseptic. Illustrate each.
2. What is meant by infection? How would you
treat it? What precautions will aid in preventing it?
3. What are the signs of flat-foot? Outline your
treatment for same.
4. Name and describe three congenital deformities
of the foot.
5. Outline a treatment for excessive foot-sweating.
6. Describe the formation of corns and outline your
treatment for same.
7. Outline your immediate and remote treatment of
chilblains.
8. Give causes, preventive measures and treatment
of ingrowing nails.
9. How would you "recognize and how would you
treat eczema of the foot?
10. Name four different foot conditions that you
would refer to a physician or surgeon, giving reasons
for doing so in each.
ANATOMY AND PHYSIOLOGY
1. State the relations of the two tibial muscles at the
ankle. Give their attachments. State their functions.
2. What part of the body is supplied by the musculo-
cutaneous nerve? Name the muscles supplied by this
nerve. Of what nerve is it a branch ?
3. Define briefly (a) tendon, (b) periosteum, (c)
bursa, (d) synovial membrane.
4. Name and describe in detail the structures of the
joint in which a bunion most usually occurs.
5. Describe adipose tissue. State its function in the
feet.
6. Describe the process of coagulation of the blood.
7. Give the origin, course and termination of the
long saphenous vein.
8. State the general divisions of the nervous system.
Describe the functions of each division.
9. Of what structures is the nail composed? De-
scribe in detail how a nail is nourished?
10. What are the functions of the (a) liver? (b)
kidney? (c) pancreas?
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February, 1921
ABSTRACTS FROM STATE JOURNALS
333
ABSTRACTS FROM STATE MEDICAL
JOURNALS
FRANK F. D. RECKORD, M.D.,
Assistant Editor.
THE MODERN TREATMENT OF SYPHILIS
OF THE CENTRAL NERVOUS SYSTEM
Bv H. G. Mehrtens, M.D.,
San Francisco.
From the Neurological Clinic of Stanford
University Medical School.
The clinical results of 1,500 treatments for syphilis
of the central nervous system, given in the last three
years in the neurological service of Stanford Uni-
versity Medical School have brought out the following
facts :
To get the maximum results, each case must be
treated according to individual requirements — there
can be no rigid routine treatment.
There is no greater danger in treating syphilis of the
central nervous system than there is in treating visceral
lues when a proper technique is developed.
Cerebro-spinal syphilis (meningeal type) was arrest-
ed in 80 per cent, of cases, intramuscular and intra-
venous therapy were sufficient in about 40 per cent. —
of the remainder 35 per cent, were benefited by intra-
spinous therapy, and 15 per cent, improved somewhat
but were not arrested. About 5 per cent, of cases
diagnosed cerebro-spinal lues developed paretic symp-
toms. Headaches cleared up in 90 per cent, of in-
stances— generally after one or two intraspinous
treatments.
Tabes — early cases — nearly all did well clinically.
Some lightning pains recurred from time to time.
Late tabes showed marked improvement in about
60 per cent., but there was no evidence to show return-
ing function of reflexes — pupillary reaction or Rom-
berg sign. There was sufficient improvement to send
most of this class back to work.
In paresis the results were poor. A few cases went
into remissions, but ultimately deteriorated and had to
be committed. Several cases so diagnosed cleared up
permanently, but this unusual result tended to make
us doubt the original diagnosis. It does emphasize the
benefit for a doubtful case of paresis.
It may be said in conclusion that our present meth-
ods of treating neuro-syphilis are by no means so suc-
cessful as we would like to make them. Certainly the
last word has yet to be said, particularly in the de-
velopment of the intradural methods. Even so, we can
feel that our present methods enable us to arrest cases
intractible to the older methods and give us hope that
the future will evolve methods which, used in time,
will arrest a large majority of cases of neuro-syphilis.
ANALYSIS OF MORE THAN TWO HUNDRED
CASES OF EPILEPSY TREATED WITH
LUMINAL
By C. C. Kirk, M.D.,
Superintendent
Arkansas State Hospital for Nervous Diseases
The method of treatment consisted oi I'/i grains of
luminal at bedtime. Luminal was prepared- in tablet
form. After about sixty days our supply of luminal
was exhausted and it was necessary to use luminal-
sodium. The luminal-sodium seehied to be as effec-
tive as the luminal. At no time was there complaint
on the part of the patient of being dizzy or heavy with
this dosage. Within a few days there was a change in
the number and severity of the seizures of the patients
who were under treatment. The dosage was increased
in five instances. In these particular cases we used
I'A grains of luminal or luminal-sodium night and
morning, and in two instances we used it three times
per day; but after the seizures were under control
we then resumed our old method of lyi grains at
bedtime.
Conclusions. — There was immediate decrease in the
number of seizures, a decrease in the severity of the
seizures, many of them changing from grand mal to
petit mal ; decrease in the severity of furore and a
shortening of the time of confused states; an improve-
ment of the mental and physical health of all patients,
fewer accidents ; a general improvement of the moral
tone of the wards, and a complete cessation of the
seizures in a large number of cases. No deleterious
effects were observed on kidneys or stomach; circu-
lation, temperature and respiration are uninfluenced.
It is not a habit-producing drug and is not attended
by any pleasurable or disagreeable sensation. .In cer-
tain cases the drug is effective in twenty-four to forty-
eight hours, in others not until a week or more has
passed.
The purpose of this paper is to make a preliminary
report on the effects of luminal on institutional cases,
which are obviously the most severe types of epilepsy
to be seen. The reports made by neurologists are apt
to cover milder types of epilepsy which are treated in
private practice. The results have been so gratifying
that the author desires to present to the medical pro-
fession his results that they may see for themselves
just what can be done with the severest types of epi-
lepsy. Luminal gives promise of being the most ef-
fective and the least harmful of all drugs that have
ever been used in the treatment of this disease. — From
The Journal of the Arkansas Medical Society for
November, ig^o.
A CASE OF ERYTHROMELALGIA TREATED
WITH ADRENALIN CHLORID
By James I. Tyree, M.D.,
Joplin, Missouri
Erythromelalgia was first defined by Wier Mitchell
in 1872, again in 1878 and in 1893, when he described
the condition as a painful, red state of the limb.
Cassirer was one of the first to describe these condi-
tions elaborately. We learn that the most common
age at which the disease occurs is between 2t and 31,
and that it sometimes follows gonorrhea, syphilis,
rheumatism, exposure to cold and wet and overexer-
tion; that in sixty-seven cases both feet were affected
twenty-four times; both hands were affected two
times; one foot affected nine times; one hand af-
fected four times.
Cassirer classifies the disease into two divisions as
to distribution: (1) where symptoms are localized in
some definite nerve area ; (2) where the lesions are
distributed over the distal segment of the limb with-
out reference to the nerve distribution, the latter type
having as its etiologic factor a disturbance of the vaso-
motor system.
Boden emphasizes the importance of vasomotor in-
fluence in this disease. He found in his case atony
and ptosis of the colon and the patient improved when
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334
THE PENNSYLVANIA MEDICAL JOURNAL Frbruary, 1921
treatment was directed towards relieving that condi-
tion. The case reported is of the type due to a vaso-
motor disturbance. It is so classified by reason of the
distribution of the lesion and by the response to treat-
ment.
Extremities: Patient walked with a great deal of
difficulty and was unable to extend or flex his feet
after resting but following exercise was able to do so.
While hanging down both feet were swollen but did
not pit; above the color was bright red which fused
into a dusky or mottled red below. The red color or
swelling did not extend up the legs. The superficial
vessels stood out prominently and pulsation could be
observed. There was marked tenderness over heels
and balls and the right foot had a small trophic ulcer
on outer surface of the heel. Feet were moist and
felt much warmer than the rest of his body. No loss
of sensation. On elevating the feet color became nor-
mal, no prominence of vessels noticed and tempera-
ture became lower, pain left immediately.
Inasmuch as the 'blood pressure was far below nor-
mal on different days with no apparent circulatory
cause for it, the patient was given adrenalin chlorid
I 1,000 solution, 15 drops three times daily. This was
dropped on the tongue and held there as long as pos-
sible. After the second dose he noticed marked relief
from pain for about two and one-half hours after
taking and at the end of three days resumed his work.
The patient was greatly improved, working every day
but continued to have some pain. He was then started
on roentgen-ray exposures, as advised by Sutton which
resulted in still further improvement.
After stopping the adrenalin, the patient became
much worse in both feet, right worse than left. Blood
pressure showed diastolic, 80 ; systolic, 100. The
adrenalin was resumed, five drops four times daily.
He began to feel better at once and has continued to
do so to the present date. He now takes four drops
of adrenalin three times a day and roentgen-ray ex-
posures every ten days.
The author does not believe that all cases of erytho-
melalgia will respond so nicely to the use of adren-
alin, for there are many different causative agents,
but when a low blood pressure is found with no ap-
parent cause other than a disorder of internal secre-
tion, it will be of marked benefit. — From The Journal
of the Missouri State Medical Association for Decem-
ber, 1920.
MEDICOLEGAL
The Attorney General's Department of the
Commonwealth of Pennsylvania has advised the
Bureau of Medical Education and Licensure
that advertising to treat diseases of the genera-
tive organs is not a crime involving moral turpi-
tude, and the right of a person to practice
medicine may not be revoked by the bureau on
account of his conviction therefor.
The Act of June 3, 191 1, Pamphlet Laws,
page 639, creating the Bureau of Medical Edu-
cation and Licensure, provides :
"The Bureau of Medical Education and
Licensure may refuse, revoke, or suspend the
right to practice medicine or surgery in this
State for any or all of the following reasons,
to wit: The conviction of a crime involving
moral turpitude, habitual intemperance in the
u.se of ardent spirits or stimulants, narcotics,
or any other substance which impairs intellect
and judgment to such an extent as to inca-
pacitate for the performance of professional
duties."
The Act of July 21, 1919, Pamphlet Laws,
page 1084, provides :
"That it shall be unlawful for any person,
copartnership, association or corporation to
advertise, in any manner whatsoever, repre-
senting .such person, copartnership, associa-
tion, or corporation as being engaged in the
business or profession of treating diseases of
the generative organs of either sex. * * * *
"Any individual, or the member or agents
of any copartnership, association, or the of-
ficers or directors or agents of any corpora-
tion violating the provisions of this act, shall
be guilty of a misdemeanor, and, upon con-
viction, shall be sentenced to pay a fine not
exceeding $1,000, and to imprisonment for a
period not exceeding one year."
A man licensed to practice medicine under the
Act of 191 1 was convicted of violating the pro-
visions of the Act of 1919 in that he advertised
himself as being engaged in the business or pro-
fession of treating diseases of the generative
organs. Under the opinion of the Attorney-
General's Department, this is not a crime in-
volving moral turpitude, and the license of the
physician to practice medicine cannot be revoked
for this reason.
The Commissioner of Health of Pennsylvania
is said to have a comprehensive program of leg-
islation to be introduced at this session of the
legislature looking toward the increased effi-
ciency of the department and the betterment of
the public health. Among the important of
these acts are the following :
Giving to the Commissioner of Health of
the Commonwealth of Pennsylvania medical
and surgical supervision over all Hospitals of
the Commonwealth receiving State aid, either
in whole or in part, by requiring the Hospitals
to furnish reports to the Commissioner of
Health of the work done therein.
Authorizing the Commissioner of Health
to call upon Hospitals receiving an appropria-
tion from the State to furnish to the State
Department of Health, upon request, room or
rooms with light and heat for the purpose of
establishing dispensaries under the direction
of the State Department of Health.
Giving the Department of Health general
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February, 1921
NEW AND NONOFFICIAL REMEDIES
335
powers to regulate the water supply of private
water companies.
Giving to the Department of Health the
sanitary control of third class cities where
Boards of Health of such cities prove inade-
quate and fail to function.
Joint building and maintaining by counties,
of Hospitals for transmissible diseases.
Giving to the State Department of Health
supervision over all agencies undertaking
public health nursing work.
An amendment to the act relating to the quar-
antining of contagious diseases, giving the su-
pervisory board of the Department of Health
the power to order and regulate the various
quarantine periods.
Judge C. V. Henry, President Judge of the
52d Judicial District, comprising Lebanon Coun-
ty, specially presiding in the Court of Common
Pleas of Dauphin County, handed down an
opinion on January lo, 1921, deciding that the
cajrt had no power to mandamus school direc-
tors to compel them to comply with the law re-
lating to vaccination of pupils oh the ground that
an adequate remedy was provided by the act of
assembly by prosecution for failure to comply
with the act.
This is a case arising in Millcreek Township,
Erie County. Three of the members of the
school board of that district, being a majority
thereof, refused to enforce the provisions of
Section 12 of the Act of June 5, 1919, Pamphlet
Laws, page 399, relating to vaccination of school
children. Hon. William I. Schaffer, Attorney-
General of the Commonwealth of Pennsylvania,
presented a petition to the Court of Common
Pleas of Dauphin County asking for a peremp-
tory writ of mandamus to compel the school di-
rectors to enforce the provisions of the law.
The court refused the writ for the reasons here-
inbefore stated. The Commonwealth has taken
an appeal in the case to the Supreme Court in
order that the question may be finally deter-
mined by that tribunal.
The Bureau of Medical Education and Li-
censure proposes to try out in court the question
whether corporations of other states with
schools located in Pennsylvania may confer the
degrees of Doctor of Neuropathy, Doctor of
Chiropractic, etc., when such corporations have
not complied with the laws of Pennsylvania im-
posing certain conditions upon Pennsylvania
corporations having authority to confer degrees
in medicine.
This litigation should be of great interest to
the medical profession. If the present acts of
assembly do not give the state authorities suffi-
cient power to oust such foreign corporations,
they should be amended immediately so that
state authorities have such power, for it is in-
tolerable that foreign corporations have rights
in this respect which domestic corporations do
not have. Bernard J. Myers.
NEW AND NONOFFICIAL REMEDIES
Culture of Bacillus Bulgaricus — Coleman. — A pure
culture of Bacillus Bulgaricus, marketed in bottles
containing about 90 Cc. This culture is stated to be
suitable for all purposes for which Bacillus Bulgaricus
is used (See general article on Lactic Acid Producing
Organisms and Preparations, New and Nonofficial
Remedies, 1920, p. 156). Coleman Laboratories,
Wheeling, W. Va. (Jour. A. M. A., Dec. 18, 1920, p.
1717.)
Pneumococcus Glycerol Vaccine (Types I, II, III
Polyvalent) — Lederle. — A suspension of killed pneumo-
cocci of characteristic strains of Types I, II and III
(equal proportions) in a vehicle composed of glycerol,
66 per cent. ; physiological solution of sodium chlor-
ide, 33 per cent., and cresol, i per cent. Supplied in
packages of three vials containing the glycerol vac-
cine and of three vials of sterile diluent with which
to make the proper dilution of the vaccine at the time
of injection. For a discussion of the actions and uses
of pneumococcus vaccine, see New and Nonoffiial
Remedies 1920, p. 286. Lederle Antitoxin Labora-
tories, New York.
Pertussis Glycerol Vaccine — Lederle. — A suspension
of killed pertussis bacteria (Bordet) of eight strains,
in a vehicle composed of glycerol, 66 per cent. ; physio-
logical solution of sodium chloride, 33 per cent., and
cresol, 1 per cent. The product is supplied in pack-
ages of five vials containing the glycerol vaccine, and
five vials of sterile diluent with which to make the
proper dilution of the vaccine at the time of injection.
For a discussion of the actions and uses of pertussis
bacillus vaccine, see New and Nonofficial Remedies
1920. p. 235. Lederle Antitoxin Laboratories, New
York.
Typhoid Glycerol Vaccine (Prophylactic) — Lederle.
— A suspension of killed typhoid bacteria (Rawling's
strain) in a vehicle composed of glycerol, 66 per cent.,
physiological solution of sodium chlorid, 33 per cent.,
and cresol, i per cent. The product is supplied in
packages of three vials containing the vaccine, and
three vials of diluent with which to make the proper
dilution of the vaccine at the time of injection. For
a discussion of the actions and uses of typhoid vac-
cines, see New and Nonofficial Remedies 1920, p, :^i.
Lederle Antitoxin Laboratories, New York.
Typhoid Combined Glycerol Vaccine (Prophylac-
tic)— Lederle. — A suspension of killed typhoid bacteria
(Rawling's strain), 50 per cent.; killed paratyphoid
bacteria, Type A, 25 per cent., and killed paratyphoid
bacteria, Type B, 25 per cent., in a vehicle composed
of glycerol, 66 per cent. ; physiological solution of
sodium chlorid, 33 per cent., and cresol i per cent.
The product is supplied in packages of three vials
containing the vaccine, and three viles of sterile dilu-
ent with which to make the proper dilution at the time
of injection. For a discussion of the actions and uses
of typhoid vaccines, see New and Nonofficial Remedies
1920, p. 291. Lederle Antitoxin Laboratories, New
York (Jour. A. M. A., Dec. 25, 1920, p. 1783).
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336
THE PENNSYLVANIA MEDICAL JOURNAL February, 1921
THE PENNSYLVANIA
Medical Journal
Published monthly under the supervision of the Publication
Committee of the Trustees of the Medical Society of the State
of Pennsylvania.
Editor
FREDERICK L. VAN SICKLE, H.D Harrteburg
Awistent Editor
FRANK F. D. RECKORD Harrlsburg
Aasoetate Editon
JosKPH McFakund, M.D Philadelphia
Gioact E. Pfahlh, M.D Philadelphia
l.AW«tHC( LiTCHFiXLD, H.D Pittsburgh
GiORCE C. Johnston, M.D Pittsburgh
J. Stcwaut Roouah, M.D Philadelphia
John B. McAustu, M.D Harrisburg
Bernakd J. Mtirs, Es<) lAncaster
Pnbltoattoii OommlttM
Ira G. Shoiuaku, M.D., Chairman Reading
Theodou B. Appil, M.D t,ancaster
FtAHK C. Hauuohd, M.D Philadelphia
All communications relative to exchanges, books for review,
manuscripts, news, advertising and subscription are to be ad-
dressed to Frederick L. Van Sickle, M.D., Editor, aia N.
Third St., Harrisburg, Pa.
The Society does not hold itself responsible for opinions ex-
pressed in original papers, discussions, communications or ad-
vertisements.
Subscription Price — $3.00 per year, in advance.
February, 1921
EDITORIALS
DIAGNOSTIC CLINICS
The Workmen's Compensation Laws now
operative in many states are likely to improve
the character of medical and surgical service in
hospitals. The employers and corporations are
compelled to pay hospitals for care of the in-
jured and the fees of the doctors, who give the
treatment, whether in hospital or in the home of
the surgeon. This fact insures a certain degree
of inspection of the efficiency and honesty of
the service and will lead to criticism of its
worthiness. Delay in effecting a cure of minor
injuries will be noticed ; as will also the reliance
on old-fashioned and discarded methods of
treatment.
An important factor in successful medical
and surgical treatment is the ability to read at
an early date a true diagnosis of the cause of the
patient's illness or injury.
A hospital, which happens to have a disloca-
tion treated as a synovitis or as rheumatism,
cannot expect the railroads or factory to .send
many future patients into its wards. An ap-
pendicitis treated as a mere contusion will create
the impression that the ho.spital requires a
change in surgical staff to retain the confidence
of corporation treasurers.
Diagnostic clinics have been suggested as a
proper way of rendering aid to industrial physi-
cians in charge of plants too small to justify the
creation of a plant hospital service. This has
been done in the West, why not in Pennsylvania ?
When a proper diagnosis is reached, the stand-
ardized treatment may often be available.
Hence the course is plain to the medical officer
in charge of the health of the workers. Experts
are ready as a group to investigate blood, excre-
tions, secretions, chest, abdominal, and cerebral
conditions, psychic neurologic and environal
complications. Upon these questions and with
the combined experience of occulist, aurist, and
surgeon, a diagnosis is reached. A report is
made to the industrial medical attendant and the
fee for expert investigation to be paid for by
the company or firm. This form of aid will do
much to insure the workman's return to health
promptly in disabling injuries and illness. The
hospital will be benefited by the fees, the staif
secure valuable experience and some remunera-
tion, and great chance be given pupil physicians
to learn diagnostic methods.
Teaching hospitals should adopt the diagnos-
tic cHnic idea. J. B. R.
THE NEWER TECHNIQUE FOR DEEP
X-RAY THERAPY
Much has been accomplished in the x-ray
treatment of even deep-seated malignant dis-
ease during the past twenty years, and in recent
years this means of combating this dreaded dis-
ease is recognized as a definite procedure by all
well-informed physicians and surgeons, but
there have been too many failures even in the
hands of those most skilled and best informed to
justify us in feeling satisfied. Therefore, when
rumors reach us of any radical change in tech-
nique which gives greater results it behooves us
to take due notice. The good results obtained
have run parallel with the improvement of skill
in technique and with the improvement in appa-
ratus and equipment. These advances noted in
America have consisted in the production of ap-
paratus which would give a more continuous
high voltage current, and the Coolidge tube
which gives a more uniform quality and quan-
tity of rays, and which permits a greater degree
of filtration, thus producing x-rays which more
and more approach those of the most penetrat-
ing type given out by radium.
During the past year several books have
reached our .country describing the progress
that has been made in Germany. '■* Reports
have also been brought back to us by Drs. Cool-
idge,' Schmidt "and Sittenfield* of the clinical
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February, 1921
EDITORIALS
337
results obtained, the apparatus used and the
technique which has been developed. In our
own country we have gradually passed from a
current of practically 40,000 volts to a current
of 90,000 volts, and we have gradually gone
from no filtration to six and even ten milli-
meters of aluminum as filter. The object of
this filter is, of course, to eliminate the softer
rays which are absorbed in the superficial tissues
so as to obtain relatively greater effect in the
deeper tissues. We now learn that in Germany
there has been developed apparatus which will
produce a high tension current running as high
as 160,000 or even 200,000 volts, and that filters
are used consisting of one-half millimeter of
copper or zinc, and even a millimeter of copper.
A millimeter of copper has been estimated to
equal approximately 18 millimeters of alumi-
num. Therefore a half millimeter of copper
would equal approximately 9 or 10 millimeters
of aluminum in filter value. Therefore, the more
moderate grade of filtration used in Germany
would probably correspond to the heaviest fil-
tration used in this country. The greater the
amount of filtration the longer the prolongation
of each treatment. In this country with filtra-
tion of 10 millimeters of aluminum or glass,
and 90,000 volts, and 5 milliamperes of current
flowing, at a focal distance of 30 centimeters,
the time of exposure over a single area has been
extended as long as 40 to 60 minutes. This has
produced results never equalled before." In
Germany, with a voltage of 190,000 and with a
focal distance of 30 centimeters through a milli-
meter of copper the exposures have been as
long as 90 minutes and, for instance, in carci-
noma of the uterus, treatment is given through
the four surfaces making a total of six hours
exposure which, in Bumm's clinic, is given all
in one day. This is apt to make the patient very
sick. Therefore, the patient is placed in the hos-
pital, a transfusion of blood is given together
with other general medical attention. This is
very radical but the results are reported as being
superior to any obtained before and to any other
form of treatment of malignant disease with the
pelvis.
The greatest caution is necessary in this coun-
try in transferring from former technique to
this deeper technique, for while excellent results
are possible, unless the greatest care and skill is
used, serious dangers to the patient may result.
In the Gynecological clinic of Opitz in Frei-
burg, all cancers of the uterus have been treated
by this means since January i, 1919.
It is the duty of those who are in the best po-
sition for investigation to study these methods
most thoroughly and if the improvement in re-
sults justifies it such more, radical treatment
should be adopted even though some risks are
involved.
1. Seitz u. Wientz — Unsere Methode der RdntEcn-Tiefen-
therapie, und, ihre Erfolge. Urban and Schwarzenberg. Ber-
lin 1030.
2. Kronig u. Friedriech — Pbyaicaliacbe und Biologiacbe
Grundlagen der Strablentberapie. Urban and Schwarzenberg.
Berlin 191 8.
3. Coolidge. Proceedings of the American Roentgen Ray
Society. Minneapolis. September 1930.
4. Sittenfield. Journal of the A. M. A., Jan. 8, 1931, page 99.
5. Pfahler. .Proceedings of the Eastern Section of the
American Rtentgen Ray Society, Altantic City, Jan. 29, 1921.
G. E. P.
SWAT THE "BABY KILLERS"
Holt gives the dosage of morphin to children
as follows: at one month, i/iooo grain; at
three months, 1/600 grain ; at one year, 1/200
grain ; at five years, 1/30 to 1/20 grain.
Congress, in its wisdom, exempted from the
restrictions of the Harrison law preparations
containing not to exceed % grain of morphin to
the fluid ounce — this at the behest of the makers
of proprietary cough syrups, etc., supposedly
given to adults.
At once many of the makers of baby drops,
soothing syrups, infant anodynes, etc., common-
ly and justly regarded as "baby killers" by
physicians and enlightened mothers took it
upon themselves to incorporate this same amount
of exempted morphin in their products.
As will be seen a fluid ounce of such an infant
anodyne contains 250 doses of morphin for a
baby one month old, 150 doses for one three
months old, 50 doses for one a year old, five
doses for one five years old, and only two doses
for an adult. It is true that some infant ano-
dynes contain less than J4 grain of morphin to
the fluid ounce, while most of them carry di-
rections on the bottle, or circular-directions, as
to correct dosage, the idea being to give the ordi-
nary therapeutic dosage.
This is, in practice, a subterfuge to evade the
intent of the law by allowing children to receive,
regularly or irregularly, and without the pre-
scription of a physician, full doses of morphin,
while an adult may not receive such doses.
Ignorant mothers and nurses, knowing little
about the effects of morphin, commonly exceed
the printed directions, the result being that ad-
dicts are being made in the cradle, many of
them receiving ascending doses until just as
much a drug addict as any adult, becoming wan,
sickly, and sometimes degenerates who grow up
feeble-minded or confirnfied drug addicts.
Recently there came to our attention H — 's
Anodyne for Babies, guaranteed to contain "at
least }i grain of hydrochlorate morphia in each
fluid ounce" and advertised in the newspapers
as follows :
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THE PENNSYLVANIA MEDICAL JOURNAL
February, 1921
"TO KEEP BABY WELL it must have iwo
small doses of H — 's Anodyne every day. Pre-
scribed by doctors."
Think.of it! A regular "campaign of educa-
tion" in the making of drug addicts in the cradle,
"fo keep baby well." This advice was not given
for sick babies but for well ones. A more
vicious advertisement could hardly be imagined.
The Pennsylvania Department of Health,
realizing the menace of the "Baby Killer," and
operating under a State law which prohibits the
sale without prescription to a known drug ad-
dict of morphin or other narcotic in any quantity
whatsoever, has, by ruling of the Commissioner
of Health, classed all infants to whom these
"Baby Killers" are administered regularly or at
frequent intervals as drug addicts, which tney
certainly are; and all dealers are warned not
to make continued .sales to or for the use of any
infant of any of these nefarious preparations.
Reports of such sales must be rendered monthly
to the Bureau of Drug Control at Harrisburg.
Unfortunately, there is no law requiring the
manufacturer to eliminate all narcotics from
infant anodynes.
This campaign for the safety of the babies is
being pushed hard by the Department, the result
being that sales of such products have fallen off
immen.sely and several manufacturers of infant
anodynes have eliminated all narcotics from
their formulae. The Proprietary Association of
America also favors such elimination as a na-
tional policy.
Physicians need not be told more than these
facts to realize their duty to the babies under
their care; but perhaps there are doctors who
have been perplexed over some infantile cases.
Let them ascertain what mother is buying at the
drug store for baby, and the problem may be
solved, although it may require very careful
treatment to bring baby back to normal again.
Again, let the physician lock into the matter
at the drug store he patronizes, asking the
proprietor to eliminate all of the "Baby Killers"
from his .stock. Even this is not enough, for
hundreds of small grocery stores sell these
preparations, usually in entire ignorance on the
part of the proprietors of the harm being done.
Doctor, Help Swat the Baby Killers !
T. S. Blair.
GRADUATE MEDICAL TEACHING
The appreciation of the life and work of the
late Dr. John B. Murphy, by Sir B. G. Moyni-
han, in the December issue of Surgery, Gyne-
cology and Obstetrics is a masterpiece of short
biography. One can not help a feeling of pride
in the achievements of this great fellow country-
man, acclaimed by Moynihan as the greatest
clinical teacher of surgery of this age. For
those interested in Dr. Murphy's remarkable
career Moynihan's article is strongly recom-
mended as he has set forth there with his usual
clearness and grace of expression the story
which should be an inspiration to others. To
the few is given the genius of Murphy, but to
the many is now given a better opportunity of
acquiring a training in a speciality by organized
Graduate Education. In the days when Mur-
phy and the present leaders of the profession
got their early training there was but one way
to do it. This was to attach one's self to some-
one already established and to learn from him
as an assistant. This process undoubtedly is
efficient, but it also takes time, three to seven or
eight years, and there are not enough such posi-
tions available to train all of those desiring such
training. Prior to the world war many men
went abroad, particularly to Germany and Aus-
tria, for graduate study, but this field is closed
and probably will be for some time to come. It
seems natural, therefore, that the educational
resources of this country should be augmented
and particularly with regard to graduate in-
struction. Few now realize the ereat necessity
for systematic graduate teaching and that such
an opportunity is being offered to qualified stu-
dents in our own State. The Graduate School
of Medicine of the University of Pennsylvania,
is one of the first in this country to recognize
this need. The time is rapidly coming when
the public will demand evidence of special train-
ing before trusting one with undertakings which
demand such training. It will not be possible
then to plunge into special work with only the
qualifications that a medical degree and hospital
internship can furnish.
Unhappily this has often been the case in the
past and means that the necessary experience
and skill is slowly learned iand more by mistakes
than successes. The higher qualification in spe-
cial fields may mean that higher degrees in these
fields will have to be earned, a plan which is
even now working out well at one of the founda-
tions devoting itself to graduate teaching (Mayo
Foundation of the University of Minnesota).
This plan is warmly advocated by the Commit-
tee on Graduate Medical Teaching of the Ameri-
can Medical Association and others who have
given this matter serious thought. If training
such as one would take years to get by indi-
vidual effort can be given under the supervision
of competent teachers and in a much shorter
time in a Graduate School of Medicine cer-
tainly such a course should appeal to all those
contemplating entering a special field of work.
Such an undertaking, however, needs the ear-
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February, 1921
EDITORIALS
339
nest support of every member of the profession
and such support should be given to the Uni-
versity of Pennsylvania in its effort to fulfill
this need. J. S. R.
COUNTY MEDICAL SOCIETY PUBLI-
CATIONS
From time to time, since the days of our
friend and late president, Dr. John B. Donald-
.son, of Washington County, who did so much
for the county societies in urging them to pub-
lish their transactions, it has been the custom
to remind the county societies of the value of
these publications.
There has been some difference of opinion
among members as to the benefit of these publi-
cations. It is not possible, nor would it be in
good taste, to review each county publication in
this article, but recently we have observed a
marked improvement in some of them, which
calls for commendation, and we also note the
"adieu" of one of our county bulletins.
As to the need, benefit, advantage and desir-
ability of a bulletin as a source of information
for the members of the county societies — we
believe that these points have been discussed so
frequently that they do not need any further
elucidation; we can only comment upon meth-
ods of improving these journals and lament the
fact that some have deemed it wise to cease pub-
lication.
Philadelphia and Allegheny Counties, with
their large membership, have wisely refrained
from overstepping their field of publication, by
producing a regular "journal" — a field which is
always so alluring to an editor. In fact they
have the rather been ultra-conservative in pub-
lishing only the brifest excerpts of their trans-
actions and the notices of meetings of the parent
and branch divisions of their societies. To
somewhat the other extreme have gone the pub-
lications of Lackawanna, Cambria, Montgom-
ery, Berks and a few others, in reviewing to a
greater length the papers read before their so-
cieties, as well as publishing communications.
This, of course, is not objectionable unless it
be carried to too great an extent. That would
defeat the very object for which the county so-
ciety publication was promulgated.
■A mere announcement of meetings through
postal card or single page notification was the
first step in the effort to increase the interest of
the members of the societies. From that has
grown the one to a possibly too-many page bul-
letin. It would seem most desirable to those
who have canvassed the field, were each county
society to publish at least a folder of four pages
per month, increasing the number as meetings
would require, and giving brief news notices
and other items of interest both to the members
of the society and to the Pennsylvania Medi-
cal Journal "information bureau," thus pass-
ing them on to the entire State.
Can we not, therefore, interest those who
have publications in making them more newsy
and can we not persuade those counties that
have no publication to produce one, even during
these days of the high cost of printing, both for
the benefit of their own members and that of
their friends in the other parts of the State?
Think it over.
MEDICAL PROFESSION AND THE
PUBLIC.
The attitude of the Council of Health and
Public Instruction of the American Medical As-.
sociation at its recent meeting in New Orleans,
gives us cause for great felicitation. It denotes
great progress in the relation of the medical
profession and the public.
New truths have followed each other so rap-
idly, we physicians have scarcely been able to
digest them. Much less can the people be ex-
pected to keep pace with them. They accept
new "pathies", foolish in the light of science, yet
we allow them to become fixed in their beliefs.
We permit the public to be educated (?) by
patent medicine advertisements, and the char-
latanism of the commercially interested. The
time has now coqie to take the public into our
confidence and enlighten them, for, with the
people lies the final word.
The Council of the American Medical Asso-
ciation took favorable action upon the advis-
ability of teaching the nature and transmission
of communicable diseases in the public schools
of the country, and to frame a model bill to in-
troduce in the legislatures of those states which
have not as yet provided for such instruction.
It recommends that teachers in the public
schools shoul know something about communi-
cable diseases, and what should be done with
pupils developing the same; that a course in
epidemiology should be required in normal
schools and in universities, and that no one
should be permitted to teach without having had
such instruction.
For a long time the legitimate physician con-
sidered his profession possessing secrets that
could in no wise be given to the public. Yet the
bulk of medical knowledge consists of nothing
but simple truths that can be imparted with
safety to the average intelligent person.
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THE PENNSYLVANIA MEDICAL JOURNAL
Fkbruary, 1921
In his individual capacity, medical men have
rarely been found wanting; collectively he has
lacked the influence to inaugurate and carry on
great movements. Our most altruistic purposes
must be standardized, if we are to gain and
maintain the preeminent position to which we
are entitled. We must unite for the common
good, and the Council in recommending closer
association between the profession and laymen
interested in sanitation and public health, which
is a big step forward.
Society appreciates the saving of a sick per-
son's life by a skilled physician, but fails to see
the priceless gift to the human race made by
preventive medicine and sanitary science. This
is because we appeal to them as one individual
to another without the weight of authoritative
ot^nization in legislation. But despite this,
sanitary matters are becoming generally under-
stood through medical influence. The public
has.been educated in regard to the "Great White
Plague." We see the good results from teach-
ing the habits of mosquitoes, and the necessity
of quarantine of patients afflicted with con-
tagious disease.
The typhoid fever crime of cities through pol-
luted water supply is an important phase of
popular education. There is no reason why a
man who has become inflicted with typhoid
fever from a city's neglect should not sue for
damages as he would for personal injury from
falling through a defective sidewalk.
The suggestion of the Council that the Amer-
ican Medical Association publish a popular, up-
to-date journal upon sanitation and epidemiol-
ogy to give the public the latest and best inf or- -
mation upon communicable diseases, marks an
epoch in medical history.
The additional recommendations of the Coun-
cil have been thoroughly formulated and if car-
ried to full fruition would prove an inestimable
boon to many practitioners, and give to pre-
ventive medicine and general health work a
momentous uplift.
For instance : Steps to secure proper diagnos-
tic facilities for practitioners, especially for
young physicians in rural communities, who
would be handicapped by this lack, and to in-
sure proper nursing and medical care for resi-
dents removed from hospitals and dispensaries.
The great movements of the future cannot be
brought about by individual action. They must
be initiated by united effort; in no other way
can the epoch-making truths of medicine and
public health bear fruit. Unity is the spirit of
the time.
Therefore, it behooves us, one and all, to ap-
prove and wholeheartedly cooperate with the
action taken by the Council of Health and Pub-
lic Instruction of the American Medical Asso-
ciation in the relation of the medical profession
toward the public. In this line of action lies the
future usefulness of our profession as a whole.
J. B. McA.
"SOCRATES REDUX"
THE HERO BUSINESS
I supposed that our business for the day was
at an end, and that we would be able to settle
down to purely literary work, when a rustle of
paper from the adjoining room called attention
to another of our many visitors still waiting.
With a sigh that probably was audible we said
"come in," and with a still deeper sigh saw ap-
pear the well-known bald head and spectacles
of Socrates.
He held a medical periodical in his hands,
and as he sat down, he took off his spectacles,
and with a show of pretended grief, wiped his
eyes ostentatiously.
We watched him curiously, wondering what
was coming, and did not have to wait long.
"I've just been reading this article," and he
designated a lengthy address, by a prominent
member of our profession, that we had scanned
with interest and admiration a short time before.
"It moves me to tears. Until I read it I had
no idea of the superior quality of the men com-
posing our profession. We are indeed Nature's
noblemen." "The Unselfish Profession" he
read. "Here we are, daily running enormous
risks, exposing ourselves to the dangers of in-
fection,- frequently falling victims to diseases
contracted in the performance of our duties,
suffering death in many forms, perpetually in-
terfering with our own future successes, and
threatening ourselves with poverty and disaster,
all for the love of our fellow men, by whom we
are more often denounced than approved !"
He wiped his eyes again. "Just look at it,"
he said. "Here the writer tells the sad story of
Dr. A — , who acquired diphtheria in treating a
child suffering from the disease; here of Dr.
B — who got it through experimenting with the
bacillus in the laboratory ; here, of Dr. C — who
died of cerebro-spinal meningitis after treating
several cases during the epidemic at Q — ; here
is the story of Dr. D — who died horribly of
cancer acquired after years of patient endeavor
to benefit his fellows by making radiograms of
their bodies so that the surgeons would know
what to do for them, and so on, and so on."
"Well," we answered, "and isn't it all true?"
"Surely, every word of it. Why, I knew
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February, 1921
EDITORIALS
341
some of the men referred to myself and know
it's true."
"Well, then, why these crocodile tears ?"
"Think of the way we destroy our opportuni-
ties, look at the list of instances in which we
have interfered with business — I b^ pardcMi,
I mean practice. We vaccinate people and so
deprive ourselves of the cases of small-pox that
our forefathers used to find so lucrative."
"You don't mean to say that you are opposed
to vaccination?"
"We purify the water supply and so extin-
guish typhoid fever — why, when I was a young
man, most of my practice was typhoid fever, I
often wondered what had become of it, now I
know— I killed it."
"But you wouldn't like to go back to impure
water yourself, would you ?"
"We are having school children and industrial
workers instructed so that they may keep them-
selves well, when it would be to our advantage
to have them get sick and stay sick."
"But we look upon that as one of the greatest
things ever tmdertaken for the public good."
"Yes, yes, all these things that are for the
public good work out to the doctor's prejudice."
"But surely the author of the article you were
reading was right. That only goes to show that
we are indeed the great, noble, self-sacrificing
body of public-spirited men that he is proud to
think we are, and to fill us with pride in be-
longing to it."
He said nothing in answer, but as he slowly
took from his pocket a large, old-fashioned
wallet, and from it, in turn, a package of clip-
pings, he muttered to himself — "great, noble,
self-sacrificing body of public-spirited men."
At l«igth he handed me the clippings, one at
a time, and we read them hurriedly, though not
without interest, for we knew well enough that
something was coming, and wondered what it
was. The first read somewhat as follows :
• Fatal Accident at Box Factory
We have to report with regret that at the
large fire that occurred yesterday, F — B — , the
senior member of fire company No. 5 of this
city, was killed. B — was one of the most in-
trepid fireman our department has ever known,
and has saved more lives than any other single
man. At the fire two years ago in the apartment
house on Fifty-sixth Street, against the advice
of his chief, B — dashed through the flames and
at the risk of his own life, for the walls fell
as he returned, and converted the entire build-
ing into a fiery furnace, saved two little chil-
dren. For this he was to have been awarded a
Cam^e medal, but he refused it, saying that
he did nothit^ but his duty.
We read no further, but handed the paper
back, with the simple quotation "He did noth-
ing but his duty."
"Of course not ; he was paid for doing it. It
was no more than was to be expected of him."
He handed me another, and I read :
Policeman Victim of Assassin's Bullet
Last night Patrolman Benedict, hearing cries
from the back room of McGrorry's saloon, and
knowing that the place had an evil reputation,
rushed in and up the stairs, to find two unknown
men in the midst of. a terrific fight. The one
had the other down and was pounding his head
with the leg of a chair, demolished in the battle,
when he realized the entrance of Benedict.
Getting up quickly and seeing that he would be
overpowered in his somewhat exhausted condi-
tion he shot the patrolman dead, and then es-
caped through a back window.
We handed back the clipping. "It is another
similar case. These things are always deplor-
able, but they cannot be helped."
"No, of course not, he was only doing his
duty."
He fumbled the clippings a moment, then said,
"Do you want to see the rest ?'
"How many are there?"
"Oh, lots of them! Here is one that tells of
a railroad engineer who died at his post as the
train collided with another because a switchman
was drunk ; here is another that tells how when
the "Caledonia" sank at sea, the entire crew was
saved except one of the firemen who was cau-
tioned to remain at his post until the very last
minute in the hope that their signals would be
heard and help arrive. When it did arrive, he
could not get out and was burned to death. He
left a wife and three small children."
"But we said, all of these are cases like the
first; they are all men who, in the course of
their ordinary pursuits were overtaken by dis-
aster, and did their duty as might be expected
of men everywhere."
"I know it," he said. "They were just men.
They did nothing more than was to be expected
of them. If they had behaved otherwise, we
would have looked upon them with contempt.
But, you know, we do it anyway, because they
did not belong to the 'great, noble, self-sacrific-
ing body of public-spirited men' who constitute
the 'self-sacrificing prof essicm.' "
We never seem to ourselves to be so slow in
catching on to what is coming as when we talk
with Socrates. We felt stupid, and embar-
rassed, and did not know what to say, but felt
called upon to say something in defence of our-
selves, so we added, "Well, these men were j
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THE PENNSYLVANIA MEDICAL JOURNAL February, 1921
heroes, as were also the doctors mentioned in
the paper you were reading."
"Maybe, maybe," he said, "but you know,
they only did their duty, and nothing less was
to be expected of them. Don't you think that
our hero business has been a bit overdone?
Maybe it would be just as well not to talk too
much about it."
PROPAGANDA FOR REFORM
More Misbrandeo Nostrums. — The following prod-
ucts have been the subject of prosecution by the
Federal authorities charged with the enforcement of
the Food and Drugs Act: Linonine (Kerr Chemical
Co.), held misbranded on the ground that the curative
claims were held false and fraudulent. Valentine's
Sarsaparilla Compound with Potassium Iodide (Allan
Pfeiffer Chemical Co.), sold under therapeutic claims
which were false and fraudulent. Olive Branch
(Olive Branch Remedy Co.), misbranded in that the
curative claims were false and fraudulent. Prince's
Pills, Liniment and Tru- Vigor Nerve Tablets (Bos-
ton Drug and Chemical Co.), misbranded in that the
therapeutic claims made for them were held false
and fraudulent. Mrs. Summers' Absorbent Pile
Remedy, Mrs. Summers' Womb, Ovarian and Kidney
Tonic and Vitalizer Tablets and Mrs. Summers' Heart,
Brain and Nerve Pills (Vanderhoof and Co.), mis-
branded in that they were sold under therapeutic
claims which were false and fraudulent. Compound
Syrup of Hypophosphites, Bromo Febrin, Hystoria,
Aromatic Cod Liver Oil, Red Cross Kidney and Liver
Regulator, White Pine and Tar Syrup, and Boro-
Thymine (Cal-Sino Co.), misbranded in that the
therapeutic claims were false and fraudulent (some
were also held adulterated because their composition
was misleadingly or falsely declared) (Jour. A. M. A.,
Dec. II, 1920, page 1663).
I'HE Parry Medicine Co. Barred From the Mails.
— For some years Pittsburgh has harbored a quack
concern known as the Parry Medicine Company. The
president of the company was one Leonard L. Parry,
who advertised himself as "Dad Parry, the Healer"
and also as "The Miracle Man." In April, 1917,
Parry, who is an obviously ignorant faker, was ar-
rested and convicted of the illegal practice of medicine
and was sentenced to pay a fine and to serve a six
months' sentence in jail. Apparently as soon as
Parry got out of jail he went right back to his quack-
ery. As a result the Federal authorities took action,
and the Parry Medicine Co. has been denied the use
of the mails. The "medicines" put out by the Parry
concern were fourteen in number and were numbered
consecutively. They were essentially the same in
composition, differing only in flavoring. Each was
composed approximately of alcohol 25 per cent. ;
water, 25 per cent., and olive oil, 50 per cent., to which
was added a few drops of essential oils. No. 1 was
for Tuberculosis, Lungs, Bones or Flesh, Gallstones or
Tapeworm. No. 2 was for Cancers, Adenoids, Hemor-
rhoids, Piles, Asthma, Goiter, Typhoid and all other
fevers. Extensive curative claims were similarly
ascribed to the remaining twelve preparations (Jour.
A. M. A., Dec. 18, 1920, p. 1732).
Physician's Stock in Prescription Products.— Is
the public getting a square deal when physicians are
financially interested in the products that they may
be called on to prescribe? Is the average layman's
confidence in the medical profession likely to be en-
hanced when he learns that the physician to whom he
went for treatment has a financial interest in the thera-
peutic agent which was prescribed? It cannot be too
often emphasized that it is against public interest and
scientific medicine for physicians to be financially in-
terested in the sale of products which they may be
called on to prescribe for the sick. It is perfectly
true that there are many physicians who would not
consciously permit financial considerations to warp
their judgment, but it is not humanly possible to
remain unbiased in cases of this sort (Jour. A. M. A.,
Dec. II, 1920, p. 1662).
German Institute for Examination op Pharma-
ceuticals.— It is proposed that the commission
founded years ago by the German internists — the Arz-
neimittel-Kommission — is to be changed into an insti-
tution to investigate new pharmaceutical articles and
supply information thereon to physicians on demand.
An information bureau and bibliographical center is
planned, and it is proposed to test new inventions for
the manufacturers. 'The commission announces that
it has been decided not to restrict the examinations to
the chemical, pharmaceutical and pharmacologic side
of the matter, but in given cases tests and investiga-
tions at the bedside will be made. It is stated that the
pharmacologic investigations are to be made at the
pharmacologic institute of the University of Berlin,
which is in charge of Heffter, and that the institu-
tute is to be the headquarters of the new Prufungsamt
(Jour. A. M. A., Dec. 25, 1920, p. 1791).
BLOOD ALKALI RESERVE WITH EXPERI-
MENTAL INFECTIONS
Edwin F. Hirsh, Chicago (Journal A. M. A., Oct
30, 1920), found that the blood alaki reserve of ex-
perimentally infected animals is lowered coincidentally
with the initial leukopenia, and during the subsequent
increase of the leukocytes rises to or exceeds the level
determined originally for the animal. These changes
occur within relatively short timed intervals. Graphs
of these reactions resemble in. contour those generally
known for immune body production.
AVERAGE COST PER FAMILY OF DENTAL
AND MEDICAL CARE, AS PER STATIS-
TICS OF U. S. DEPARTMENT OF LABOR
Average cost per family per year
Total fainilies
No expense
No less than $1.00
$1.00 to $10.00
$20.00
$30.00
$40.00
$50.00
$75.00
$11.00 to
$21.00 to
$31.00 to
$41.00 to
$51.00 to
$76.00 to $100.00
$101.00 to $150.00
$151.00 to $200.00
$201.00 to $250.00
$251.00 to $300.00
$301.00 to $350.00
$351.00 to $400.00
$401.00 to $450.00
$451.00 and over
Digitized by
$44.64 .
1,214
8— 0.7%
Sl
201
201
193
154^95-8%
122
157
85
54J
20I
7\
5l
4 13.47%
i|
2|
3J
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The Medical Society of the State of Pennsylvania
OFFICERS' DEPARTMENT
WALTER F. DONALDSON, M.D.,
Secretary
8014 Jenkins Arcade Bldg., Pittsburgh
ATTENTION OF SECRETARIES
Archives are defined as records preserved as
evidence, or as history pertaining to a family,
an organization, state or nation.
Many of our component county societies now
have periodical publications that contain official
and other transactions comprising the nucleus
of an invaluable history of the Society. Their
preservation is a duty that at present falls to
the County Society Secretary, but should in the
larger societies be assigned to a committee. In
addition to maintaining permanently the records
of the county society, such committees should
also arrange for the preservation of the Penn-
sylvania Medical Journal and the Journal of
the American Medical Association. In certain
societies such efforts would undoubtedly result
in an occasional service to a member in search
of information, and might result in the develop-
ment of a library.
The 1920 Committee on Archives of the Med-
ical Society of the State of Pennsylvania con-
cluded their report as follows :
"It is also urgently recommended that each
county medical society secure, as far as possible,
a complete set of the Journals for their own fu-
ture reference."
The House of Delegates at the 1920 session
adopted the following:
"Resolved, That the Committee on Archives
of the Medical Society of the State of Pennsyl-
vania work in conjunction with similar commit-
tees of the county societies, and the data ob-
tained be published in the Journal of the
Medical Society of the State of Pennsylvania,
in a series of articles, and subsequently be re-
produced in a single volume."
The adoption of the above recommendation is
urged upon component societies.
The 1921 Committee on Archives of the State
Society composed as follows: Cyrus Lee Ste-
vens, Athens; Samuel Gerhard, Philadelphia,
and Walter F. Donaldson, Chairman, Jenkins
Arcade, Pittsburgh, invites cooperation and of-
fers assistance to all interested societies.
PEP
On January 21, 1921, the per capita tax for
the current year for 1,152 members had been
received at the secretary's office. On the same
date 1920, receipts from ''peppy" members num-
bered 941 ; in 1919, 502, and in 1918, 736.
The progress indicated by these figures is en-
couraging, but the total for 1921 falls far short
of the possible. The time is approaching when
we will send out our S. O. S. letters to members
on the verge of delinquency, and then will fol-
low the grand chorus of protests, ranging from
"Well, I wasn't notified in time" to "My check
has just been mailed."
Members not yet paid up for 1921 are urged
to remit to-day to the secretary of their county
society. In so doing you will spare the officers
that serve you a certain amount of unnecessary
work, your societies unnecessary expense, and
assure yourself of that profound sense of satis-
faction that accompanies the prompt discharge
of a just obligation.
SECURITY
Since December i, 1920, five members of the
State Society from scattered points outside of
Philadelphia County have made application for
defense against suits for alleged malpractice.
Had any of these members neglected to pay
his 1920 dues until after March 28, 1920, he
would not now be entitled to defense by the so-
ciety, if his alleged malpractice had occurred
between January i, 1920, and the date of his de-
linquent payment. Moral — avoid moth holes in
your (possible) alleged malpractice suit. Pay
your 192 1 dues when due, i. e., January 1st.
Don't flirt with delinquency and disaster by
postponing payment until March 28th or later.
PAYMENT OF PER CAPITA ASSESSMENT
The following payment of per capita assessment has
been received since December 23d. Figures in first
column indicate county society numbers; second col-
umn, state society numbers:
7111
7112
$500
500
For 1920 —
Dec. 24 Allegheny 1135
Jan. 3 Fayette 122 71 12 5
5 Philadelphia 1966-2046 7113-7193 40500
8 Luzerne 237 7194 S-OO
-■ "-- "- '— --■ 7195 5-00
7196 5.00
14 Northampton 134
18 Luzerne 235
For 1921 —
Dec. 2z Huntingdon
1-12 303-314 60.00
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344
THE PENNSYLVANIA MEDICAL JOURNAL Fbbruary, 1921
Dec.
Jan.
:. 24
I Bradford
11-17
31S-321
as .00
Wayne
ID
322
S.oo
Mojitgomery
i3-i6
323-326
20.00
Allegheny
lo-ii, 143.
146-158, 160-185,
187-20R
327-390
320.00
31
Columbia
26
391
500
• 3
Blair
1-8
392-399
40.00
Venango
3
400
5.00
Wayne
II
401
5.00
Elk
6-8
402-404
15.00
Washington
22-27
405-410
30.00
All^heny 209-231,233-234 411-43S
125.00
4
Venango
4
436
5.00
6
. uniata
1-6
437-442
30.00
Vayne
12
443
5.00
Northumberland 4-10
444-450
35-00
Armstrong
2-16
451-465
75 00
7
Allegheny 235-248, 254-274,
250-252
466-503
190.00
8
Erie
1-16
504-519
80.00
Luzerne
1-39
520-558
195.00
10
Somerset
5-6
559-560
10.00
Mifflin
3-12
561-570
50.00
Crawford
1-14
571-584
70.00
11
Mercer
4-6
585-587
1500
12
Erie
17-26
588-597
50.00
Wayne
13-14
598-599
10.00
Mifflin
13-14
600-601
10.00
13
Mercer
7-9
602-604
15.00
14
Cumberland
1-13
605-617
65.00
Bradford
18-27
618-627
50.00
Susquehanna
1-14
628-641
70.00
IS
Juniata
7
642
5.00
Warren
I
643
500
Mercer
10-25
644-659 •
80.00
Luzerne
40-47
660-667
40.00
17
Lehigh
1-17
66&^584
85.00
Adams
4-13
685-694
50.00
Clinton
1-12
695-696
10.00
Northampton
4-32
697-725
145.00
Allegheny 275-
-334, 336-357
■ 726-807
410.00
18
Greene
1-18
808-825
90.00
Wyoming
1-4,6-9
826-833
40.00
Columbia
27-31
834-838
25.00
Elk
9-17
839-847
45.00
Luzerne
48-53
848-853
30.00
Cambria
4-24
854-874
105.00
Union
I-IO
875-884
50.00
Mifflin
15-16
88^-886
10.00
Venango
5-7
887-889
1500
Cumberland
14-16
890-892
15.00
20
Mercer
27-28
893-«94
10.00
Somerset
7-15
895-903
45.00
Franklin
1-13
904-916
65.00
Venango
8-30
917-939
115.00
Westmoreland
1-39
940-978
195.00
Lycoming
4-55
979-1030
260.00
Berks
1-48, 50-61
1031-1090
300.00
Wayne
15-16
1091-1092
10.00
Northumberland 11-27
1093-1109
85.00
Clarion
1-20
1110-1129
100.00
21
Montgomery
17-39
II30-II52
11500
22
Mercer
29-31
11S3-II5S
1500
CHANGES IN MEMBERSHIP OF COUNTY
SOCIETIES
The following changes have been reported to Jan-
uary 2ist:
Adams: New Members — James G. Stover, Benders-
\ille. Removal — Harry S. Crouse from York to Lit-
tlestown.
Allegheny : Xczv Members— Erie F. Smith, 510 Hay
St., Wilkinsburg; James C. Fleming, 654 Herron
Ave.; Rae P. McGee, Jenkins BIdg. ; Charles R.
Price, 1227 Wylie" Ave. ; Thomas B. McCollough, 816
Empire Bldg. ; James B. McConnaughy, 5460 Penn
Ave.; Pittsburgh; Ralph J. Raybeck, 914 W. North
Ave., N. S. Pittsburgh; J. Jay Schein, igo8 Carson
St., S. S. Pittsburgh; William S. Broadhurst, Tyre;
Harry O. Pollock, 207 Marguerite Ave., Wilmerding.
Reinstated Members — Charles L. Reed, 613 Jenkins
Bldg.; Benjamin R. Almquest, Jenkins Arcade Bldg.,
Pittsburgh; William H. Gardner, 714 Cedar Ave., N.
S., Pittsburgh; H. Milton Smith, 1346 Walnut ^St,
McKeesport. Removal — Joseph A. McCready from
Pittsburgh to Greenwich, O.; Carl L. Lutz from At-
lantic City to Rice's Landing (Greene Co.). Death—
Harry B. Patterson (Univ. of Penna. '01) Jan. 2, aged
42.
Armstrong: New Member— Thonaa L. Aye, Tar-
entum.
Blair: Removal — ^Fred. H. Bloomhardt from Al-
toona to Camp Benning, Ga.; Chas. L. Schultz fro«
JuniaU to 3613 Woodland Ave., Philadelphia.
Bucks: Removal— yiaXtn H. Brown from Wash-
ington, D. C, to c|o Rockefeller Foundation, Paris,
France.
Crawford: New J/cmfr^r— Clarence E. Spicer,
Titusville.
Cumberland: New Member— HatoXA F. Lausche,
New Cumberland.
Delaware: Death — H. Furness Taylor (Univ. of
Penna. '03) of Ridley Park. Dec. 26, aged 40. Trans-
fer—OriiCt Taukersley of Philadelphia to Philadelphia
County Society.
Erie: New Members— .Kr^ar C. Wheeler, 538 W.
7th St.; Robert L. Gibbons, 420 E. nth St.; John W.
Schmelter, 213 W. 8th St, Erie; Warren S. Gillespie,
Edinboro; George S. Durbin, Fairview; Harry H.
Olds, Wesleyville; C. W. Hotchkiss, Wesley ville; J.
A. Russell, 206 Masonic Bldg.; James A. Schurgot,
711 Commerce Bldg.; Herman C. Galster, 129 W.
2Sth St., Erie. Death— John W. Wright (Jeff. Med.
Coll. '90) of Erie, recently, aged 53.
Franklin: New Member—}. J. Palmer (Fulton
Co.). £)ea<A— William P. Noble (Jeif. Med. Coll.
'69) of Greencastle, Oct 28, aged 76.
Fayette: New Member— Xi. E. Lowe, Uniontown.
Greene : New Members— Vf. J. Rouse, Rice's Land-
ing ; Arthur T. Murray, Nineveh.
Indiana : Removal— John Henry Smith from Creek-
side to 410 E. Main St, Bradford (McKean Co.).
Juniata: New Member— John W. Deckard, Rich-
field.
Lawrence: Death— 'Robert G. Miles (Jeff. Med.
Coll. "95) of New Castle, recently, aged 59. Removal
— Lenore H. Gageby from New Castle to Venice, Cal.
Lehigh : New Members — Clarence C. Rodgers, 324
E. Hamilton St, Allentown; Albert N. Miller, E.
Texas.
Luzerne: New Members— Augustus C. Trapold,
Jr., 239 S. Washington St ; Joseph McNelis, City Hos-
pital, Wilkes-Barre ; J. C. Fleming, Dallas. Rein-
stated Members— P. E. Fagan, Hazleton ; Geo. M. Mc-
Conner, Savoy Bldg., Wilkes-Barre.
Lycoming: Removal— F. J. Norris of Somerset to
St Peter, Minn.
Mercer: Reinstated Member— John H. Martin,
Greenville.
Montgomery : New Member— John D. Perkins, Jr.,
Conshohocken.
McKean: Death— Osczr F. Kunkel (Jeff. Med.
Coll. '03) of Bells Comp, recently, aged 41.
Northampton: Reinstated Member— Reuben Raub,
Easton. New Member— Arthur B. Hamilton, Bethle-
hem.
Philadelphia : Reinstated Members— Albert C. Men-
ger, 1502 N. 29th St ; Richard A. Kern, 330 S. 16th St;
Edmund B. Sweeney, 1721 N. i6th St. ; W. B. McKin-
ney, 2100 Girard Ave. ; Hubley R. Owen, 319 S. 16th
St; Robert B. Grimes, 1147 S. Broad St.; J. Metz
Cunningham, 2018 E. Chelten Ave. ; Hyman Schenker,
946 N. Franklin St; James Williamson, 2030 Tioga
St; Thomas F. Mullen, Pocatello, Idaho; Matthew
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February, 1921
OFFICERS* DEPARTMENT
345
S. Watson, 537 Pine St. ; Robert P.. Register, 705 Pine
St. ; George L,., Megargee, i Madison Ave., New York
City; Arthur P. Keegan, 1411 S. 29th St; Jacob E.
Ellinger, 7th and Clearfield Sts.; William L. Weber,
52 N. 13th St. ; David N. Rosenfeld, 801 S. 58th St. ;
George P. Rishel, 2035 Diamond St.; J. Neeley
Rhoads, 1635 S. Broad St.; John M. Laferty, 3656
Frankford Ave. ; William B. Wilcox, 914 N. 44th St. ;
Preston M. Edwards, 3957 Warren St. ; Horace James
Williams, 3908 Greene St, Germantown; Stanley Q.
West, 138 West Walnut Lane, Germantown; Leo G.
Flannery, Southwest cor. Broad and York Sts. ; John
B., Ludy, 2042 Chestnut St; Charles Herbert Doe,
U. S. P. H. S., Tacoma, Washington; Joseph F.
Comerford, 2321 W. Lehigh Ave. ; William H. Crow-
ley, 2402 E. Allegheny Ave. ; Carlton N. Russell, 130
S. 18th St ; T. Maude Ramer, 2137 N. College Ave. ;
Cecilie H. Wollman, 5907 Christian St; L S. Ravdin,
1930 Spruce St ; A. B. Lichtenwalner, 2435 N. 7th St. ;
Joseph H. Schoenfeld, 2534 N. 6th St; John A.
Nevergole, 132 S. 23d St ; Aller G. Ellis, 1644 Surisak
Road, Bangkok, Siam ; Robert S. HeflFner, Philadelphia
General Hospital; Mortimer W. Blair, 269 Green
Lane, Roxboro; Walter J. Scner, 1539 Spruce St.;
Victor L. Baker, 1722 Foulkrod St., Frankford; Man-
ley F. Gates, United States Navy ; Norman M. Mac-
neill, 4401 Market St ; Russel C. Seipel, 6000 Jeffer-
son St; Frederick E. Keller, 2218 E. Huntingdon
St.; Francis J. Kownacki, 2372 Orthodox St, Frank-
ford; Edward W. McCloskey, 5720 Main St., Chest-
nut Hill; M. Valentine Miller, 6612 Germantown
Ave.; Charles S. Schafer, 1745 N. 17th St; John
Ricciardi, 1 104 Ellsworth St; Charles W. Dubin-
Alexandroff, 706 N. sth St; Ralph M. Tyson. 6709
N. Sth St; Harold T. Antrim, 1947 N. rsth St.;
Henry W. Banks, 2404 N. 29th St. ; Hyman M. Gins-
berg, 1013 S. 60th St ; Joseph Turner, 1625 Butler St. ;
James P. Inslee, 1309 Arch St ; James P. Hutchinson,
133 S. 22d St ; S. B. McDowell, 925 N. Broad St ;
William J. Harrison, 3452 Kensington Ave.; Ellis E.
W. Given, 2714 Columbia Ave. ; Joseph M. Spellissy,
317 S. 15th St; David A. Roth, 3029 Diamond St;
Arturo Padilla, 6159 Elmwood Ave.; D. A. Modell,
121 7 Lindley Ave.; Howard A. McKnight, 241 S. 13th
St; H. H. Gushing, 431 S. 51st St.; Charles M. Ker-
win, 5211 N. 3d St; J. Jacob Schoening, 1908 N. Park
Ave. ; Charles P. Stubbs, 220 W. Coulter St, German-
town ; S. Elizabeth A. Schetky, Hotel Colonial, Phila-
delphia; Josephine Wheeler Hildrup, Hotel Colonial,
Philadelphia; Raymond F. Campbell, 1305 Allegheny
Ave. ; David J. Moylan, 3729 Spring Garden St ; John
A. Murphy, 313 Dickinson Ave., Swarthmore, Pa. ;
Alfred O. Marshall, 6to S. 22d St. ; Newell A. Chris-
tensen, 6717 Elmwood Ave. ; Roy L. Langdon, 539 E.
CheltenAve.; Morris Segal, 4759 N. nth St; Eugene
T. Hinson, 1333 S. 19th St. ; William F. Donnelly, 616
N. 53d St Z»M*fc— Walter J. Freeman (Columbia
Univ. '8s) of Philadelphia, Dec. 20, aged 61. Removal
— Helen J. Cowie from Philadelphia to Chicago, 111.;
Samuel Wolfe from Philadelphia to 718 Clift Bldg.,
Salt Lake City, Utah ; John M. Flude of Philadelphia
to 529 Hill St, Wilkinsburg (Allegheny Co.).
Potter: Removal — John G. Steele from Galeton to
112 i8th St, Philadelphia.
Union : Removal— Udith L. Matzke from Ithaca, N.
Y., to 311 Wayne Ave., Wayne.
Waynb: Reinstated Member — Edward B. Gavitte,
Lilly (Cambria Co.).
Warken: New Mctnfcfr— Hubert J. Phillips, Bear
Uke.
Westmoreland: New Member — W. Irvine Hamer,
Greensburg. Reinstated Member — R. J. Hunter,
Greensburg. Removal — R. H. Ferguson from Her-
minie to West Newton ; W. Craig Byers from Belle
Vernon to Webster.
FREDERICK L. VAN SICKLE. M.D.,
Executive Secretary
Harrisburg, Pa.
SENATE AND HOUSE COMMITTEES ON
PUBLIC HEALTH AND SANITATION OF
THE LEGISLATURE FOR 1921
In the January number of the Journ'al we
published the entire list of Senators and Repre-
sentatives believing that the members of the
medical societies should have at hand a ready
reference of the members who serve from their
counties.
The two committees which have been named
in the Senate and House of Representatives are
most important as associated with affairs med-
ical, in the State, inasmuch as practically all
bills in which the medical and allied professions
are interested, these committees receive for con-
sideration and report prior to action.
We hope that our members will take sufficient
interest to also preserve this number of the
Journal and we trust that our effort will create
sufficient interest among the members to have
them look at the list of these committees and
should there be a member from their county, the
first duty is to congratulate the member upon
his appointment to that committee and assure
him that the medical profession rely upon his
ability to properly care -for medical legislation,
both that which is opposed by the profession,
and that which is favored by the profession,
when such matters came before his committee.
Legislators are human ; like to be favored by
interviews and congratulated upon their suc-
cesses. To be placed upon the committee of
Senate or House, often designates the man as
being preferred. We need the help and encour-
agement of the members. Not only the mem-
bers of the Committee of Public Policy and
Legislation, but each individual member and
friend of a lawmaker could do much to make
the pathway for the Medical Legislative Con-
ference easy when asking favors during the ses-
sion of 1921.
The following are members of the Committee
of Public Health and Sanitation of the Senate
and House of Representatives :
SENATE PUBLIC HEALTH AND SANITATION COM-
MITTEE, I92I.
Messrs. Miller, S. J., Chairman; Snyder,
Daix, Jones, Whitten, Weaver, Leslie, Mur-
doch, Woodward, Gray, Barr, Einstein, Smith,
Boyd, Herron, McNichol, Sisson. Aron, Sones,
Baldwin, ex-officio.
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346
THE PENNSYLVANIA MEDICAL JOURNAL
February, 1921
HOUSE OF REPRESENTATIVES PUBLIC HEALTH AND
SANITATION COMMITTEE, I92I.
Messrs. Steedle, Chairman; Campbell, Jones,
W. W. ; McVicar, Sprowls, Mitchell, Ehrhardt,
Soffel, Wettach, Haines, Beckley, Miller, D. I.;
Sinclair, Blumberg, Bums, Smith, Howard;
Dunn, Elgin, Thomas, Baker, Gearhart, Shan-
non, McCann, Shaffer, Brenneman.
IN MEMORIAM RESOLUTIONS ON THE
DEATH OF E. C. BULLOCK, M.D.
Whereas, God, in His all-wise providence, has seen
fit to call from our midst our associate and fellow-
member, Dr. Edwin C. Bullock of Upland, be it
Resolved, That the Delaware County Medical So-
ciety has lost one of its most active members, who was
ever ready to respond to the call of the afHicted, who
was earnest and courageous in his work, and who, it
seems to us, was called away prematurely, having
reached the time of life when he would have been of
most service to his community. Be it further
Resolved, That the community has lost a substan-
tial and exemplary citizen, that the family has lost a
kind and loving husband and father, and that the
Delaware County Medical Society extends to them its
sincere sympathy for their bereavement. Be it also
Resolved, That these resolutions be spread on the
minutes of the Society, and that a copy be sent to the
family of Dr. Bullock, and to the Pennvlvania Medi-
cal JoURNAt..
Fred. H. Evans, M.D.,
C. I. StiteOER, M.D.
EDEMA DISEASE IN HAITI
The clinical manifestations of this disease described
by W. L. Mann, J. B. Helm and C. J. Brown, Wash-
ington, D. C. (Journal A. M. A., Nov. 20, 1920), simu-
late beriberi, but no paralysis of the extremities has
been noted, and the rate of the heart beat is slower
than in beriberi. It likewise resembles "prison," "war"
or "nutritional" edema but the Haitian dropsy is ap-
parently more rapid in development, the mortality rate
is greater, and a change in diet and environments has
not been observed to have any marked eflFect as a cura-
tive. The symptoms and the incidence of the condi-
tion correspond somewhat closely to "epidemic dropsy,"
and may be diiTerentiated from it by the absence of
fever. The authors' observations comprised approxi-
mately 3,000 cases, with a study of more than 200
necropsies.
PREFERRED BASE FOR ZINC OXID OINT-
MENT
By means of a questionnaire Torald Sollmann,
Cleveland {Journal A. M. A., Nov. 20, 1920), found
that the consensus among the leading dermatologists
is' distinctly in favor of petrolatum as the basis of zinc
oxid ointment as being equal to lard therapeutically,
and superior in consistency, keeping quality, and ab-
sence of irritation. It is therefore recommended that
this be made the basis of the official ointment. Lard
may have the advantages as a base for compound oint-
ments, in which case the entire ointment may be made
up extemporaneously.
CO-OPERATIVE BUREAU
Dear Doctor:
The Journal and the Cooperative Medical Adver-
tising Bureau of Chicago maintain a Service Depart-
ment to answer inquiries from you about pharmaceuti-
cals, surgical instruments and other manufactured
products, such as soaps, clothing, automobiles, etc.,
which you may need in your home, office, sanitarium
or hospital.
We invite and urge you to use this service.
It is absolutely FREE to you.
The Cooperative Bureau is equipped with catalogues
and price lists of manufacturers, and can supply you
information by return mail.
Perhaps you want a certain kind of instrument
which is not advertised in The Journal, and do not
know where to secure it; or do not know where to
obtain some automobile supplies you need. This
Service Bureau will give you the information.
Whenever possible, the goods will be advertised in
our pages; but if they are not, we urge you to ask
The Journal about them, or write direct to the Co-
operative Medical Advertising Bureau, 535 X. Dear-
born Street, Chicago, Illinois.
We want The Journal to serve YOU.
THE SPIRITUAL ADVANCEMENT OF THE
PHYSICIAN
It is eyident that general educational and cultural
advancement has occurred among physicians within
the last few decades. The frontier atmosphere and
the crude manners of pioneer days are largely giving
way to the finer type and character of a more civilized
state. This advancement may be traced definitely to
the broad fundamental education now being required
of medical students, which gives them the fine dis-
criminating sense of the cultured man and enables
them to measure and evaluate the factors that go to
make up human life. Of course, such extension of
medical education means also better professional
equipment. In urging cultural advancement it is not
meant that physicians should become artists, musicians
or poets, or even perhaps experts in the realm of
sciences indirectly related to medicine. Although the
physician need not have an intimate knowledge of all
those matters of higher education comprehended under
the term "humanities," he should nevertheless have
some acquaintance with these subjects. In every com-
munity to-day, one finds physicians who exhibit culti-
vated taste. While acknowledging first obedience to
the vocation of healing the sick, they find in the by-
paths of artistic activity not merely amusement and
recreation, but also opportunity for contributing to
community betterment. — Jour. A. M. A., Dec. 11, 1920.
Helping the Council. — There are many physicians
who, while figuratively patting the Council on Phar-
macy and Chemistry on the back, do nothing to aid its
efltorts. On the other hand, there are men in the pro-
fession who give the council active support. Such a
man wrote to a pharmaceutical concern that he was
receiving advertising concerning its products and sug-
gested that until these products had been accepted by
the council, it was a waste of postage to send this.
He explained that he depended entirely on the council
in such matters as these. — (Jour. A. M. A., Nov. 6,
ir20, p. 1275.)
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County Medical Societies
REPORTERS OF COUNTY SOCIETIES:
Adams — Henry Stewart, M.D., Gettysburg.
Allegheny — Paul Titus, M.D., Pittsburgh.
Armstrong — Jay B. F. Wyant, M.D., Kittanning.
Beaver — Fred B. Wilson, M.D.. Beaver.
Bedford — N. A. Timmins. M.D., Bedford.
Berks — Clara Shetter-Keiscr, M.D., Reading.
Blair — James S. Taylor, M.D., Altoona.
Bradford— C. L. Stevens, M.D.. Athens.
Bucks — Anthony F. Myers, M.D., Blooming Glen.
Butler- -L. Leo Doane. M.D., Butler.
Cambria — Frank G. Scharmann, M.D., Johnstown.
Carbon — Jacob A. Trexler, M.D., Lehighton.
Center — James L. Seibert, M.D., Bellefonte.
Chester — Henry Pleasants, Jr., M.D., West Chester.
Clarion — Sylvester J. Lackey. M.D., Clarion.
Clearfield — J. Hayes Woolridge, M.D., Clearfield.
Clinton— R. B. Watson. M.D.. Lock Haven.
Columbia — Luther B. Kline. M.D.. Catawissa.
Crawford — Cornelius C. Laffer, M.D.. Meadville.
Cumberland — Calvin R. Rickenbaugh, M.D., Carlisle.
Dauphin — Marion W. Emrich. M.D., Harrisburg.
Delaware — George B. Sickel, M.D., Chester.
Elk — Samuel G. Logan, M.D., Ridgway.
Erie — J. Burkett Howe, M.D.. Erie.
Fayette — George H. Hess, M.D.. Uniontown.
Franklin — John J. Coffman. M.D.. Scotland.
Greene — Thomas B. Hill. M.D.. Waynesburg.
Huntingdon — John M. Beck, M.D., Alexandria.
Indiana — Alexander H. Stewart, M.D., Indiana.
Jefferson — John H. Murray, M.D., Punxstitawney.
Juniata — Isaac G. Headings, M.D., McAlisterville.
Lackawanna — Harry W. Albertson, M.D., Scranton.
Lancaster — Walter D. Blankensbip, M.D., Lancaster,
Lawrence — William A. Womcr, M.D., New Castle.
Lebanon — Samuel P. Heilman, M.D., Lebanon.
Lehigh — Martin S. Kleckner, M.D., Allentown.
Luzerne — Peter P. Mayock, M.D., WilkesBarre.
Lycoming — Wesley F. Kunkle, M.D., Williamsport.
McKean — James Johnston. M.D., Bradford.
Mercer — M. Edith MacBride, M.D., Sharon.
Mifflin — Frederick A. Rupp, M.D., Lewistown.
Monroe — Charles S. Logan, M.D., Stroudsburg.
Montgomery — Benjamin F. Hubley. M.D., Norristown.
Montour — Cameron Shultz, M.D., Danville.
Northampton — -W. Gilbert Tillman, M.D., Easton.
Northumberland — Charles H. Swenk, M.D., Sunbury.
PERRY^Maurice I. Stein, M.D., New Bloomfield.
Philadelphia — Samuel McClary, 3d. M.D., Philadelphia.
Potter — Robert B. Knight, M.D., Coudersport.
Schuylkill — George O. O. Santee. M.D., Cressona.
Snyder — Percy E. Whiffen. M.D.. McCIure.
Somerset — H. Clay McKinley, M.D., Meyersdale.
Sullivan — Carl M. Bradford, M.D., Forksville.
Susquehanna — H. D. Washburn, M.D., Susquehanna.
Tioga— Lloyd G. Cole, M.D., Blossburg.
Union — William E. Metzgar, M.D.. Allenwood, R. D. 2.
Venango — John F. Davis. M.D., Oil City.
Warren— M. V. Ball, M.D,, Warren.
Washington — Homer P. Prowitt, M.D., Washington.
Wayne — Sarah Allen Bang, M.D.. South Canaan.
Westmoreland — Wilder J. Walker. M.D., Greensburg.
Wyoming — Herbert L. McKown, M.D., Tunkhannock.
York — Nathan C. Wallace, M.D., Dover.
February, 1921
COUNTY SOCIETY REPORTS
ADAMS— JANUARY
At the regular meeting of the Adams County So-
ciety, held January 14th, the following officers were
elected: President, Geo. H. Seaks, New Oxford; First
Vice-President, J. McC. Dickson, Gettysburg; Second
Vice-President, H. E. Gettier, Littlestown ; Secretary-
Treasurer, Henry Stewart, Gettysburg (17th year);
Censor, E. A. Miller, East Berlin.
The retiring president gave an interesting descrip-
tion of his personal experiences in England and France
during the war, with comparisons of the French, Eng-
lish and our own medical service.
Henry Stewart, Reporter.
ALLEGHENY— JANUARY
The annual dinner of the Allegheny County So-
ciety, held on January 11, was the occasion for the
presentation of a testimonial to Dr. William Sill
Foster, for over fifty-three years a member of this
society.
The three hundred and eighty-two members present
acclaimed the ascendency of the upright life in the
spontaneity and sincerity of their greeting to Dr.
Foster. The evening's entertainment throughout was
clothed with dignity that evinced thorough prepara-
tion by the committee and officers in charge. The
menu was composed of only the choicest food, and
excellent music was furnished by a high-class or-
chestra.
The motive and spirit of the occasion are perhaps
best expressed in the remarks of Dr. George W. Mc-
Neil in presenting, and of Dr. Foster in receiving the
mag^nificent silver cup given to the latter in the name
of the Allegheny County Medical Society. Dr. Foster
was most happy in stressing the value to him of asso-
ciations formed and possible only by attendance upon
the meetings of the county, state and national medical
societies. In his advice to beginning practitioners of
medicine, one might have thought he was inspired by
the inscription engraved on the silver testimonial, were
it not for the fact that the silver gift was a complete
surprise to its recipient. The events of the evening
will no doubt furnish inspiration in years to come for
"solidarity of the medical profession."
Dr. Foster became a member of the society on May
21, 1867. He was ever faithful in the work of organ-
ized medicine and served as president in 1890, and as
president of the Medical Society of the State of Penn-
sylvania in 1895. He was further honored with the
vice-presidency of the American Medical Association
in 1907. Dr. Foster's position in the eyes of Pitts-
burgh is one which does great honor to our society.
The editor has received the following interesting
letter from one of the participants in the dinner to
Dr. Foster. It is too good to keep.
"Enclose program for testimonial dinner (on the
occasion of annual meeting of the Allegheny County
Medical Society) to Dr. W. S. Foster. Three hundred
and eighty-two present. Dining hall packed. The
other 918 are sore and threaten to come next year.
The Secretary is already worrying where to dine next
year, and no room at present capacious enough.
"One fellow says, 'The only decent affair the society
ever conducted !' Another was heard bragging in the
lobby that he 'got a swell ten-dollar dinner for three
dollars.' We all acquired swelled stomachs and the
program committee 'swelled heads.' The society cynic
who lives at the hotel, did not emit even one of his
usual snarls — he evidently fared better than usual. So
dazed with agreeable amazement were the members of
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THE PENNSYLVANIA MEDICAL JOURNAL February, 1921
the program committee that each one failed to claim
'It was my idea.' We'll say that they did the job
well, and say it could not have been better done, nay,
not even in Philadelphia or Harrisburg, old Soc.
Redux."
ARMSTRONG— JANUARY
The Armstrong County Medical Society held its
regular meeting and annual election on January 4,
1921. This society has been noted for its promptness
in organization work in so far as a county of its size
can possibly be. It is one of the accredited 100 per
cent, societies of the State.
At this meeting the following officers were elected
for the ensuing year : President, Dr. George S. Mor-
row, Dayton; secretary-treasurer, Dr. Jay B. F. Wy-
ant, Kittanning; first vice-president, Dr. Edward Mc-
Clister, Kittanning; second vice-president, Dr. David
H. Riffer, Leechburg; district censor. Dr. Thomas N.
McKee, Kittanning; legislative committee, Drs.
Thomas N. McKee, Kittanning; Dr. Joseph D. Orr,
Leechburg ; Dr. Jesse E. Ambler, Ford City ; reporter.
Dr. Jay B. F. Wyant.
The society is to be congratulated upon its continu-
ance in office of Dr. Jay B. F. Wyant as secretary, as
his efficiency is shown, not only as secretary for this
society but also as chairman of the board of trustees
of the Medical Society of the State of Pennsylvania.
May Armstrong County continue to be efficient, and
a good example for the other counties of the State.
BLAIR— DECEMBER
The November meeting was our annual experience
meeting, and during the afternoon many interesting
cases were presented for both diagnosis and discus-
sion, and the thirty members present thoroughly en-
joyed this kind of a meeting.
Our December meeting was held the afternoon of
December 28, and a most excellent address was given
by Dr. J. D. Findley, of Altoona, who took as his topic
"Compound Fractures." The subject was thoroughly
gone over by the speaker of the day, and many of the
points brought out in his talk were further emphasized
by a rather free discussion. An enjoyable discussion
came up as regards Dakin's solution, and it is believed
that some good will come of this meeting.
Plans have been made for our January banquet, at
which our local legislative representatives will be the
guests and we are going to inform them of our stand
on the question of compulsory health insurance.
The Professor of Animal Husbandry of State Col-
lege presented to the society the question of supplying
the City of Altoona with certified milk from the State
College dairy herd. His proposition was most heart-
ily approved, and the plan for such a milk supply en-
dorsed.
The society elected in the past year seven members
and lost by transfer six members.
A baby was bom in the home of each of the follow-
ing three members: J. R. Morrow, R. O. Gettemy,
and R. S. Magee.
The marriages in our society in the past year are
four in number: Drs. W. H. Howell, E. H. Morrow,
H. B. Replogle and W. E. Preston.
Dr. Fred H. Bloomhardt, who was discharged from
the service June, 1919, with the rank of Lt. Col.,
successfully passed the examinations for entrance into
the regular army, and received the commission of Lt.
Col., M. C, and reported for duty December 15, at
Camp Benning, Ga., which assignment is a most en-
viable one to receive.
The City of Altoona has seen fit to extend its child
welfare work, and we now have in the city a center for
infant welfare work on each side of the city and they
are doing a great work, and the limit has not yet been
reached. There are also functioning in the city ven-
ereal clinics for both men and women, and their work
is necessarily enormous.
At the Altoona Hospital in the past year there have
been inaugurated pre- and post-natal clinics, and this
work is growing steadily, and the recorder feels cer-
tain that by this time next year the number of ob-
stetrical patients receiving this care will be quite large,
and the maternal and foetal mortality in our com-
munity will be lessened accordingly.
James S. Taylor, Reporter.
CLINTON— DECEMBER
The Clinton County Medical Society met at 4 : 30
P. M., December 21, in the parlor of the Fallon
House, with the following members present : Drs.
Campbell, Watson, Holloway, McD. Tibbins, J. E.
Tibbins, Dumm, McGhee, Green, Corson, Blackburn,
Kirk, WelHver, Painter, Shoemaker, Thomas and
Harshberger. Drs. Vale, Locke and Seibert from
Bellefonte, Centre County, and Dr. Chapelle, of Wil-
liamsport, were also present.
The following officers were nominated for 1921.
Nomination is equivalent to election : President, Dr.
E. C. Blackburn, Lock Haven; vice-president, Dr.
M. D. Campbell, Loganton; secretary and treasurer.
Dr. R. B. Watson, Lock Haven; recording secretary.
Dr. C. B. Kirk, Mill Hall ; member of the House of
Delegates of the Medical Society of the State of Penn-
sylvania, David W. Thomas; alternate, John B.
Critchfield, of Lock Haven; censors, Drs. McGhee,
McDowell Tibbins and Painter; Legislative commit-
tee, Drs. Critchfield and Watson.
Dr. Corson read a very interesting and instructive
paper on Diseases of the Gall Bladder, which was dis-
cussed generally.
At the close of the meeting we proceeded to the
dining-room of the Fallon House and partook of a
very fine turkey dinner on the invitation of Dr. David
Thomas, the retiring president.
We all missed Dr. John B. Critchfield, as he has
just returned from the Lock Haven Hospital, where
he had been operated on for a large rectal abcess and
was not able to be with us.
R. B. Watson, Reporter.
CUMBERLAND— JANUARY
The annual meeting of the Cumberland County
Medical Society was held in the Carlisle Hospital,
January nth, with a large number of members present.
A most interesting and instructive paper was read
on "Cardio-Vascular Disturbances Occurring in In-
fectious Diseases," by Dr. G. H. Wells, of Philadel-
phia.
The following officers were elected for the year
1921 : President, Dr. N. W. Hershner, Mechanicsburg ;
First Vice-President, Dr. S. I. Cadawallader, West
Fairview; Second Vice-President, Dr. G. L. Zimmer-
man, Carlisle; Recording Secretary, C. R. Ricken-
baugh, Carlisle; Corresponding Secretary, Dr. H. A.
Spangler, Carlisle; Treasurer, Dr. A. & Peffer, Car.
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COUNTY MEDICAL SOCIETIES
349
lisle; Censors, Dr. P. R. Koons, Mechanicsburg; Dr.
H. C. Lawton, Camp Hill; Dr. D. W. Van Camp,
Plainfield.
Dr. H. F. Landsler, of New Cumberland, was elected
to 'membership in this society.
C. R. RiCKBNBAUCH, Reporter.
DAUPHIN— JANUARY
At the January meeting of the Dauphin County
Medical Society, held in the Academy of Medicine,
Dr. Clarence R. Phillips, former chief of the Harris-
burg State Tuberculosis Dispensary and County Med-
ical Director, was elected president of the Society.
Other members elected to office were : first vice-presi-
dent. Dr. E. M. Green ; second vice-president. Dr. C.
W. Batdorf ; secretary and treasia-er. Dr. A. J. Griest,
of Steelton, Pa.; trustee, Dr. H. C. Myers, the retir-
ing president; censor. Dr. J. W. MacMullen, chief
of the Harrisburg State Tuberculosis Ginic; district
censor. Dr. Hiram McGowan ; reporter. Dr. Frank F.
D. Reckord; delegates, Dr. E. R. Whipple and Dr. J.
W. Ellenberger ; alternates, Drs. H. F. Gross, Jesse L.
Lenker, J. R. Plank, H. B. Walter.
The society decided to keep the annual dues at $8.00
per year.
The retiring president. Dr. H. C. Myers, of Steelton,
Pa., read a paper, entitled "The Medical Society with
Reference to Some Points of Ethics." In abstract he
said:
Since the time of /Ssculapius and early dawn of
medicine, men engaged in practicing the healing art
have been associated one with the other. Coopera-
tion and exchanging of views with the purpose to live
and learn, found its beginning with the inception of
treating disease ; in fact the early accounts and photo-
graphs as well as the modern records of cases rarely
if ever found a physician alone. With these facts in
mind it is readily seen where the basis of our medical
associations have originated. With the centuries
through which the science of medicine has passed, we
find the fundamental principles remaining and to-day,
aside from a few petty jealousies, there exists among
the members of our profession a most generous feel-
ing of fellowship and good will, every one striving to
do his best and willing to see the other fellow do the
same.
The Medical Society is sometimes compared to the
latter day trade unions, and to the tminformed, are
somewhat similar, but there is not an organization of
either profession or trade to-day that has for its sole
purpose the betterment of its constituency and enlight-
enment of its members, as the medical society. There
are no secret meetings, no closed doors, and in the
twenty years that I have been a member of this so-
ciety, there have been but two occasions in which the
members were materially benefited and those took a
world war to bring about. We are united to learn
and thereby earn.' The medical society denounces any
acts of oppression and only recognizes such demands
as are commensurate. Its sole purpose is to set forth
a higher standard of efficiency so that we may meet
the demands that confront us from time to time, keep-
ing abreast with the rapid advances in every phase of
life and it takes a steed of mighty speed to do it A
noted divine from Delaware once said "that the great-
est progress and advance in the last fifty years has been
in electricity, surgery and photography." The healing
art takes in all of tiiese and more. The doctor who
does not read, listen and learn soon becomes a medical
degenerate. The medical associations are the open
doors for all who care to avail themselves of these op-
portunities. Many of our most learned men are mem-
bers of not only one association but many, thereby en-
deavoring to grasp every opportunity to obtain a
broader vision of medical science and to promote its
cause. It is sometimes even good politics to belong to
the medical society.
The medical profession has a part in the readjust-
ment of conditions following the recent war and if
ever there was a time for concerted action in our pro-
fession, it is now. The only logical procedure is
through our various societies. You are all familiar
with the various attacks and schemes propagated dur-
ing the last few years in the form of unjust and op-
pressive legislation, and while we can smile on the
past let us not lose sight of the possibilities of the
future and be ever ready to meet any uprising that
may appear, for it is not a fact that the encroachments
upon us have cemented the ties that bind us closer
together.
I am convinced that the medical society makes for
better practice of medicine and surgery, whether it is
with fear and trembling for conscience' sake. We are
not going to hold membership with our fellow man
and wilfully practice non-ethical medicine; to do so
would subject ourselves to rightful criticism and re-
veal the hidden things of darkness.
Frank F. D. Reckord, Reporter.
ELK— DECEMBER AND JANUARY
The regular meeting was held on the 9th, Dr. Wil-
son presiding. The committee on the annual meeting
for January reported progress and announced that
the speakers for that meeting would likely be Dr.
Colcord, of Clairton, possibly one of the younger
operating surgeons from Philadelphia, and Dr. Guthrie
from Sayre. It was decided not to have anything in
the nature of a public meeting where the problems of
child welfare, venereal disease, etc., might be taken
up. Other matters of routine were disposed of and
Dr. Maurfce T. Leary, Ridgeway, read a paper written
by a friend of his on "Feeding of Infants."
The meeting was well attended and most interesting.
The annual meeting of the Elk County Society was
held January 13th. Dr. Guthrie, of Sayre, was present
and gave a very interesting and illuminating talk on
Compulsory Health Insurance. We were especially
pleased to have with us Hon. J. M. Flynn, member of
the House from this district and member of the Com-
mission having this matter in charge. Dr. S. M. Free,
of Dubois, also expressed himself in no uncertain
terms. Unfortunately the time was too short for pro-
longed discussion, but the Secretary was instructed
to send at the rate of two dollars per member to the
Legislative Conference, and more later, if needed.
Dr. Colcord, of Clairton, then gave a mighty inter-
esting talk on First Aid and Industrial Surgery. Dr.
Colcord is a very enthusiastic and convincing speaker,
but was also limited for time. Among other things, he
stressed the absolute importance of being ready for
emergency work, having your office so arranged that
work could be done without extra steps, having uten-
sils, instruments and dressings sterile and convenient.
Dr. Colcord's talk was full of good things and was
greatly appreciated.
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Dr. J. Stewart Rodman next read a paper on Gastric
and Duodenal Ulcer. Dr. Logan, opening the discus-
sion on the paper, said that he presumed the other
members of the committee arranging for this meeting,
thought that he could at least discuss ulcer sympa-
thetically, if not scientifically, as it was just g years
ago this date, that he had a perforated duodenal ulcer,
from which his colleagues, with very good judgment,
allowed him to recoved without meddlesome interfer-
ence. In regard to the diag^nosis of ulcer, he said that
it was not always the simple matter that Dr. Rodman
implied, that while a careful history was the most im-
portant means, yet much depended upon how the his-
tory was taken, it being very important not to make
any suggestions to the patient. As to the x-ray, he
said there were some ulcers that the x-ray missed,
and that the gastric analysis was more important from
the standpoint of after treatment than for diagnosis.
In taking the history of a patient with digestive dis-
turbance, begin with the lips and end with the anus,
not forgetting the teeth, thyroid, heart, kidneys, gall
bladder, appendix and tubo-ovarian region. Even
after investigating all these regions, there remain a
certain number of individuals who have ulcer for
which we cannot blame any one factor, unless it be
some upset in the vegetative nervous system. But in
a given case with ulcer, what are you going to do with
your patient? Every case without stenosis, or fre-
quent repeated bleeding, or frequent "spells" of not
being able to work, should have careful, intelligent,
persistent and consistent medical treatment for at
least six months. There have been entirely too much
zeal on the part of the operating room technicians, too
many operators and not enough surgeons, not enough
intelligent after care by the surgeon and not enough
care shown in the selecting of cases for operation, to
make surgery an unqualified success. Gastroenter-
ostomy will cure 70%, 15% will be improved, and 15%
unimproved. Finney Miculiz pyloroplasty will cure
60%, 20% will be improved, and 20% unimproved.
Th^se are not figures to be enthusiastic about, when
from 5 to 10% of people dying from all causes, have
ulcer (Brinton). As to life expectancy, quoting Bal-
four, 17% die in less than 4 years following gastric
ulcer and gastroenterostomy, 5% die in less than 4
years following gastroenterstomy for duodenal ulcer,
and 10% die in less than 4 years following operation
for gastrojejunal uker. As to the possibility of can-
cer, observers differ, running from 2 to 70%, duodenal
ulcer practically never becoming cancerous.
There will be fewer gastroenterosomies done in the
future than in the past, and those that are done will
be in properly selected cases, with careful follow-up
treatment and the results will be more encouraging.
Many members had to leave to make trains and fur-
ther discussion was impossible.
We were too busy to elect officers in January.
Samuel G. Locan, Reporter.
FRANKLIN— NOVEMBER AND DECEMBER
Our regular monthly meeting was held in Waynes-
boro, November i6, at the Leland Hotel, where we had
dinner at 6 130 P. M. About 8 P. M. the meeting was
called to order. We had several very interesting
papers, which were actively discussed. The members
turned out very well for the kind of weather we had,
it being a most disagreeable, rainy night. I am sure
all who were present had a good time and enjoyed the
scientific program.
The December meeting was held in Chambersburg,
December 21. Dr. J. E. Kerapter read a paper on
"Venereal Disease — Its Modern Aspect and Treatment
from a General Practitioner's Standpoint." The paper
was well written. As this is a subject everyone is in-
terested in more or less, the discussion was general.
We had a good attendance.
S. D. Shull, Acting Secretary.
HUNTINGDON— JANUARY
The Huntingdon County Medical Society met in the
Huntingdon Club Rooms, Huntingdon, Thursday,
January 13th, at 2 : 30 o'clock, with the President, Dr.
H. C. Wilson, in the chair, and the following members
present: Drs. Richards, Frontz, Evans, Schum, Har-
man, Brumbaugh, St. Clair, Sears, Simpson, Reiners,
Koshland, Hutchison, Herkness and Keichline. After
the business session. Dr. Frontz urged every member
to get ii\ touch with the legislators whom we person-
ally know and let them know how we stand on the
various bills which affect our profession and the public
health. Our county legislative committee is empowered
to act as they see fit with every measure of such
nature.
■ Drs. Sears and Herkness presented two very in-
structive cases. The first, a patient suffering from a
brain lesion, and the second, a patient who developed
a chancre a year and a half after having been cured
of syphilis. Both of these cases will be presented in
full at a later date. A general discussion on the diag-
nosis, treatment and prevention of syphihs brought out
many interesting observations. Patients suffering from
syphilis, who refuse treatment and are allowed to run
at large are a menace that we do not know how to deal
with and we ought to have power to isolate such per-
sons. Next month, Dr. C. R. Reiners will read a
paper on Diagnosis of Fetal Positions and Presenta-
tions, and Dr. H. C. Frontz will present a Case Report.
John M. Keichline, M.D., Reporter.
JEFFERSON— DECEMBER
Jefferson County Medicine Society met in Reynolds-
ville, December 9, 1920, with 19 members present.
Officers for 1921 were nominated as follows: Presi-
dent, S. M. Davenport, of DuBois; first vice-presi-
dent, I. R. Mohney, of Brookville; second vice-presi-
dent, A. J. Simpson, of Summerville; secretary and
treasurer, N. C. Mills, of Eleanor; reporter, J. P.
Benson, of Punxsutawney ; censor (for three years),
H. B. King, of Reynoldsville.
The scientific program was as follows.
Dr. J. P. Benson read a paper of Dr. F. C. Smathers
on X-ray Diagnosis, With Especial Reference to the
Teeth.
Dr. W. A. Hill read a paper on The Treatment of
Constipation.
Report of delegates to the state meeting.
The society adjourned to meet in Reynoldsville the
second Thursday of January, 1921.
J. H. Murray, Reporter.
LAWRENCE— DECEMBER
Lawrence County Medical Society held a banquet
on December 9 in New Castle. Dr. V. D. Lespinesse,
of Chicago, was the speaker. Dr. W. A. Womer was
the toastmaster, and toasts were responded to by Drs.
Pollock, Helling, Snyder, and Dlller, of Pittsburgh;
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February, 1921
COUNTY MEDICAL S0CIP:TIES
351
Hauser and Elder of Youngstown; Reed, O'Brien and
Kennedy, of Sharon, and Hope, of Mercer.
W. A. WoMER, Reporter.
LUZERNE— DECEMBER AND. JANUARY
At the regular meeting of the society held December
i6 the following officers were elected for the ensuing
year: President, Dr. L. Edwards; vice-president. Dr.
W. Davis ; general secretary, Dr. E. L. Meyers ; finan-
cial secretary. Dr. M. C. Rumbaugh; treasurer, Dr.
E. U. Buckman ; censors, Drs. Ashley, Ross, Sheridan ;
directors, Drs. L. Edwards, W. Davis, S. P. Mengel,
S. M. Wolfe, Robinhold; editor and librarian, Dr.
L. H. Taylor ; reporter, Dr. W. L. Lynn.
Dr. S. P. Mengel read a very interesting paper on
Traumatic Hernia, which, because of its medico-legal
import, brought out much discussion by various
members of the society. His conclusions were: i.
Real traumatic hernia can be produced only by a pene-
trating wound and that truma is the rarest of all the
causes of hernia. 2. That if injury were such an im-
portant factor as is generally supposed, the direct
inguinal variety should be more common than the in-
direct oblique. 3. Hernia is of gradual formation,
requiring months and even years to develop. 4. That
it is usually congenital, due to a partially closed or un-
closed processus vaginalis. 5. That the supposed sud-
den development of hernia is usually a mistake in ob-
servation, and if it does actually occur, the number of
cases is extremely small. 6. That compensation
boards and commissioner^ should interpret the hernia
according to medical facts and surgical truths, thus
eliminating the necessity of leaving claimants to prove
what really does not exist or occur.
The regular annual banquet date was set for Janu-
ary 19. Several interesting speakers are expected to
be present.
By subscription during the past year, the society has
paid off its mortgage which amounted to over fifteen
thousand ($15,000.00). Luzerne County Medical So-
ciety can be proud of its new and completely modern
building, which it now owns in entirely. The library
containing over 7,150 bound volumes, carefully in-
dexed, deserves much praise to the librarian. Dr.
Lewis H. Taylor, who painstakingly keeps it up to
date. The reading rooms and auditorium are very
comfortable and not to be surpassed.
At the regular meeting held January 5, 1921, the
paper read by Dr. H. W. Croop, of Kingston, Pa., was
on "Acidosis."
The subject, which is commanding more attention
daily, was thoroughly covered. He summarized as
follows :
(a) Acidosis is not a disease in itself but an inci-
dent of a disease, never primary, but secondary. It
is not really a condition of acidity, but a draw on the
alkali reserve, causing alkali starvation, or decreased
alkalinity.
(b) Symptoms may be entirely absent, hence the
necessity of laboratory diagnosis. Acetonuria alone
does not prove acidosis.
(c) The alkali tglerance test is probably the best
test of acidosis we have, and is even said to be pathog-
nomic of acidosis. ' At least, it is of great value in
widening the knowledge of acidosis.
(d) The treatment consists in the use of alkalies.
particularly sodium bicarbonate, which, however, is
only symptomatic.
(e) Arterial blood must be kept neutral or slightly
alkaline. This is done by the removal of surplus acid
radicals by the kidneys, and by the neutralization of
the. excess of acids by body bases, and by ammonia,
which, if not used, would be excreted as urea. When,
for any reason, the balance mechanism is disturbed or
destroyed, the alkali reserve is lost, alkali starvation
results, all nutritional functions are disordered, and
coma or even death may follow.
Dr. C. A. Miner led the discussion, demonstrating
Mariotts apparatus, its advantages and disadvantages.
For practical use, Sellard's test, consisting of meas-
uring the amount of sodium bicarbonate which the
body will retain, is useful. "It has been shown, that
when the bicarbonate of the blood as a result of the
administration of soda has risen approximately to the
highest normal levels, the urine becomes alkaline. In
the normal individual s to 10 grams of bicarbonate are
sufficient to produce an alkaline reaction in the urine
and that if more than 10 grams are retained, a condi-
tion of acidosis has existed, according to Henderson."
He also states that if sodium bicarbonate is admin-
istered at frequent intervals in quantities just suf-
ficient to make the urine as alkaline as the blood, acid-
osis can not exist. The reaction of the urine can be
followed closely enough with litmus paper, a so-called
amphoteric reaction indicating that sufficient alkali
has been provided, and if the reaction does not become
more alkaline than this, there seems to be no danger
of injuring the. kidneys.
Acidosis is probably a more common condition than
fever in many pathological states and should be looked
for. W. L. Lynn, Reporter.
McKEAN— JANUARY
The McKean County Medical Society held a meet-
ing at the Bradford Hospital January 4, 1921, when
Dr. Koenig, of Buffalo, gave a review oif the history
of x-ray work and described its usefulness. He
showed before the medical men a number of plates of
great interest and gave out many interesting facts that
had to do with the subject.
The society elected the following officers for the
year 1921: President, Dr. Ben F. White, Jr.; vice-
president. Dr. Burg Chadwick; secretary -treasurer,
Dr. Wade T. Paton; censors, Drs. Stewart, Joseph
and E. O'N. Kane.
Dr. Francis de Caria was elected to membership.
Suitable resolutions were adopted on the death of Dr.
O. F. Kunkel.
At the conclusion of the meeting the physicians ad-
journed to the nurses's dining-room, where a dainty
lunch was served by the hospital superintendent, Miss
P'lizabeth Callender, assisted by a corps of pupils.
James I. Johnson, Reporter.
MERCER— JANUARY
The Mercer County Medical Society met in the
Courthouse at Mercer, Pa., Thursday, January 13th,
at 1 : 30 p. m. The minutes of the last meeting were
read and the Secretary's and Treasurer's reports for
the year 1920 were read and approved.
The following officers were elected for the year
1921 : President, Dr. A. M. O'Brien, Sharon ; First
Vice-President, Dr. David E. Ferringer, Stoneboro; j
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THE PENNSYLVANIA MEDICAL JOURNAL
February, 1921
Second Vice-President, Dr. Clarence W. McElhaney,
Greenville; Secretary-Reporter, Dr. Edith MacBride,
Sharon ; Treasurer, Dr. Carl J. Mehler, Sharon ; Cen-
sor, Dr. Frank M. Bleakney, Grove City.
Dr. C. L. Palmer, of Pittsburgh, was on the pro-
gram for a paper, but owing to illness in his family,
could not be present. Drs. Joseph Reed, R. M. Hope,
C. W. McElhaney, P. P. Fisher, Pres. Frank M. Bleak-
ney, and E. M. McConnell presented a discussion on
quarantine laws and their enforcement
The President appointed a committee of five to col-
lect data for a history of the Mercer County Medical
Society. Resolutions pertaining to medical legislation
were read. These resolutions had been drafted by the
society and copies sent to our senator and legislators.
Society adjourned to meet second Thursday in
March, at Buhl Hospital, Sharon, Pa.
Edith MacBride, M.D., Reporter.
NORTHAMPTON— DECEMBER AND
JANUARY
The Physicians' Protective Association of Easton,
Phillipsburg and vicinity held its annual meeting
Wednesday, January 5, 1921, at the Hotel Easton with
nearly the entire profession of the city in attendance.
The P. U. Co. recently changed the physicians' light-
ing schedule from a residential to a commercial rating,
which brought forth the appointment of a committee
at the last meeting to confer with the P. U. Co. and
ascertain why the change. The committee reported
having met the company but to no avail, so by unani-
mous consent the committee was continued and in-
structed to get together all the necessary data and take
the matter up with the Public Service Commission.
The question of compulsory health insurance was
fully discussed, every member present pledging him-
self to use all efforts against this pernicious bit of
legislation.
A committee of five physicians from Allentown
were present, pledging their support and cooperation
of any measure for the benefit of the profession.
Dr. Joseph Stotz, of 303 Cattell Street, was elected
to membership.
The following officers were elected for the year
1921 : President, Dr. Paul Correll; first vice-presi-
dent. Dr. W. P. O. Thomason; second vice-president.
Dr. H. C. Leigh ; secretary and treasurer, Dr. W. Gil-
bert Tillman.
The next meeting will be held on the first Wednes-
day of February.
The December meeting of the Medical Society of
Northampton County was held at the Easton Library
on Friday, December 17, 1920, with the largest attend-
ance of any meeting this year.
The Pennsylvania Utilities Company, which fur-
nishes the electric current in this section of North-
ampton County, recently changed the physician from
a residential rate to a commercial rate. This matter
was brought before the meeting and strenuous ob-
jections were raised, with the result that the County
Society endorsed the committee already appointed by
the Physicians' Protective Association of Easton to
carry on the fight against this change.
Dr. E. S. Everhart, associate director of the Ven-.
ereal Disease Dispensaries, was present and talked
about the work of his department, showing a film
demonstrating the methods used to control the spread
of venereal diseases.
A committee was appointed to establish a minimum
fee for the treatment of those venereal cases referred
to the profession by the State Dispensary and to make
a report at the next meeting.
Time being exhausted the meeting was compelled to
adjourn, and the members, without any coaxing, went
to Seip's Cafe, where dinner awaited them.
On the third Friday of January the annual meeting
will be held, at which the officers for the new year will
be elected. W. Gilbert Tillman, Reporter.
SUSQUE'HANNA— JANUARY
The annual meeting of he Susquehanna County
Medical Society was held at the home of Dr. E. R.
Gardner, of Montrose, on Tuesday, January 11, 1921.
After the business meeting a royal dinner was given
by Dr. Gardner. About fifty per cent, of the members
of the society were in attendance. Following the din-
ner the society adjourned to the Ideal Theatre, where
they were entertained by the moving pictures sent out
by the State G-U Clinic. These were both entertaining
and very instructive.
The officers for the ensuing year were reelected as
follows: President, A. J. Denman, of Susquehanna;
vice-president, W. E. Park, of New Milford ; secretary
and treasurer, E. R. Gardner, of Montrose; censor,
W. B. Lathrop, of Springville, and reporter, H. D.
Washburn, of Susquehanna.
Each member expressed with enthusiasm their de-
light at being entertained so royally by Dr. Gardner.
H. D. Washburn, Reporter.
WARREN— DECEMBER
Twenty-seven members of our society attended the
December meeting at the Elks' Club, Warren, on Mon-
day the aoth. This is a record attendance, although
all our meetings during the year have been well at-
tended.
The committee appointed to consider the establish-
ment of a venereal clinic made a favorable report, and
the members voted to arrange for such a clinic, if
possible, at the General Hospital. The same com-
mittee, to be known as the "Committee on Venereal
Disease," was retained in order to perfect details.
Dr. W. M. Baker, who has been a member of the
society longer than anyone else, read a very interesting
paper on the subject of "Syphilis," in which he urged
the necessity of the medical society, collectively, and
its members individually, acting as educators of the
public. They must get back of the board of health
and the health laws, so that the people will know the
reasons for obeying the legislation that is in force. No
law will succeed unless there is an enlightened public
opinion back of it. Several members took part in the
discussion, emphasizing the author's statements that
syphilis can be eradicated if the medical profession
will do its duty and assist the State Department of
Health in its campaign.
Dr. Elizabeth Beatty has just returned from a year's
travel in the Orient, where she visited mission hos-
pitals and made many interesting observations.
She gave an informal talk, telling of some of the
habits and customs of the Chinese, and showed a few
models of wood that she brought with her and which
illustrated her talk. Dr. Beatty said that the mission
hospitals were very much undermanned. The doctors
in charge had little leisure time, as the clinics and
wards are always overcrowded. At the conclusion of
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February, 1921
STATE NEWS ITEMS
353
her talk each member of the society was given a sou-
venir from the East
Resolutions regarding the death of Dr. George Sig-
gins were adopted, and Dr. Philips, of Bear Lake, was
admitted to membership.
A very excellent dinner was then served in the
dining-room of the Elks' Club, Dr. Clancey acting as
host M. V. Baix, Reporter.
WARREN— JANUARY
The annual meeting of our society was attended by
twenty-six of the forty-eight members of the organi-
zation, an unusual percentage. The meeting was held
at the Conewango Club, Warren, on January 17. The
president, on account of illness, was absent Election
of officers resulted as follows : President, Dr. Roy L.
Young, Warren; first vice-president, Dr. R. B. Mer-
vine, Sheffield; second vice-president. Dr. W. M.
Baker, Warren; secretary and treasurer, Dr. E. S.
Briggs, Warren. The regular committees were ap-
pointed. The dues of the society were increased to
eight dollars per annum. A banquet preceded the
business meeting.
The society has had a harmonious and successful
year. The meetings were well attended and the pro-
g^m, with few exceptions, was executed as planned.
There are but four regular physicians in the county
unaffiliated with the society and only two of these are
eligible. One of these two is not likely to remain
in practice, the other applied for membership but for
personal reasons he was requested' to withdraw his ap-
plication. Has any other society in the State such a
record? M. V. Bau, Reporter.
WAYNE— DECEMBER
The December meeting of the Wayne County Medi-
cal Society was called to order by the president. Dr.
Nielsen, at 2 P. M., December 16.
By invitation, Dr. Bishop, of Scranton, addressed
the society on the use of the bronchoscope, demon-
strated its use, showed a quantity of apparatus used in
conjunction with it and explained the technique of
this delicate work. The x-ray pictures, showing for-
eign bodies in the bronchi, were passed around and
carefully inspected by the members. Dr. Hotlister, of
Scranton, and Dr. Gibbons, of Honesdale, discussed
the paper at length.
Dr. Albertson, district councillor, explained to the
Society the work accomplished by the State Society
during 1920, the efforts made by the Legislative Con-
ference to combat bills inimical to the profession and
outlined the work expected to be done by it in 1921.
By motion, duly seconded, the treasurer was directed
to draw an order for $29.00 to Dr. George Knowles,
Philadelphia, as a per capita contribution to the Leg-
islative Conference.
The following officers were elected to serve during
next year: President, Dr. A. M. Cook; vice-presi-
dent. Dr. Wm. T. McConvill ; vice-president, Dr. Wm.
H. Tassell; censors, Drs. Ely, Burns and Powell;
district censor, Dr. Simons; committee on public
policy and legislation, Drs. F. W. Powell and E. M.
Bums ; secretary and reporter, vacant.
Edwarl O. Banc, Reporter.
WYOMING— DECEMBER
The Wyoming County Medical Society met at Hotel
Graham, Tunkhannock, December 27, 1920. The min-
utes of the previous meeting were read and approved.
Correspondence was read relative to medical legisla-
tion, the printing of the Pennsylvania Medicai, Jour-
'NAL in Harrisburg instead of Athens, and the Victor
Safety Film Corporation, followed by a discussion.
Mr. O. D. Stark, representative, was interviewed rela-
tive to medical legislation, and agreed to help us in
protection of same, he being guided by the desires of
Dr. F. L. Van Sickle, Executive Secretary of the State
Society.
The name of Frank L. Austin, Laceyville, was pro-
posed for membership, and referred to the censors.
The election of officers was held, followed by a short
address by the retiring president. The following offi-
cers were elected: President, V. C. Decker, Nichol-
son; vice-president, G. M. Harrison, Meshoppen;
secretary-treasurer, H. L. McKown, Tunkhannock;
censors, W. W. Lazarus, Tunkhannock, and W. B.
Beaumont, Laceyville'; committee on public policy
and legislation, George M. Kinner and George H.
Ranch; delegate, T. M. Baird, Tunkhannock; alter-
nate, W. W. Lazarus, Tunkhannock.
The members present were Drs. T. M. Baird, W.
W. Lazarus, George H. Ranch, George M. Kinner, A.
D. Tewksbury, H. L. McKown.
Moving picture films which were shown during the
week of November 15 (of an educational character
and loaned by the State Department of Health) were
a great success and seemed to be appreciated by the
people in this community. The exhibition of these
pictures was under the auspices of this society.
H. L. McKowN, Secretary.
STATE NEWS ITEMS
Otnt READERS will find this month a larger proportion
of "fresh" news items than for many months past
The reporters and secretaries have responded nobly to
our requests for the same. Thank you, reporters!
We hope you will keep up the good work.
DEATHS
John H. Koon, M.D., died at his home at Waynes-
boro, on September 27, 1920, as a result of apoplexy,
aged 66.
David A. PnaiPS, Linesville, Pa.; Western Re-
serve University, Cleveland, 1867; aged 80; died, De-
cember 3.
CoLLEY J. Miller, Haddenville, Pa. ; Western Penn-
sylvania Medical College; Pittsburgh, 1892; aged 50;
died, September 11, from diabetes.
Dr. Leonard Bradford, for fifty years a practicing
physician in Sylvania and vicinity, died in December
at his home there. He was a Civil War veteran and
was 87 years old.
William P. Noble, M.D., Jefferson Medical Col-
lege, 1869, died at his home in Greencastle, Pa., Thurs-
day, October 28, 1920, aged 78 years. Dr. Noble
served with the 151st Pennsylvania Infantry and was
wounded at the Battle of Gettysburg.
Dr. Walter Jackson Freeman, a widely known
laryngologist, died December 20, at his home in Phila-
delphia, after a long illness. He was 60 years old.
Dr. Freeman was professor emeritus of the Philadel-
phia Polyclinic Post-Graduate School. He was _ a
member of virtually all the prominent medical socie-
ties, a fellow of the College of Physicians and a mem-
ber of the board of governors of the American College
of Surgeons.
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THE PENNSYLVANIA MEDICAL JOURNAL February, 1921
Dr. George A. Rudy, aged 80, died January 15, at
his home in Summerdale. Dr. Rudy resided in Sum-
merdale for the last twelve years and at one time
practiced in Harrisburg. He is survived by his "wife,
Mrs. Erna Rudy, two sons and four daughters.
Oscar Franklin Kunkel, Bells Camp, Pa.; Jeffer-
son Medical College, 1903; aged 40; for ten years
medical director of Bon Air Sanatorium, Bells Camp;
a member of the National Association for the Preven-
tion of Tuberculosis; died, December 17, from tuber-
culosis.
Dr. J. T. Ambrose, a widely known physician of
Westmoreland County, died at his home on January
15th. Dr. Ambrose was born near Ligonier, Dec. 6,
1837. He was a Civil War veteran, serving from 1862
until near the close of hostilities. He was graduated
from Long Island Medical College in 1870 and located
at Stahlstown. He remained there until early in 1874,
when he removed to Ligonier, practicing here actively
and successfully for more than 44 years.
Dr. Ambrose is survived by the following sons and
daughters : Cora Ambrose, Luella Ambrose, Mrs. Boyd
Aiken, and Dr. Charles D. Ambrose, of Ligonier;
George Ambrose, of Youngstown, Ohio, and Frederick
Ambrose, of Grand Rapids, Michigan.
Mrs. M.\ry A. Dougherty, aged 71, a member of
one of the oldest and most widely respected families
of Pittston and Wilkes-Barre, and who has borne the
unique distinction of having been the mother of five
doctors, died December 23, at the family home in
Wilkes-Barre. General debility was the cause of
death. She had been ill for several weeks, but not
critically until a short time before her death. Five
doctors, each a professional man of exalted standing,
were given by this mother to the community. Dr.
Anthony and Dr. Edward Dougherty, both deceased,
were greatly beloved by the people of their community.
The surviving sons are Joseph, who is a physician of
Ashley, and a member of the Luzerne County Society,
and John A. and Frank E., both prominent dentists.
Dr. Horace Furness Taylor, coroner's physician,
founder of the Taylor Hospital at Ridley Park, promi-
nent surgeon and widely known throughout the county
and state, died Sunday morning, December 26, after
an illness of several weeks' duration. Stricken No-
vember 1 1 with an attack of pneumonia,' Dr. Taylor's
condition at the outset was considered critical. The
patient, however, rallied and indications were that he
would recover. A week before his death Dr. Taylor
suffered a relapse and from that time his condition
continued to grow worse. When it became evident
on Christmas Day that Dr. Taylor was sinking and
the end was not far distant members of the family
were summoned to the bedside and remained with him
until he passed away. Dr. Taylor, a native of Chester
County, was 39 years old. For the last ten years he
was coroner's physician for Delaware County. He
was a prominent Mason, a graduate of the University
of Pennsylvania and a member of many fraternal or-
ganizations.
BIRTHS
Born to Dr. and Mrs. Harry W. Croop, of Kingston,
a son.
Born to Dr. and and Mrs. L. W. Grossman, of New
Castle, a son.
A DAUGHTER WAS BORN to Dr. and Mrs. M. T. Leary,
Ridgeway, December 19, 1920.
A SON, Richard Demme Bauer, on Christmas Day,
to Dr. and Mrs. Edward L. Bauer, of Philadelphia, Pa.
MARRIAGES
The MARRIAGE of Miss Celia M. Burke and Dr. J.
Nelson Douglas, both of Scranton, took place in Phila-
delphia, December 21. Dr. and Mrs. Horace Ewing,
of Philadelphia, were the attendants.
Dr. and Mrs. Nathan Callender Mackey, of Wa-
verly, have announced the marriage of their daughter,
Anna Frances, to Walter Littell Matthews, Jr., of
Maplecroft, Clark's Green, on Tuesday evening, Janu-
ary 4, at 7 :30 o'clock, in the Waverly Baptist church.
A small reception followed at the residence of Dr.
and Mrs. Mackey.
ENGAGEMENTS
Dr. Joseph M. Corson and Mrs. Corson, of Chat-
ham Run, have announced the engagement of their
daughter. Miss Darthea May, to Bruce Smith, of
Hughesville.
Dr. AND Mrs. A. G. Bowman, of Lancaster, have
announced the engagement of their daughter. Miss
Helen Eugenie Bowman, to John Frederick Pyfer, of
the same city.
The engagement of Miss Margaret Atticks, of
Steelton, to Dr. John L. Good, of New Cumberland,
was announced at a card party given by Miss Henri-
etta Porr, at her home in Steelton. Miss Atticks is
a graduate nurse of the Methodist Hospital, of Phila-
delphia, and Dr. Good is connected with the Harris-
burg Hospital. The wedding will be an early fall
event.
The engagement op Miss Florence C. Finger, of
Steelton, Pa., and Dr. Dwight Hanna, Jr., of Phila-
delphia, was announced at a "500" party given in her
honor by Miss Azalea Wigfield, at her home in Steel-
ton. After cards, the engagement was announced by
"letting the cat out of the bag." Around the cat's
neck was attached small cardboard cats bearing the
names of the couple. Miss Finger is a graduate nurse
of the Methodist Episcopal Ho.'pital, of Philadelphia,
and is now engaged in private nursing in that city.
Dr. Hanna is at present practicing in Austin. The
wedding will be a spring event.
appointments
Dr. H. H. H.\rtman has been appointed head of the
child welfare clinic at Gettysburg.
Dr. W. C. Stewart has been appointed medical in-
spector of schools for Cross Creek Township, Wash-
inton County.
Dr. J. Q. Thomas, of Conshohocken, Montgomery
County, was named as a member of the trustees of the
Norristown State Hospital.
The first two- appointments of chiefs of child
health stations for some time were made to-day when
Dr. Robert K. Rewalt was named for Williamsport
and Dr. Charles F. Lynn for Monongahela City.
Dr. Thomas S. Blair, of Harrisburg, chief of the
Bureau of Drug Control of the State Health Depart-
ment, has been appointed a member of the Commit-
tee on Narcotic Drugs of the American Medical Asso-
ciation.
Dr. a. B. Hamilton, of Bethlehem, has been ap-
pointed by Col. .Edward Martin, State Commissioner
of Health, as assistant in the State Tuberculosis Clinic
at Bethlehem, and W. H. Shilling as health officer for
Porter and Ringgold Townships, Jefferson County.
Dr. David I. Miller, member of the House in
the Harrisburg district, has been named as the Eight-
eenth Congressional District member of the House
slate committee, which will apportion the patronage
of the lower branch of the Legislature. It has been
customary for years to have a Harrisburg member of
the committee.
Dr. Henry Wilson, of Somerset, has again been
selected as superintendent of the Somerset County
Home and Hospital, following the resignation of Dr.
A. M. Uphouse. Dr. Uphouse handed in his resigna-
tion several weeks ago, to take effect on the appoint-
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February, 1921
STATE NEWS ITEMS
355
ment of his successor. Dr. Wilson was elected to the
county poor board a few years ago and served in that
capacity until his recent appointment.
Dr. a. T. McCuntock, Dr. G. A. Clark, Dr. Charles
H. Miner, Dr. S. M. Wolfe and Dr. H. B. Gibby have
been appointed by Luzerne County Medical Society
members of a committee to investigate milk conditions
and to try to have Wilkes-Barre city and nearby bor-
oughs enforce new milk ordinances suggested by the
State Department of Health. This action has been
taken because of the high mortality prevailing among
infants up to one and one-half or two years of age in
Luzerne County and during the conference held by the
local physicians with E. W. Irwin, assistant engineer
of the State Department of Health in Wilkes-Barre,
the latter recommended that this city and borough
adopt a milk ordinance outlined by the State, which
provides for the supply of certified, grade A raw and
pasteurized milk.
Harsisburg, Pa., Jan. 6. — Dr. A. B. Hamilton, of
Bethlehem, has been appointed by Dr. Edward Martin,
State Commissioner of Health, as assistant in the
State Tuberculosis Clinic at Bethlehem, and W. H.
Shilling as health officer for Porter and Ringgold
Townships, Jefferson County. Registrars named in-
clude : A. O. Hefflefinger, Bernville Borough and
Upper Bern, Jefferson, Penn and Upper Tulpehocken
Townships, Berks County; Mrs. Sarah M. Ridenauer
for Bethelsville and Bally Boroughs, Washington dis-
trict and Hereford Township, Berks County ; William
C. Yeattes for Bendersville Borough, Tyrone and
Menallen Townships, Adams County; Chester Stauf-
fer for Dillsburg Borough and Carroll and Monaghan
Townships, York County; Mrs. Qara B. Hughes for
Blossburg Borough, Ward, Hamilton and BIoss Town-
ships, Tioga County; Samuel E. Renner for Littles-
town Borough, Germany, Union and Mount Joy Town-
ships, Adams County.
ITEMS
Dr. T. W. Canon has located in New Castle.
Dr. Lenore H. Gageby, of New Castle, is spending
the winter in California.
Dr. W. S. Ramsey has located in New Castle, for
the practice of pediatrics.
Dr. Ellen E. Brown, Chester, is confined to her
home with a severe attack of lumbago.
Dr. J. M. Blackwood, of New Castle, is t^ing a
month off for recuperation and study.
Dr. H. S. CrousE, who had removed to York, has
relocated in Littlestown, Adams County.
Dr. Adolfh Koenig, of Pittsburgh, is reported as
seriously ill at the West Penn Hospital, Pittsburgh.
Dss. Shaw and McAllister, of Ridgeway, did an
emergency tracheotomy recently, with brilliant results.
Dr. B. E. San key, of New Castle, has returned to
his home from a course of post-graduate work in New
York.
Dr. Henry Stewart, of Gettysburg, has been elected
physician to the Adams County Almshouse and Insane
Asylum.
Dr. Alfred Gordon, of Philadelphia, has been elected
a member of the Neurological Society of Paris
(France).
Dr. and Mrs. E. C. McComb, of New Castle, are
spending the winter in Florida for the benefit of Mrs.
McComb's health.
Dr. C. P. Large, of Meyersdale, Pa., recently under-
went an operation for a serious stomach lesion in a
Cumberland, Md., hospital. Latest reports state that
he is doing well ; Dr. Large is the medical inspector
for Somerset County.
Dr. James E. Rutherford, of Ridgeway, is back on
the job after six weeks' rest, seeing how they do
things in the East.
Dr. H. W. McKeE, of New Castle, is convalescing
after an operation by Dr. Young in Johns Hopkins
Hospital, Baltimore.
Dr. T. M. Baird reports that he is about to leave
Tunkhannock to accept a position with the United
States Public Health Service.
Dr. S. G. Logan, Ridgeway, spent the holidays at
Clifton Springs Sanatorium, and is at present recov-
ering nicely from his recent operation.
Dr. Edward Stieren, of Pittsburgh, by invitation
addressed the Buffalo Ophthalmological Club at its
January meeting, on "Glaucoma Following Cataract
Extraction."
Dr. Ethan Allen Campbell, well-known surgeon
of Chester, has recently undergone a serious opera-
tion at the Joseph Price Private Hospital, Philadel-
phia. He is making a nice recovery.
Dr. and Mrs. W. A. Peck, of North Scranton, left
January 2 for New York, where Dr. Peck will spend
the month of January in post-graduate work in the
Post-Graduate Hospital and other hospitals of New
York.
Our good friend, the erstwhile Medical Council,
now the American Physician, is to be congratulated
upon its attractive new make-up, its excellent choice
of a new name, and its new policy in devoting itself
to the interests of the general practitioner.
Dr. Edward R. Sibley has sold, through E. A.
Havens Company, to Bernard S. Berlin, his residence
on the east side of Elkins Avenue, between Spring
Avenue and Old York Road, Elkins Park. The lot
is 150x200 feet. The property was held at $22,500.
Dr. Frank Sass, of Boswell, recovered from a case
of "buck fever" just in time to bring down a fine speci-
men during the late hunting season. Quite a few of
his friends were feasting on deer meat for a while,
that was not dear, and we are informed that the ant-
lers now adorn his office as notice to his patrons that
he can cure buck fever just in time.
Allegheny County Society is to be congratulated
^upon their growth during the past year. Their mem-
bership report for the year follows : Membership be-
ginning 1920 was, active, 1,122; associate, 54; hon-
orary, 13. There were 157 new members elected, 5
new members by transfer, making a total of 1,327.
There were 15 granted transfers to other societies, 3
resigned and 6 deceased. There are 1,303 members in
good standing at this time.
We wish to congratulate the Ladies' Auxiliary of
the Lehigh County Medical Society upon the work ac-
complished for the society. The wives are well or-
ganized and are gathering a nucleus — ten thousand
dollars — to secure a permanent home for the society
in Allentown. The women are working with a deter-
mination, for it will mean that the Lehigh County
Medical Society will be second to none. All are striv-
ing together ; their loyalty and good fellowship is 100
per cent, to the good and their purpose will be real-
ized.
The Mifflin County Medical Society held its an-
nal banquet at the Coleman House, Lewistown, on
Thursday night, January 6. The toastmaster was Dr.
F. A. Rupp and the speakers and their topics as fol-
lows : Dr. J. A. Frantz, of Huntingdon, "Medical
Ethics" ; Dr. J. W. Mitchell, Lewistown, "My Experi-
ences as a New Member of the State Assembly" ; Dr.
B. B. Kohler, Reedsville, "Investments of the Doctor" ;
Dr. R. T. Barnett, Lewistown, "The Doctor in the Lit-
erary World." The doctors' wives and ladies were
guests of honor.
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THE PENNSYLVANIA MEDICAL JOURNAL
February, 1921
At a recent meeting of the Ridgway physicians, at
which all were present, it was thought in order to in-
crease the usefulness of the Elk County General Hos-
pital, that a real live, honest-to-goodness staff be or-
ganized. Accordingly it was suggested to the trustees
that they appoint the following : Dr. Frank G. Earley,
Dean of Staff ; Andrew L. Benson, Secretary of Staff ;
Surgical, James G. Flynn; Walter C. Shaw; Medical,
Frank G. Earley, James E. Rutherford, Samuel G.
Logan, Maurice T. Leary ; Eye, Ear, Nose and Throat,
J. C. McAllister ; Roentgenologist, Andrew L. Benson ;
Obstetrician, M. M. Rankin; Genito Urinary, S. G.
Logan; Pathologist, M. T. Leary. So far the trustees
have taken no definite action, but their approval is ex-
pected.
The Wimodausis Club op Haskisbusg, composed
of the wives, mothers, daughters and sisters of the
Harrisburg physicians, is to be congratnlated upon jts
good work in renovating the Academy of Medicine
building and in waking up the doctors to the need of
proper care for their professional home. In addition
to this labor of love, the ladies meet every month to
enjoy good fellowship, frequently an entertaining
program, and usually also delicious refreshments. At
the meeting on December lo the following officers
were elected: President, Mrs. C. S. Rebuck; vice-
president, Mrs. J. H. Fager, Jr. ; secretary, Mrs. G. L.
Laverty; treasurer, Mrs. R. L. Perkins.
Judge C V. Henry, of Lebanon, in a decision
handed down recently in the Dauphin County court,
refused a mandamus against certain school directors
of Millcreek Township school district, Erie County,
requiring them to enforce vaccination laws on the
ground that the Act of 1895, as amended by the Act
of 1919, "has sweeping provisions for its enforcement,
entailing penalties and imprisonment," and therefore
has provided means for enforcement. The judge says :
"It is with great reluctance that we are compelled to
reach this conclusion, for the three directors are act-
ing in open defiance of the plain mandate of the Act
of Assembly, but if the penalty provided by the act is
insufficient or ineffective, the fault is in the act itself
or its enforcement and the remedy lies with the Legis-
lature."
In the January Number op the Pennsylvania
Medical Journal was an editorial, entitled "Pneu-
moperitoneum." Evidently this editorial has reached
the eyes of at least one of the prominent ' Philadelphia
practitioners, as we have received the following:
"Relative to the practice of inflation of the peritoneal
cavity with gas for the purpose of x-ray study, I
would report the occurrence of death within five
minutes after injection of a small amount of oxygen
in a patient with a chronic myocardial degeneration.
The pathology in this case apparently was due to ex-
cessive inhibition through the pneumogastric nerve.
I feel that this instance should be reported so as to
sound a word of caution in this valuable procedure."
We trust that this also may be noticed by other mem-
bers of the medical profession of the State.
Opening an Attack by the State Health Depart-
ment on "quack" doctors practicing in the city of
Harrisburg, two women and a man were held under
$300 bail each for court after a hearing before Alder-
man William L. Windsor, Jr. The arrests were made
by State police and the net closed around Mary M.
Hummel, 913 North Third Street ; Mrs. OIlie Martin,
1212 North Fifteenth Street, and H. G. Grandone, 1434
Market Street. They had been under observation for
some time, and Dr. Lewis A. Saltzman, ol the State
Health Department, Bureau of Licensure, conducted
an inspection of the methods of the three. It was de-
clared that not only had they been practicing without a
license, but had also been representing themselves to
be physicians of marvelous healing powers. In sev-
eral of the offices conducted by these people, waiting
lines of ten to fourteen people thronged the waiting
room, patiently taking their turn to be "examined and
treated." According to authorities of the State Health
Department, these arrests are not to be the only ones
in the city.
On January 20Th a testimonial dinner at the Belle-
vue-Stratford, Philadelphia, was tendered to Dr. W.
W. Keen, in celebration of his 84th birthday. A life-
sized bronze bust of the doctor, modeled by a noted
sculptor, was presented on behalf of those participat-
ing. Dr. George E. de Schweinitz presided and acted
as toastmaster, and the list of speakers included Dr.
Faunce, president of Brown University; Dr. J. Chal-
mers DaCosta, the Hon. David Jayne Hill, Dr. Wm.
H. Welch, of John Hopkins Unviersity, and Dr. Keen.
A reception followed the dinner, in the Clover room
of the hotel. The list of guests included the names of
many men of eminence throughout the country, repre-
senting all walks of professional life, as well as states-
men and leaders of industry. It is generally con-
ceded that Dr. Keen to-day stands in the front ranks
of Philadelphia's foremost citizens, as is evidenced
by the national and international honors bestowed
upon him by reason of his magnificent achievements.
His contributions to the science, art and literature of
medicine; his establishment, by his work, of the es-
teem for America in foreign countries ; his record in
the Civil and the following wars; his position as
dean of American surgery, make a record unexcelled
by that of any other living American physician. Many
letters of tribute were received by the committee of
arrangements, which were incorporated into a bound
volume, and presented to Dr. Keen at the dinner.
DiTRiNG the World War the Rockefeller Founda-
tion helped the French with their tuberculosis work
and proved to them the need for public health work
along the lines of prevention and control of disease.
After the war, France established a Government
Health Department with a minister of health in the
cabinet. This minister will have charge of securing
health legislation and the administration of these laws
in the whole country. The French Government sent
an official to Washington, D. C, to find some one to
help them with their health work and the International
Health Board thought that Dr. Walter H. Brown, a
member of the Bucks County Society, had the all-
around training to help them. He has accepted the
position and he and his family sailed for France on
the 8th of January. They will spend six months in
Paris studying the language. Dr. Brown's particular
job will be to help the miriister formulate the laws
and then help them to build up a modern health ad-
ministration for the country of France. A smaller
city will be chosen as a demonstration center where
the French will be taught by Dr. Brown to develop
such a public health system as he established in
Bridgeport, Conn., which has given him a reputation
among health workers. All the work Dr. Brown has
done since he left Richlandtown has made him an
all-around experienced worker along this line. His
post-graduate course at Harvard, then state work in
Massachusetts, municipal work at Bridgeport, and
national work at Washington, D. C, lead up naturally
to this international work in Prance. Some of the
functions ot the Department of Health will be safe-
guarding the milk and water supply, prevention and
quarantine of contagious diseases, child welfare work,
etc. It simply means teaching people how to live so
they don't get sick. Dr. Brown will help the French
to help themselves. This work will probably require
a two-years' stay in France.
The plans and purposes of the expedition, now
being organized by Dr. H. H. Rusby and which he will
lead through certain regions of the upper Amazon
basin, have aroused quite widespread interest An-
nouncements of the expedition, which is known as
the Mulford Biological Exporation of the Amazon
Basin, have appeared in the American Journal of
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February, 1921
GENERAL NEWS ITEMS
357
Pharmacy, the Journal of the American Pharmaceu-
tical Association, the Pharmaceutical Bra, the Prac-
tical Druggist, and other periodicals.
Dr. Rusby is dean of the College of Pharmacy of
Columbia University and is also recognized as one
of the leading botanists of the day. On previous ex-
peditions he made extensive collections in Central
and South America and is the highest authority on
the flora of Bolivia. His plans for the work of the
coming exploration, which will be his fifth sojourn in
the tropics, have been carefully laid and well organ-
ized.
Three or more scientists will accompany Dr. Rusby
and will give all their time to their specialties. One
is an ichthyologist, who will devote practically his
entire time to the collection of fishes. An entomolo-
gist will study the hisect life of the tropical wilderness
and make a general collection of insects. He will also
investigate several methods calculated to repel or
destroy the insects which make these regions so unin-
viting and almost uninhabitable. Provision is a]so
made for the collection of reptiles and other zoological
material.
The botanical work of the expedition, to which Dr.
Rusby will devote all his attention will consist, first,
of general collections in the regions traversed. These
will be studied by the experts of Harvard University,
The New York Botanical Garden, and the U. S. De-
partment of Agriculture, who are preparing a flora of
northern South America. These collections will
also enable Dr. Rusby to complete a large work on the
flora of Bolivia on which he has been engaged for
some years.
The second, and one of the principal objects of the
work will be the collection and investigation of vari-
ous medicinal plants, special attention being given to
new or little known drug plants.
The party will start in May, 1921, and actual field
work will begin soon after they leave Le Paz, Bo-
livia. They will explore the upper valley of the Beni
River and the Yacuma River. They will descend the
Mamor6 River to the Madeira and proceed to Manaos.
After replenishing supplies they will ascend the Negro
and Uaupes Rivers, making special studies along the
upper waters of the latter and some portions of the
eastern slopes of the Andes, across which they will
make their way to Bogota.
For the study of the materials which the party will
bring back elaborate preparation has been made. Dr.
Rusby has secured the cooperation and assistance of
many groups of specialists. Considering the number
of men in the party and the length of time in the field,
it is reasonable to anticipate that this expedition will
be among the most fruitful in scientific results.
One of the most gratifying aspects of the enterprise
is_the_ cooperation of business interests in a purely
scientific project such as this. The financial support
and active interest which the H. K. Mulford Company
has given is very significant of a more sympathetic
understanding on the part of industry of the aims and
ideals of science. It is a combination of forces which
augurs well for the future of both, and it is to the
interest of both to foster such cooperation and to fur-
ther cultivate mutual understanding and helpfulness
on a highly ethical basis.*
'From the Philaddphia Weekly Roster for January i, 1921.
GENERAL NEWS ITEMS
To THE Editor:
The New York Committee on After-Care of In-
fantile Paralysis Cases published and distributed the
report of "The Survey of Cripples in New York City."
Our aim has been to send this report to those in a po-
sition of responsibility in agencies for cripples and to
all those who might have a general interest in cripples,
and in plans for their aid. The undersigned would be
glad to know of anyone who has been overlooked and
would appreciate suggestions for further possiblr 'im
tribution of the report Robest Stuart, Director,i
N. Y. Committee on After-Care of Infantile
Paralysis Cases, 69 Schermerhom Street,
Brooklyn, N. Y.
VivisecTiON. — BuflFalo, N. Y., Dec. 3.— The efforts
of antivivisectionists to prevent experiments upon ani-
mals by qualified surgeons was denounced at the first
public meeting of the clinical congress of the American
College of Surgeons now in session here. Dr. John
B. Deaver, professor of surgery. University of Penn-
sylvania, said that vivisection as it is carried on to-day
is done as carefully as any human operation.
"Anyone who promotes legislation designed to hin-
der the battle against human disease deserves to die
a premature death," Dr. Deaver said.
The Fifth Annual Session of the American Con-
gress on Internal Medicine will be held at Baltimore,
Md., week of February 21-26, 1921.
The activities of the congress will be largely clinical.
Ward-walks, Laboratory Demonstrations and Group
or Amphitheatre Clinics will be conducted daily by
members of the medical faculties of the Johns Hop-
kins and the Maryland Universities.
Further information may be secured by addressing
the Secretary-General, 1002 N. Dearborn St., Chi-
cago, 111.
Dr. Henry S. Houghton has been appointed Direc-
tor oi the Peking Union Medical College. Dr. Hough-
ton, a graduate of the Ohio State University and of
the Johns Hopkins Medical School, has spent the
greater part of the past fifteen years in China, where
he has served as physician of the WuHu General^ Hos-
pital, as Dean and Professor of Tropical Medicine of
the Harvard Medical School of China in Shanghai,
and recently as a member of the staff of the China
Medical Board and Peking Union Medical College in
Peking.
Fewer Homicides During 1920. — In spite of the so-
called "crime wave" which in certain cities has as-
sumed so prominent a place in the public press during
recent weeks, the year 1920 will probably be the most
favorable one on record for homicide among insured
wage earners. In the Industrial Department of the
Metropolitan Life Insurance Company, the death rate
from this cause for the period January ist to Decem-
ber 18, 1920, reached the comparatively low level of
5.5 per 100,000. This is a decline of over 20 per cent,
from the rate for 1919, which was 6.9. These insur-
ance figures nearly always reflect conditions in the
total population of the United States and Canada and
we may, therefore, expect that one of the features in
the good general mortality record of 1920 will be a
low homicide rate.
Only one month, namely, September of this year,
shows a mortality record from this cause of death
(8.4 per 100,000) which was equal to or exceeded that
for the year 1919 (6.9 per 100,000). Since September,
the rate has progressively declined. The present
"crime wave," with murder as its chief element, has
apparently been confined to a- few localities and to a
very short period. It is not likely to affect seriously
the homicide figures for the whole country and for
the whole year.
Higher Maternal Mortality During 1920.— The
unfavorable trend of mortality from puerperal dis-
eases during 1920, to which attention directed in pre-
vious bulletins of the Metropolitan Life Insurance
Company has prompted the company to communicate
the facts for the year to the leading obstetricians of
the country and to health officers especially interested
in maternal welfare. It is hoped that through this
inquiry of specialists acquainted with actual field con-
ditions some facts may be gathered which will explain
the high death rate in childbirth this year.
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THE PENNSYLVANIA MEDICAL JOURNAL February, 1921
Not only has there been a high mortality from acci-
dents of pregnancy during the influenza period, Janu-
ary to March of this year, but for each of the first
three (quarters, from January to September, there was
a heavier death rate from puerperal sepsis and from
puerperal albuminuria and convulsions. The facts are
shown in tabular form in the Metropolitan Bulletins
for May, August, and November.
The summer death rates of ijeo are of especial in-
terest. For white persons this summer (July to Sep-
tember) for all puerperal diseases there was an in-
crease of s points per 100,000 over the corresponding
figures for 1919; the group of colored persons regis-
tered an increase of 1.4 points per 100,000. Puerperal
septicemia among white persons registered a death
rate three points per 100,000 in excess of the summer
rate of 1919. There was an increase also in puerperal
albuminuria and convulsions.
Any increase at all in puerperal mortality is disap-
pointing because of the increased emphasis which has
been placed in recent years upon better obstetrical
service, upon advice to and care of expecunt mothers
and upon the control of midwifery by public and pri-
vate agencies. The situation warrants close inquiry by
health officers, maternal welfare workers, heads of ob-
stetrical services in hospitals and executives of visit-
ing nursing associations into the field conditions which
have produced the higher 1920 mortality from two pre-
ventable conditions — sepsis and eclampsia in childbirth.
Workers in obstetrics and maternity nursing, and oth-
ers, are invited to send in their observations in order
that the facts may be consolidated and then given to
the whole group through these Bulletins or by other
publications.
Sex Education and Venereai, Disease.— Washing-
ton, D. C. — Does sex education begin too late to be of
real service in safeguarding young people against
venereal disease is the question raised in a recent re-
port issued by the U. S. Public Health Service. The
authors of the article. Dr. C. C. Pierce, assistant sur-
geon-general and Edgar Sydenstricker, statistician, are
careful to explain that the statistics available as to the
ages at which the disease is most often contracted are
as yet too scanty to do more than suggest the question
and cannot answer it.
These statistics, so far as they go, however, suggest
that children, especially those of the class which is
ordinarily considered most likely to be infected, leave
school long before the age at which sex education in
regard to the twin diseases is commonly given. The
earliest incidence as shown by these records appears
in men at the age of 15 and shoots swiftly upward at
16, reaching maximum at 19 and 23. After 23 it drops
as rapidly as it rose. Attention is called to the appar-
ent significance of the fact that the ages between 16
to 23 are those between the most usual ending of
school and the beginning of married life. For the
women the incidence of the diseases ranges about two
years earlier than in men.
The Public Health Service is now engaged in as-
sembling and tabulating a very much larger number
of cases that will probably give much more definite
results.
Washington, D. C— "There is absolutely no way
of definitely foretelling whether this winter will wit-
ness any recurrence of influenza in epidemic form,"
said Surgeon-General H. S. Gumming, of the U. S.
Public Health Service. "As a result, however, of
very careful analysis of the epidemiology of influenza,
especially as the result of intensive studies in homes
where influenza occurred in 1918 and 1919, it may be
stated that an attack of influenza appears to confer a
definite immunity to subsequent attacks, an immunity
lasting for several years. Inasmuch as the epidemic
of 1918 and 1919 affected so very large a proportion
of the population, there would seem to be reasonable
grounds for believing that even should 'flu' become
prevalent here and there, it would not assume the epi-
demic proportions of the past two years, nor would it
rage m such severe form.
"It is unfortunate that the public becomes so in-
tensely mterested in spectacular epidemic outbreaks of
disease and is so little moved by the daily occurrence
of many preventable deaths in all parts of the country.
Of the one and one-quarter million deaths occurring
in the United States annually, at least 100,00 could
easily be prevented by the application of available
medical knowledge. For example, one of the diseases
which becomes prevalent about this time of the year is
diphtheria. This disease is responsible for about 15,000
deaths in the United States annually. Practically every
one of these deaths could be prevented, for not only
have we an effective antitoxin for treating the disease
when It occurs, but what is still more important, we
are now able by means of a simple skin test to deter-
mine which children are susceptible to diphtheria, and,
this ascertained, we can effectively immunize them so
as to protect them against this disease.
"The 10,000 or more deaths from typhoid fever that
occur annually in the United States could also be
largely prevented if communities everywhere would
make certain that their water and milk supplies were
protected, and if simple precautions were taken in
homes where typhoid fever occurs. It is encouraging
to know that smallpox has been so well controlled that
at present the average deaths from it in the United
States number only 400 annually. Nevertheless, these
400 deaths are entirely unnecessary, for vaccination has
long shown itself an effective means of control."
In almost every community in the country the wast-
age in infant lives is still enormous, especially when
contrasted with that in New Zealand, for example,
where the death rate is only 50 per thousand births in
the first year of life as against 100 in the United
States.
Commenting on this, Surgeon-General Gumming
said: "The expense of life saving through the pre-
vention and control of disease by well-directed health
measures is very small indeed when contrasted with
the saving effected. I would strongly urge the people
of this country to recognize the fact that expenditure
in this direction constitutes the most profitable form of
investment. Effective measures of health conservation
constitutes a most urgent need of this reconstruction
period."
BOOKS RECEIVED
Books received are acknowledged in this column,
and such acknowledgment must be regarded as a suffi-
cient return for the courtesy of the sender. Selections
will be made for review in the interests of our read-
ers and as space permits.
Helping the Rich, A Play tn Four Acts, by James
Bay. 107 pages, paper cover. New York : Brentano's,
1920. Price, $1.50.
Transactions of the Mississippi State Medical
Association at the Fifty-Third Annual Session
Held at Jackson. May, 1920. Roll of Members. Con-
stitution and By-Laws.
Transactions of the New Hampshire Medical
Society at the One Hundred and Twenty-Ninth
Anniversary, Held at Concord, May 12-13, 1920.
Manchester, N. H.: printed by John B. Clarke Co.,
1920.
Regional Anesthesia (Victor Pauchet's Tech-
nique). By B. Sherwood Dunn. M.D.. Officer
d* Academic; Surgeon (Colonel) Service de Sante
Mihtaire de Paris: Physician to the Cochin Hospi-
tal. 224 figures in the text. Philadelphia: F. A.
Davis Company, Publishers. English Depot, Stan-
ley Phillips, London, 1920. Price $3.50 net.
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February, 1921
BOOK REVIEW
359
The Major Symptoms of Hysteria, Fifteen Lec-
tures Gi\XN IN THE Medical School of Harvard
University. By Pierre Janet, Ph.D., M.D. Member
of the Institute of France. Professor of Psychology
in the College de France. Second edition, with new
matter. \ew York: The Macmillan Company, 1920.
All rights reserved.
The Basis of Psychiatry (Psychobiolocical
Medicine), A Guide to the Study of Mental Dis-
orders for Students and Practitioners. By Albert
C. Buckley, M.D., Medical Superintendent of Friends
Hospital, Frankford; Associate Professor of Psy-
chiatry, Graduate School of Medicine, University of
Pennsylvania; Alienist to the Philadelphia Ortho-
paedic Hospital and Infirmary for Nervous Diseases.
79 illustrations. Philadelphia and London : J. B.
Lippincott Company, 1920.
Principles and Practice of Infant Feeding. By
Julius H. Hess, M.D., Professor and Head of the De-
partment of Pediatrics, University of Illinois, College
of Medicine; Chief of Pediatrics Staff, County Hos-
pital ; Attending Pediatrician to Cook County, Michael
Reese and Englewood Hospitals; Consulting Pedia-
trician, Municipal Contagious Hospital, Chicago. Il-
lustrated, second revised edition. Philadelphia: F. A.
Davis Company, Publishers. London, English Depot,
Stanley Phillips, 1920. Price $2.50 net.
The Radiography of the Chest, Vol. I, Pulmon-
ary Tuberculosis, with nine line diagrams and ninety-
nine radiograms. By Walker Overend, M.A., M.D.,
(Oxon.), B.Sc. (Lond.). Hon. Radiologist and Phy-
sician to the Electrotherapeutic Department, East
Sussex Hospital (Hastings) ; Radiologist to the City
of London Hospital for Diseases of the Chest (dur-
ing the War) ; late Chief Assistant in the X-Ray De-
partment, St. Bartholomew's Hospital; Physician to
the Prince of Wales' Hospital, London, and Radcliffe
Travelling Fellow. St. Louis: C. V. Mosby Com-
pany, 1920. Price $5.
The Practical Medicine Series, comprising eight
volumes on the year's progress in medicine and sur-
gery, under the general editorial charge of Charles L.
Mix, A.M., M.D., Professor of Physical Diagnosis in
the Northwestern University Medical School. Vol-
ume II, General Surgery, edited by Albert J. Ochsner,
M.D., F.R.M.S., LL.D., F.A.C.S., Major, M. R. C, U.
S. Army, Surgeon-in-Chief Augustana and St. Mary's
of Nazareth Hospitals; Professor of Surgery in the
Medical Department of the State University of Illi-
nois Series 1920. 620 pages in Volume II, illustrated.
Chicago : The Year Book Publishers, 304 S. Dearborn
St. Price of this volume, $2.50. Price of the series
of eight volumes, $12.00.
The Practical Medicine Series, Volume III, The
Eye, Ear, Nose and Throat, edited by Casey A. Wood,
CM., M.D., D.C.L.; Albert H. Andrews, M.D.;
George E. Shambaugh, M.D. 382 pages in volume III,
illustrated. Price of volume, $1.75.
The Practical Medicine Series, Volume IV, Pedi-
atrics, edited by Isaac A. Abt, M.D., Professor of
Pediatrics, Northwestern University Medical School,
Attending Physician Michael Reese Hospital, with the
collaboration of A. Levinson, M.D., Associate Pedi-
atrician Michael Reese Hospital. Orthopedic Surgery,
edited by Edwin W. Ryerson, M.D., Associate Pro-
fessor of Surgery (Orthopedic), Rush Medical Col-
lege; Professor of Orthopedic Surgery, Chicago
Polyclinic, etc., with the collaboration of Robert O.
Ritter, M.D., Associate Attending Orthopedic Sur-
geon, Children's Memorial Hospital. Price of Vol-
ume IV, $1.75.
BOOK REVIEW
PSYCHOPATHOLOGY. By Edward J. Kempf,
M.D., Clinical Psychiatrist to St. Elizabeth Hospital
(formerly Government Hospital for the Insane),
Washington, D. C. ; author of "The Autonomic
Functions and the Personality." Eighty-seven il-
lustrations. St. Louis: C. V. Mosby Company,
1920. Price $9.50.
PSYCHOPATHOLOGY by Kempf is now in the
hands of the reviewers. This volume presents an ex-
haustive study of psychopathology from the viewpoint
of the psychoanalysis!. Beginning with the autonomic
affective apparatus as the foundation of the person-
ality and completing with anlayses of phychoses both
organic and functional, the author builds up an elabo-
rate framework of psychopathological processes based
on the disorders of the autonomic affective apparatus,
the sex. segment being particularly at fault. He sup-
ports his theories by the analysis of the many cases
studied, regardless of the psychoses, and seems confi-
dent that the completeness of the studies rules out
such probable factors as metabolic disorders, consti-
tutional or hereditary inferiorities. The text makes no
reference to the pathology of mental diseases well un-
derstood and therefore is only useful to those who are
interested in psychoanalysis or those who are desirous
of familiarizing themselves with the theories of the
Freudian School.
J. Allen Jackson,
H. V. Pike.
REFRACTION AND MOTILITY OF THE EYE,
WITH CHAPTERS ON COLOR BLINDNESS
AND THE FIELD OF VISION. Designed for
Students and Practitioners, by Ellice M. Alger,
M.D., F.A.C.S., Professor of Opthalmology at the
New York Post-Graduate Medical School, etc.
Second Revised Edition, 394 pages. Philadelphia:
F. A. Davis Company, Publishers, 1920. Price,
$2.50 net.
This small book takes up only two chapters of Oph-
thalmology— Refraction, and the Motility of the Eye,
but there are also important chapters on Color Blind-
ness, Visual Fields, The Relation of Functional Eye
Diseases to General Medicine and Malingering. It is
the result of a culling of lectures delivered for years to
students. The author treats refraction in an interest-
ing and common-sense manner, giving due credit,
without over-exaggeration, to such aids to refraction
as the opthalmometer. The chapters on muscular
imbalance are particularly good for such a short
treatise, and the author's position as to the advisability
of operation upon ocular muscles for latent squint is
well handled. The chapter on Malingering would do
credit to a larger volume.
For the student and the busy eye man who wishes a
quick review of the subject this volume will fill a
needed want. G. F. G.
CHEMICAL PATHOLOGY, Fourth Edition : Being
a Discussion of General Pathology from the Stand-
point of the Chemical Processes Involved. By H.
Gideon Wells, Ph.D., M.D., Professor of Pathology
in the University of Chicago, and in the Rush Medi-
cal College, Chicago. Fourth Edition, Revised and
Reset. Octavo of 695 pages. Philadelphia and
London: W. B. Saunders Company, 1920. Cloth,
$7.00 net.
When a book reaches its fourth edition, it may justly
be concluded that it has made a place for itself, and
filled a want experienced by many readers. This we
feel to be particularly true of the book under present
consideration.
The test of new editions should be the discovery of
the author's inclination and ability to keep the work
up to date, and continually increase its usefulness.
This Professor Wells has certainly succeeded in doing
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THE PENNSYLVANIA MEDICAL JOURNAL February, 1921
with the "Chemical Pathology." It has been upon our
table for some time, and we have put it to the test
upon numerous occasions, and have not found it want-
ing. It is a great compilation of the subjects with
which it deals. In it oat Knds a useful and logical
arrangement of the chemical side of the problems of
pathology, with interesting and readable discussions
of a great variety of important questions. It is valu-
able from two points of view : first as a guide to the
problems themselves, and second as an introduction
to the literature of the subjects treated. There is
scarcely a problem, in which we ire interested, that
is not sufficiently discussed for ordinary purposes, and
not one to which there are not enough references to
open the way to a complete knowledge of any subject
that we desire to pursue further. Of it, it may truly
be said "we wonder what we did before we had it, and
we would not now know how to get along without it."
We believe it to be essential to the library of every
scientific physician. J. McF.
DEATHS OF PHYSICIANS IN 1920
During 1920, the deaths of 2,321 physicians in the
United States and Canada were recorded in The
Joumcd. Adding 2.5 per cent, to this number on ac-
count of delayed reports and possible omissions, we
may estimate the total niunber of deaths as 2,379. On
an estimate of 160,000 physicians, in the United States
and Canada, this is equivalent to an annual death
rate of 14.81 per thousand. For the eighteen previous
years the mortality rates were: 1919, 13.55; 1918,
16.88; 1917, 14-37; 1916, 14.08; 1915, 15-71; 1914.
14.41; 1913. 14-64; 1912. 14-13; 19". 15-32; 1910,
16.96; 1909, 16.26; 1908, 17.39; 1907, 16.01; 1906,
17.20; 1905, 16.36; 1904, 17.14; 1903, 13-73. and 1902
14.74. 'I'he average annual mortality rate for the
period from 1902 to 1920, inclusive, was, therefore,
1546 per thousand.
Ages. — Of the 2,272 decedents whose age was stated,
37 were under 30; 174 between 31 and 40; 351 between
41 and so; 463 between 51 and 60; 541 between 61
and 70; 436 between 71 and 80; 208 between 81 and
90, and 19 between 91 and 100. The greatest number
of deaths for a given age occurred at 63 and 64 years,
at each of which ages sixty-five deaths were noted.
Catues of Death. — General diseases accounted for
257 deaths ; diseases of the nervous system, 271 ; dis-
eases of the circulatory system, 404; diseases of the
respiratory system, 266; diseases of the digestive sys-
tem, 70; diseases of the genito-urinary system, 154;
senility, 77; suicide, 32; accidents, 102; homicide, 14.
and sequels of^ surgical operations, 74. The principal
assigned causes of death from disease and their fre-
quency were: organic heart disease, 236; cerebral
hemorrhage, 211; pneumonia, 186; nephritis and
uremia, 142; malignant tumors, 91; tuberculosis, 59;
angina pectoris, 50 ; pneumonia-influenza, 37 ; arterio-
sclerosis, 33; myocarditis, 34; septicemia, 31; influ-
enza, 29; diabetes, 28; meningitis, 17; cirrhosis of the
liver and acute dilatation of the heart, each 16; endo-
carditis and anemia, each 15; peritonitis, 12, and ap-
pendicitis and gastritis, each 11.
Accident.— Iht causes and distribution of the 102
deaths from accident were: automobile, 27; auto-
mobile-railway (grade crossing), 22; poisons, 9; falls,
8; firearms, 7; drowning, 6; railway and street car,
^ch, 5; asphyxia, 3; exposure and burns, each, 2;
crushing, i, and other accidents, 5- The thirty-two
physicians who ended their lives by suicide selected
these methods : firearms, 18 ; poisons, 7 ; cutting in-
struments, 3; strangulation, 2; jumping from high
places and drowning, each i. Of the fourteen homi-
cides, nine were due to firearms.
Civil Positions. — Of those who died, I had been a
member of Congress ; I, consul ; I a state governor ;
13, members of state senates; 19, members of the
lower houses of legislatures, and 25 had been mayors ;
I7> members of state boards of health; 24, members
of state boards of medical examiners; 4, members of
other state boards, and I, a member of the National
Board of Medical Examiners.
Association Fellowship. — Of the 520 Fellows of the
American Medical Association who died during 1920,
one had been President ; four, Vice-President ; seven,
members of the House of Delegates ; one, a member of
the Council on Medical Education, and four, section
officers. — Jour. A. M. A., Jan. i, 1921.
MEDICAL LITERATURE.
In the realm of medicine, what to read and what
not to read is a serious problem that confronts every
physician. Too often he reads without thoughtful dis-
crimination. He gives more thought to the quality
of the food he eats than to the character of the medi-
cal literature he consumes. Cheap postal service, cheap
printing and the greed of commercialism have united
to corrupt and deceive the unwary physician. .Quick
to resent the brazen quackery flouted from the pages
of the lay press, he is slow to recognize the same com-
mercial wolf in sheep's clothing, disg^uised in a medical
journal. Brochures from pharmaceutic houses are so
skilfully cloaked in the guise of science that the com-
mercial animus back of it all is unobserved. Some of
the literature emanating from such sources is highly
scientific and trustworthy. Taken all in all, however,
the conclusions drawn are usually insufficiently sup-
ported by data worthy of credence. Let the physician
always suspect the commercial motive of the appeal.
He should scan hastily and with a critical eye, reserv-
ing time for medical literature that emanates from
entirely truthworthy sources. — Jour. A. M. A., Dec.
25, 1920.
THE MEDICAL CLINICS OF NORTH AMERICA.
November, 1920. St Louis Number. Vol. IV, No.
3. Philadelphia and London: W. B. Saunders Co.
This number of the Clinics contains 20 articles of
varying degrees of value and interest, as follows:
Focal Infection and Arthritis, by Dr. George Dock ;
Endocarditis, by Dr. Ralph A. Kinsella; Heart-Dis-
ease, by Dr. Drew Luten ; Paroxysmal Tachycardia,
by Dr. Llewellyn Sale; Subacute and Chronic Non-
Tuberculous Pulmonary Infections, by Dr. J. Curtis
Lyter; Constipation, by Dr. Horace W. Soper; Dia-
betes Mellitus, by Dr. W. H. Ohnstead; Fever, by
Dr. Chas. Hugh Neilson; Basal Metabolism in En-
docrine Disturbance, by Dr. John L. Tierney; En-
docrine Amenorrhea, by Dr. Wm. Engelbach; Neu-
ropsychic Reactions Attending Ovarian Disturbances,
by Dr. Francis M. Barnes; Physical Examination of
the Nervous System, by Dr. William Washington
Graves; Neurologic Cases, by Dr. Sidney I. Schwab;
Diarrhoea in Infancy, by Dr. W. McKim Marriott and
Dr. John Zahorsky; Disturbed Weight in Infancy by
Dr. Jules M. Brady; Hereditary Syphilis, by Dr. P.
C. Jeans ; Complemental Breast-Feeding, by Dr. Bor-
den S. Veeder; Cardiolysis for Chronic Mediastinop-
ericarditis, by Dr. Elsworth S. Smith; Osteitis De-
formans, by Dr. Louis Henry Hempelmann.
A. A. E.
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TRUTH ABOUT MEDICINES
361
REPORT OF SURGEON-GENERAL GUMMING
(PUBLIC HEALTH)
In the annual report of the Public Health Service,
which has been submitted to Congress by the Secretary
of the Treasury, Surgeon-General Gumming discusses,
among many other subjects, the matter of appropria-
tions for new hospitals for War Risk Insurance pa-
tients, immigration and quarantine, situations here and
abroad, and the loss of persoiuiel to the service. He
says, in part:
IMMIGKATION AND DISEASE
"With the cessation of hostilities in Europe and the
resumption of maritime commerce the danger of the
introduction of epidemic diseases I'nto the United
States increased. During the war, sanitation and pub-
lic hygiene were more or less neglected. In the coun-
tries of Central Europe conditions became very favor-
able for the outbreak of epidemic diseases, and, in
many areas infection of typhus,, plague, and cholera
smouldered along ready to burst forth under condi-
tions that subsequently were sure to arise. The sav-
ing feature of the whole situation was the restriction
of travel from one country to another. On the re-
sumption of commercial intercourse the expected hap-
pened. Even before the armistice this condition of
affairs was foreseen and medical officers of the Public
Health Service were sent to Europe for the purpose
of investigation and to make preparation for the ap-
plication of preventivi measures at European ports of
departure whenever there should be resumed trans-
Atlantic travel. At present officers of the Public
Health Service are stationed at practically all of the
important ports of continental Europe for the purpose
of inspecting vessels and personnel prior to their de-
parture for posts of the United States. All verminous
persons coming from typhus-infected areas are re-
quired to undergo appropriate treatment and detention
when necessary before embarkation. Notwithstanding
this precaution, however, typhus has broken out on
several of the vessels bound for ports of the United
States, but, with the detection of the disease on the ar-
rival of the vessel and the appropriate treatment of
personnel at quarantine stations, the efforts to prevent
the introduction of typhus from Europe has proved
entirely successful. Measures in force along the
Texas-Mexican border to prevent the introduction of
typhus from Mexico into the United States have been
equally effective. While typhus would probably never
cause such a serious epidemic in the United States, as
in other countries, it is by no means improbable that
the conditions in the tenement sections of the larger
cities would not be productive of a serious epidemic
of typhus if the infection were introduced into such
localities."
I.EGAI, STATUS Of SERVICE
"It is believed to be of the utmost importance that
the legal status of the Public Health Service in its war
risk work should be firmly established by placing an
administrative head over the three major agencies in-
volved, namely, the War Risk Insurance Bureau, the
Federal Board of Vocational Education, and the Pub-
lic Health Service, and that these three bureaus should
operate there-under as coordinate and independent bu-
reaus in close cooperation."
HOSPITAI, APPROPRIATIONS
In October, 1919, the department submitted to Con-
gress a program recommending an appropriation of
$85,000,000 for the construction and acquisition of ad-
ditional facitties to meet the growing needs of the
service in connection with the care and treatment of
war-risk insurance beneficiaries. Congress in its wis-
dom, however, deemed it unadvisable to appropriate
this money for hospital purposes. _ Since tiien, the
number of beneficiaries has steadily increased, and re-
cent reports indicate that about 20,000 patients were,
on July ist, receiving hospital care from the Public
Health Service, as against 2,000 when the request was
made.
In addition to increasing existing facilities by the
construction of new hospitals, it is desired to bring to
the attention of Congress the dilapidated and unsatis-
factory condition of many of the hospitals now owned
and operated by the Public Health Service. Some of
these hospitals have been owned by the government
for years and were used for the treatment of seamen
of the merchant marine and other beneficiaries of the
service prior to the act which admitted ex-service men
of the recent war as beneficiaries. It is presumed that
these institutions, will be made use of for years to
come for these beneficiaries, despite action which Con-
gress might take with reference to the beneficiaries of
tilt War Risk Insurance Bureau. It is therefore nec-
essary that these institutions be placed in first-class
condition. All of the marine hospitals at the present
time, with but few exceptions, are of antiquated con-
struction and badly in need of repair. But a few years
will elapse before it will be necessary to discontinue
entirely the use of these institutions, unless steps are
taken to reconstruct and remodel the same to meet
with modern ideas of hospital construction and man-
agement. Recommendations as to the hospital needs
for patients of the Bureau of War Risk Insurance will
be presented to Congress in a separate communication.
The Public Health Service reiterates its firm belief
that ah adequate hospital construction program
should be undertaken by the National Government
far the care of ex-service men and women. It is
not clear how this responsibility can be adequately
met in any other way. It is not believed nec-
essary to go into a very extensive hospital construc-
tion program, but certain consideration should be
given to a program sufficiently adequate to meet the
needs of the situation, and this will mean the expendi-
ture of many millions of dollars. It is repeated that
the special needs to be met are those of ex-service
men and women suffering from tuberculosis and men-
tal disorders. These groups of patients will require
treatment for long periods of time, and their demand
is for care and treatment in governmental institutions.
LOSS IN PERSONNEI.
"Despite the temporary increase in compensation
granted by the Congress during its last session, the
Public Health Service, in common with the Medical
Corps of the Army and Navy, finds it impossible to
secure candidates for admission to the entrance grade
of its regular corps, and the attractions offered its
scientific personnel are such that the resignations have
actually exceeded the admissions during the past
twelve months."
TRUTH ABOUT MEDICINES
Mawgnant Endocarditis in Metastatic Abscess
IN GoNococcEMiA. — Hugh L. Dwyer, Kansas City, Kan.
(Journal A. M. A., Dec. 1 1, 1920), reports a case in a
child, aged 23 months, in which culture of the gono-
coccus was made from the blood during life. An in-
teresting feature in the case was the development of a
superficial abscess of gonococcic origin in the lumbar
region.
Treatment for Cotic in Breast-Fed Inpants.—
Morning and evening, C. G. Grulee, Chicago (Journal
A. M. A., Dec. 18, 1920), gives these breast-fed infants
about 5 c.c. of the liquid culture of active lactic acid
bacilli, and each breast feeding is preceded with I gm.
of powdered casein. The ordinary casein of coffl'
tnerce is not to be used. Powdered casein is not solu-
ble by ordinary means, hence it is necessary to make a
paste and place this on the back of the infant's tongue.
If it is impossible to obtain the powdered casein, one
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THE PENNSYLVANIA MEDICAL JOURNAL February, 1921
may carefully skim milk and take the curd of the milk.
The quantity of curd to be used before each nursing
IS approximately that obtained from an ounce of
skimmed milk. Grulee says it is unusual for a case of
colic to resist this treatment for longer than a week
or ten days, and usually the benefit begins to appear
within from twenty-four to forty-eight hours.
Narcotic Drugs in Hospital Service.— The article
by Thomas S. Blair, Harrisburg, Pa. (Journal A. M.
A., Dec. II, 1920), is based on an elaborate statistical
report rendered by the Bureau of Drug Control of
Pennsylvania to the Commissioner of Health, and
deals with findings collected from the public hospitals
of the state by experts in the field service of this
bureau.
Milk-Borne Diphtheria.— An analysis is made by
Jonathan E. Henry, Boston {Journal A. M. A., Dec.
18, 1920), of an outbreak of diphtheria in Williams-
town, Mass., which was traced to infection of a milk
handler's finger with B. diphtherioe.
Abscess of Spleen.— Elliott C. Cutler, Boston {Jour-
nal A. M. A., Dec. 18, 1920), reports a case of abscess
of the spleen following an acute bilateral otitis media
in which recovery followed drainage of the infected
region. The spleen substance had given way, extensive
adhesions had formed so that splenectomy was not
iwssible. The infection extended into the left chest.
Suppurating Myoma Uteri.— J. W. Nixon, San An-
tonia, Texas {Journal A. M. A., Dec. 18, 1920), reports
one case occurring among more than 1,200 operations
for uterine fibroids at one hospital. This was the first
instance of its kind encountered. A brief review is
made of the literature.
Relation of Contact with Tubercle Bacillus to
Development of TuBERCUtosis.— Experimental evi-
dence obtained by J. B. Rogers, Cincinnati {Journai
A. M. A., Dec. 18, 1920), has shown that such objects
as gauze used to cover the mouth when coughing,
pillow cases used twenty-four hours, patients' hands,
spoons used by patients, magazine covers picked up
indiscriminately from the wards, and door-knobs
frequently handled by patients are contaminated with
living, virulent tubercle bacilli. Patients with open
tuberculosis frequently emit infectious particles when
coughing. If these particles are collected 15 inches
from the mouth of the patients, 35 per cent, of the
group of guinea-pigs can be infected; if collected at a
distance of 6 inches, the percentage increases to 75
per cent. Such particles, no doubt, are inhaled by per-
sons in close proximity to the patients. The saliva in
open cases of tuberculosis usually contains living tu-
bercle bacilli. The sedimented urine in twenty open
pulmonary tuberculosis cases negative for genito-
urinary tuberculosis failed to infect any of the twenty
inoculated guinea-pigs. Out of 240 nurses employed
at the Cincinnati Tuberculosis Sanitarium, only three
developed tuberculosis, and one diagnosed as tubercu-
lous after working at the sanitarium for two years
gave a history of previous infection.
Operation for Tuberculosis of the Wrist. — The
operation devised by Leonard W. Ely, San Francisco
{Journal A. M. A., Dec. 18, 1920), necessitates cutting
a groove in the radius and the third metacarpal and
transplanting into it a graft from the tibia. The re-
sult is said to be a useful hand, possessing as much
rotation as before the operation, and with excellent
power in the fingers and thumb.
Tuberculous Meningitis.— The point emphasized
by George Franklin Libby, Denver {Journal A. M. A.,
Dec. 18, IC20), is that severe headache of sudden on-
set and persistent character in an adult patient with a
history of tuberculosis, either active or quiescent,
should awaken a suspicion of tuberculous meningitis.
And especially if Uken in connection with disturbances
of the motility of the eye, upper lid or pupil, or im-
pairment of vision, this type of headache should
strongly suggest tuberculous meningitis.
Saligenin as a Local Anesthetic van. the Female
Urethra.— Arthur D. Hirshfelder and H. M. N.
Wynne, Minneapolis {Journal A. M. A., Dec. 25, 1920),
assert that saligenin is a practical, nontoxic, local
anesthetic which is distinctly useful in work on the
female urethra and bladder. It is about one-fifth as
toxic to mammals as procain, and about one-fiftieth
as toxic as cocain. In all cases, 2 c.c. of a 4 per cent,
solution of saligenin was injected into the urethra.
A working anesthesia was obtained in every case, ap-
parently as satisfactory as that produced by a lo per
cent, solution of cocain. There is a great advantage
in using this anesthetic of low toxicity, for a con-
siderable quantity of the solution can be injected into
the bladder after catheterization. This reduces the
spasm so that a rapid and satisfactory examination can
be made.
Surgical Treatment of Typhoid Carriers.— Edwin
Henes ,Jr., Milwaukee {Journal A. M. A., Dec. 25,
1920), asserts that cultural examinations of the duo-
denal contents are indicated in all cases during con-
valescence from typhoid fever. Cholecystitis is a fre-
quent complication of typhoid fever. Persistent in-
fectiousness following typhoid fever is usually the re-
sult of cholecystitis. A gall-bladder may continue to
be infectious without the usual manifestations of a
cholecystitis. Cholecystectomy, with complete excision
of the cystic duct, will cure the great majority of ty-
phoid carriers.
Treatment of Acute Tetanus.— The case reported
by Robert A. Kilduffe and W. B. McKenna, Pittsburgh
{Journal A. M. A., Jan. i, 1921), derives its interest
from the successful result obtained in a well-marked
and typical example of acute tetanus in which the be-
ginning of treatment was delayed. The trauma was
sustained September 9. The wound received hospital
treatment, but a prophylactic injection of tetanus anti-
toxin was not administered. Eight days after the
original injury, the patient was conscious of pain in
the jaws and arms, and some slight stiffness of the
jaws, which became progressively worse. He con-
sulted a physican and received some medicine which
gave no relief. September 20 he came under the care
of the authors. Immediately on admission, the patient
was given 10,000 units of antitoxin — all that was on
hand. A few hours later he became extremely rigid,
the jaws tightly clenched, and a slight retraction of
the neck was noticed, though typical bowing of the
body as a whole did not occur. He complained bitterly
of pain. The wound, after having been thoroughly
cleansed and after drainage was established, was kept
wet with a constant hydrogen peroxid drip. Anaerobic
cultures gave growth of typical tetanus bacilli of classic
shape. Five hours after admission the patient received
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February, 1S>21
TRUTH ABOUT MEDICINES
363
20,000 units of antitoxin intravenously. He was also
given 40 grains of chlorbutanol by recal injection,
every four hours for two days. The antitoxin tr^t-
ment was entirely intravenous. A total of 140,000
units was given during six days of treatment. The
patient was discharged October 11, perfectly well, ex-
cept for some muscular aching in the limbs comparable
to that found after severe or unaccustomed muscular
exercise, the abdominal muscles still being somewhat
rigid.
Gastric and Duodenal Ulcer.— The experimental
study made by A. C. Ivy, Chicago (Journal A. M. A.,
Nov. 13, 1920), indicates that exposure of the mucous
membrane of the pyloric antrum to the exterior for
ten months causes no anatomic or physiologic change.
Manipulation of an acute ulcer of the mucosa of the
pyloric antrum causes a delay in healing time amount*
ing to from two to three times the normal healing time.
The healing time of an acute ulcer of the mucosa of
the pyloric antrum of a healthy dog is not influenced
by direct exposure to infection. Duodenal ulcer oc-
curs following gastroduodenostomy in the dog as-
sociated with emaciation, vomiting and cachexia, the
ulcers being located along the course of the blades of
the clamp (clamp line) and not at the site of the
suture line. Attention is called to a possible injudicious
use of the gastroenterostomy clamp as related to the
genesis of jejunal ulcer.
Gastric and Duodenal Ulcer. — A critical review
of SCO cases of peptic ulcer has convinced Elmer L.
Eggleston, Battle Creek, Mich. (Journal A. M. A.,
Dec. 4, 1920), that if peptic ulcer, particularly duodenal
ulcer, is observed early in its history, and if the
patient will submit to a carefully planned course of
treatment for a reasonable time and will follow up this
treatment by a carefully regulated dietary regimen
over a period of some months, one can be sanguine of
obtaining complete cure. In uncomplicated cases of long
standing, proper medical treatment provides relief in
at least 70 per cent, of the cases. In the great majority
of cases in which the symptoms disappear during a
course of medical treatment and there is later a return
of the symptoms, the fault is due to dietetic careless-
ness. Surgical treatment is to be preferred for the
cases complicated by pyloric stenosis not yielding
readily to medical measures, cases showing repeated
hemorrhage, penetrating or perforating ulcers, and for
cases in which a prolonged medical course is im-
possible. Simple gastro-enterostomy fails to provide
permanent relief in a considerable number of cases,
and should be supplemented by reaction of the ulcer,
cauterization, infolding or partial gastrectomy.
Precautions Necessary in the Selection of a
Donor for Blood Transfusion. — Lester J. Unger, New
York (Journal A. M. A., Jan. i, 1921), considers it
unsafe to perform a transfusion, relying simply on the
fact that donor and patient are of the same group.
Preliminary to transfusion, the blood of every patient
should be grouped and then tested directly against that
of the prospective donor. All individuals may be
grouped broadly into four main groups. These groups
are established by the presence of two "chief" agglu-
tinins in the serums and receptors for these agglutin-
ins in the cells. Besides "chief" agglutinins, "minor"
agglutinins have been demonstrated. Ninety-seven
per cent, of the adults have agglutinins in their serums.
They are, however, present in 3 per cent, of new-born
infants. Only 25 per cent, of new-born infants have
cells that can be agglutinated, as compared to 50 per
cent, among adults. The full quote of agglutinins and
receptors is acquired between the third and fourth
years of life. Incompatibility between the blood of a
mother and her new-born infant occasionally occurs.
It is unsafe, therefore, to omit testing the blood pre-
liminary to transfusion, even though the mother should
act as donor. It is not advisable indiscriminately to
use the so-called "universal donor," as severe reactions
have been observed following the use of donors of
Group IV for patients of other groups. The rouleaux-
formation substance, even though acting on the
donor's cells, is apparently harmless, and no untoward
results have been seen following such transfusions.
Treatment of Bladder Tumors. — The primary fun-
damental and all-important consideration as to the
proper treatment of the various intravesical growths,
benign or maliginant, whether electrical, operative or
palliative. B. A. Thomas, Philadelphia (Journal A.
M. A., Nov. 20, 1920), says should rest chiefly with
the experienced cystoscopist, although, occasionally,
indispensable assistance will be rendered by the cysto-
gram, the histopathologic examination of an excised
section of tissue and the general physical condition of
the patient. The importance of correctness in the
differential diagnosis of these bladder growths cannot
be too strongly emphasized, because thereon directly
depends the proper line of treatment. The treatment,
par excellence, of papilloma single or multiple is the
so-called cystoscopic high frequency fulguration, al-
though rarely cases will be observed in which such
treatment is impossible, necessitating cystotomy and
other surgical procedures. Resection of the bladder,
with or without ureteral transplantation, is the only
rational treatment for early and favorably situated
carcinoma. For malignant disease involving the neck
of the bladder, total cystectomy, very exceptionally,
may be performed. In certain cases of carcinoma, un-
favorably situated for resection or too far advanced
for radical treatment, cystotomy followed by intensive
fulguration, radium implantation and roentgen ray is
on trial, with a promise to prolong life and possibly
rarely to effect cure. In advanced and inoperable car-
cinoma of the bladder, palliation consisting of cystos-
tomy if retention of urine exists and roentgen ray and
radium for relief of distressing symptoms, offers lit-
tle consolation for the futile endeavors and vain ef-
forts of the conscientious surgeon.
Reclamation of Physically Handicapped.— The
knowledge that more than three times as many men
and women were being disabled in industry annually
as were disabled in the entire U. S. Army Harry E.
Mock, Chicago (Journal A. M. A., Nov. 20, 1920),
says has awakened the nation's conscience to the need
of rehabilitating these unfortunates and of preventing
such a casualty list. In different parts of the country,
volunteer and government agencies are endeavoring
to solve this problem. Industrial medicine and sur-
gery has in a number of large industries demonstrated
the practicability of a human maintenance department
which conserves the working force and reclaims the
disabled. The work of reconstruction and rehabilita-
tion of the disabled soldiers, while not completed, has
developed and proved broad principles of reclaiming
the handicapped. A reclamation service to be com-
plete must combine the efforts of medicine, education
and industry. It must include the following services :
(a) Prevention of accidents and disease, (b) Im-
proved hospital, medical and surgical services. As an
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THE PENNSYLVANIA MEDICAL JOURNAL
February. I92I
adjunct to these there must be provided better con-
valescent care, (c) Vocational training of the handi-
capped when needed, (d) Proper placement of the
physically and mentally handicapped on jobs where
they can be efficient with "safety to themselves, to
their fellows and to property." (e) Their continued
supervision until assured that this reclamation service
is completed in every instance. By a broader concep-
tion of our duty to handicapped individuals and by a
closer cooperation with the various lay agencies, the
medical profession can render a great service in con-
serving and reclaiming the nation's man power.
SuRCiCAi, Tkcathent ot Malignant Tumors of
Bladdbk. — The results of operations on 202 patients
are detailed by E. S. Judd and W. £. Sistrunk,
Rochester, Minn. (Journal A. M. A., Nov. 20, 1920).
The hospital mortality in the entire group, from all
causes, was 12.9 per cent By proper attention before
operative measures are undertaken, and by the selec-
tion of suitable cases for operation, the immediate
mortality can be kept well undet 10 per cent. The
ultimate results are about the same as those following
resections of the stomach and intestine for carcinoma.
Eighteen patients failed to respond to requests for in-
formation. Ninety-four are dead; sixty-four are liv-
ing; number living 10 years, 2; 9 years, 2; 8 years,
2; 7 years, 3; 6 years, 5; S years, 12; 4 years, 3;
3 years, 10; 2 years, 13, and 1 year, 12. The length
of time after operation before tht deaths of the pa-
tients occurred and the results according to type of
operation are also given.
Intubation and Visuaiuation o? thb Duodenum.
—A diagnostic procedure in duodenal ulcer and peri-
duodenal adhesions is described by I. O. Palefski,
New York (Journal A. M. A., Dec. 4, 1920), and a
summary is given of findings in 361 established cases.
In his opinion, the duodenal tube offers the best means
of visualizing the course of the entire duodenum. A
high acidity, blood in duodenal contents and a normal
duodenal curve, with the duodenal tube in situ, are
pathognomonic evidence of duodenal ulcer. A normal
or subnormal acidity, absence of blood in the duodenal
contents and a distorted duodenal curve are pathogno-
monic evidence of periduodenal adhesions, usually the
result of gallbladder infection.
Roenten-Ray Study op Mercury Injections.— This
investigation by H. N. Cole, Sydney Littmann and
Torald Sollmann, Cleveland (Journal A. M. A., Dec.
4, 1920), was made with the usual clinical doses, using
a sufficient number of patients to avoid experimental
accidents and difficulties. The investigation included
both insoluble and soluble injections, mercuric chlorid
being generally in doses of about one-eighth grain and
red mercuric iodid in doses of from one-sixth to one-
third grain; the insoluble injections of calomel and
mercuric salicylate in doses of from i to 2 grains;
and 40 per cent, gray oil in doses of from 0.125 to 0.25
«.c. The findings indicate that gray oil injections are
both inefficient and dangerous, and their use should
be abandoned. Calomel injections are also dangerous.
Mercuric salicylate injections, especially into the
gluteal muscles, give a satisfactory absorption and
present relatively little danger. The absorption of the
usual dose, from i to 2 grains, is completed on the
average in four days when injected into the buttocks,
and in nine days when injected into the lumbar mus-
cles. It is therefore effective.. The injections may be
repeated safely with these intervals. However, the
absorption is not uniform in all cases, so that even
with the salicylate, the patient must be watched care-
fully for any toxic manifestations. In treating a case
of syphilis, it must be remembered that mercury is a
very powerful drug and a dangerous poison, especially
for the kidneys. Any patient who is receiving this
drug should have the teeth and gums examined fre-.
quently by a physician, at least once a week. The
physician should inquire as to symptoms of diarrhea
and of gripping pains in the bowels, and the urine
should be examined weekly. On the appearance of
the least trace of albumin in the urine the use of the
insoluble mercury preparation should be stopped at
once. When these precautions are taken, mercuric
salicylate injections are quite safe. The authors rec-
ommend that they be employed according to the fol-
lowing formula:
Gm. or C.c.
Anhydrous lanolin 40
Distilled water 10
Sweet almond oil 150
Calomel or mercuric salicylate 291
Phenol or creosote 2o|
Camphor 40I
Dose: i c.c. equals 0.09 gm. (i^ grains) of mer-
curic salicylate or calomel.
Blood Concentration Chances in Influenza. —
Frank P. Underbill and M. Ringer, New Haven, Conn.
(Journal A. M. A., Dec. 4, 1920), point out that patho-
logically, influenza and acute phosgen poisoning pre-
sent strikingly similar effects on the respiratory tissue.
In each, pulmonary edema is a prominent feature. In
acute phosgen poisoning, death is due to a marked
change in the concentration of the blood. Extreme
blood concentration is incompatible with life. In in-
fluenza, the blood becomes greatly concentrated. This
constitutes a factor of the greatest importance in the
fatal outcome. A method of treatment evolved for
acute phosgen poisoning has been applied with success
in a few cases of influenza. The method consists in
the maintenance, under carefully controlled conditions,
of blood concentration as near the normal level as pos-
sible by venesection and fluid introduction. Changes in
blood concentration in influenza, followed by hemo-
globin estimations, allow the grouping of cases into
those demanding the prescribed treatment immediately,
and those that either do not need this type of treat-
ment at once or do not need it at all. By following
blood concentration changes, prognosis is greatly
aided.
Use of Satxhiated Salt Solution Intravenously
During Intracranial Operations. — In a case of brain
tumor presenting marked pressure symptoms, a right-
sided subtemporal decompression was undertaken.
The dura was opened rapidly, but in spite of an im-
mediate closure of the muscles the cortex ruptured at
several places. The patient remained stuporous. He
was given 100 c.c. of saturated salt solution intraven-
ously, about I c.c. per minute. Before 15 c.c had been
run in, the patient brightened up, answered questions
and showed marked signs of improvement This im-
provement lasted about twelve hours, when the patient
again relapsed into a semicomatose condition. On
three successive occasions administrations of the satu-
rated salt solution improved the patient. After the
third injection the patient improved steadily. Ernest
Sachs and George W. Belcher, St. Louis (Journal A.
M. A., Sept 4, 1920), who report this case, have also
used the solution in the wards to control cerebral
Digitized by
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February, 1921
TRUTH ABOUT MEDICINES
365
edema, and believe that it has decided uses for this
purpose.
Threb Pertinent Questions on Maternal Feed-
ing.— ^The advisability of immediate weaning in un-
complicated pregnancy, W. A. Mulherin, Augusta, Ga.
(Journal A. M. A., Sept. 25, 1920), says should be
questioned seriously. In the vast majority of cases,
uncomplicated pregnancy only -weakens the quality of
the milk and diminishes the flow ; therefore, why not
wean slowly? If the baby is weaned immediately, it
will be necessary to start with a weak cowmilk form-
ula, for the purpose of teaching the digestive organs
to digest cow's milk. Hence, it is logical, and a safer
procedure, to utilize the breast milk even though the
breast milk is not so nourishing as before pregnancy,
and slowly wean the baby. The advisability of the
slow weaning process is highly advisable in Southern
states during the excessive heat of the summer
months. It has been Mulherin's practice for many
years to wean slowly in an uncomplicated pregnancy
of the mother, and he has had uniformly good results,
and only in rare cases has he found it necessary to
resort to immediate weaning. Mulherin does not
question the advisability of immediate weaning in se-
vere cases of typhoid fever. It is only in the mild and
very mild cases in which no direct contra-indications
exist that he would raise this question. Few babies
are infected from nursing typhoid mothers. In mild
cases, in which, generally, the diagnosis has been
made on the seventh, tenth or twelfth day, with the
breasts secreting freely, the baby's blood showing posi-
tive Widal reaction, and the mother feeling equal to
nursing her baby, that Mulherin would seriously ques-
tion whether it is not good practice to continue the
baby at the breast, and piece out, if necessary, with a
complemental feeding. As to the advantages of com-
plemental feeding over the method of alternating
breast and bottle, Mulherin thinks it is a serious mis-
take to give supplemental feeding when complemental
feeding can be practiced.
Frequency op Syphilis With Cancer of Lips,
ToNOUE AND Buccal Mucous Membrane. — The tables
submitted by N. Austin Cary, Oakland, Cal. (Journal
A. M. A., Sept. 25, 1920), were compiled from 907
case histories. The series does not represent selected
cases. Of the 907 mouth lesions, 771 were malignant
and 136 benign. Of all the cancer cases, only three
occurred in the white female, and in none of these
could syphilis be proved as an etiologic factor — in all
three cases, irritation of the mucous membrane had
been produced at the site of growth by the habit of
placing snuff under the tongue. No cases of cancer
were observed in the black female and only two in the
black male, in spite of a very considerable proportion
of negro patients in Baltimore clinics. A very small
number of cases of cancer associated with or preceded
by leukoplakia have shown a positive syphilitic his-
tory. Of the 907 lesions of the mouth, 721 were can-
cer. A positive history of syphilis or a positive
Wassermann reaction or both were found in forty-
eight, or 6.23 per cent. The percentage of cases giving
evidence of syphilis is more than three times as great
in cancer of the tongue as in cancer in any of the
other locations about the mouth. The fact of greatest
importance, however, and the one which Cary empha-
sized is that a history of syphilis or a positive Was-
sermann reaction or both may be obtained in at least
one of every seven cases of fully developed cancer of
the tongue.. The inference from these considerations
is that, in the presence of a lesion, in the differential
diagnosis of which cancer cannot be ruled out with
certainty, only the briefest of courses of antisyphilitic
treatment should be carried out before proceeding to
excision and accurate histologic diagnosis.
Plastic Surgery. — Ferris Smith, Grand Rapids,
Mich. {Journal A. M. A., Dec. 4, 1920), says the es-
sentials of success in plastic surgery of the face are
sound surgical training, a proper temperament, imagi-
nation, courage and tenacity. He reviews briefly and
criticizes the types of procedure as applied to the nose,
throat and ear, and offers several original procedures,
quent as one would be likely to expect. Burns were
the vatst common ones, but even death may result
from toxemia. Radium has many advantages as com-
pared with roentgen rays, especially for application in
the nose and throat. The diagnosis of the malignant
cases should be made by a competent laryngologist,
and the radium applied either by him or in cooperation
with a "radiologist. Only in this way will correct sta-
tistics and reliable results be obtained, with greatest
benefit to the patient and the safest guidance to the
profession.
Trachoma. — ^Trachoma is a reportable disease in
many states. John McMullen, Louisville, Ky. (Jour-
nal A. M. A., Oct. 23, 1920), says that surveys in num-
bers of states have been made by the Public Health
Service, and trachoma has been found to be prevalent
in many. A number of states have taken up the
trachoma problem and appropriated money to combat
the disease. In cooperation with the several states,
free trachoma hospitals have been established in Ken-
tucky, Virginia, West Virginia, Tennessee and North
Dakota. An eye specialist is in charge, and a corps
of trained nurses are on duty in each of these hos-
pitals. In addition to these hospitals, field clinics have
been conducted in these and a number of other states.
The results have been exceedingly satisfactory. About
9,000 cases of trachoma have been treated at these hos-
pitals, the ages of the patients varying from infancy
to old age. The number of hospital cases does not
include the field clinics. Eighteen field clinics have
been held during the last seven months; 825 opera-
tions were performed, 559 under general, and 266
under local anesthesia.
Treatment op Gonorrhea. — Inasmuch as the essen-
tial pathologic lesion of the chronically inflamed
urethra is an infiltration of its submucosa, the essen-
tial treatment of chronic urethritis, according to Ed-
ward L. Keyes, Jr., New York (Journal A. M. A.,
Nov. 13, 1920), is dilatation which shall be made to
simulate massage as nearly as possible — dilatatjon ap-
plied both to the anterior and to the posterior urethra
so far as the inflammation affects both portions' of the
canal. Dilatation should not cause bleeding; —for
bleeding is evidence of laceration, laceration is the oc-
casion of infiltration, and infiltration is the lesion that
we are seeking to relieve. Dilatation should not at-
tempt to stretch scar tissue, because scar tissue can-
not be stretched. The anterior urethra may profitably
be dilated to from 28 to 32 F. ; the posterior urethra
(by means of the Kollman dilator) to from 33 to 38
F. The intervals between treatments should be from
five to ten days. The application of injections and
irrigations, however antiseptic, to the surface of the
urethral mucosa can have but little effect on its
pathologic processes. A mild urethral discharge may
be controlled by a mild injection, and for this-puro<^s|:^.
Digitized by VjVJOV Ic
366
THE PENNSYLVANIA MEDICAL JOURNAL February, 1921
astringent injections of zinc sulphate and similar sub-
stances are far more efficacious than are the antisep-
tics. If the treatments are gentle, it is often quite as
well not to introduce any antiseptics into the urethra ;
but when beginning with a patient, or if there is any
possibility of a reaction following the treatment, an
antiseptic which washes out the major number of
bacteria and tends to diminish the vitality of others is
worth while. Massage of the prostate and seminal
vesicles is the best substitute for the processes of Na-
ture, and has the added advantage of being conducted
in a relatively calm spirit. The urethroscopic treat-
ment of granulations in the posterior urethra by the
application of chemicals is most useful in cases that
resist treatment by dilatation. But the urethroscopic
treatment is not to be considered one of choice to re-
place dilatation — dilatation is always of the essence of
the treatment of chronic urethritis.
PHVsiCAt Factors in Mentai, Rbtakdation.— Fol-
lowing the plan of making first a thorough physical
examination and then intensively investigating every
clue uncovered, Edward A. Strecker, Philadelphia
(Journal A. M. A., Sept. 4, 1920), was able to deter-
mine that in eighteen, or 56 per cent., of all his cases
congenital mental deficiency did not exist at all, and in
fifteen, or 84 per cent., of the retarded group, there
were significant underlying physical factors on which
the mental retardation depended. In other words,
there is more than an even chance that unless a careful
search is made for possible physical causes, the diag-
nosis of true mental deficiency may be an error and
the child may be mistakenly admitted to an institution
for defectives. In his list there were six instances of
.congenital syphilis, including one with anemia and
ozena ; one case of chronic suppurative tonsillitis and
valvular heart disease ; one of rachitis ; one of angu-
lar gyrus lesion; one of hypopituitarism; and five
children who, although they had no definite organic
disease, were nevertheless markedly undernourished
and underdeveloped as a result of economic and en-
vironmental conditions.
Spinal Drainage in Mental Diseases. — Horace
Victor Pike, Danville, Pa. (Journal A. M. A., Dec. 4,
1920), makes a preliminary report of manometric
readings with results of treatment in twenty-five cases.
It is apparent that there exists a direct relation be-
tween intracranial pressure and general arterial pres-
sure. Increased general arterial pressure may be
markedly lowered by complete spinal drainage. In-
creased intracranial pressure exists in many diseases
of the brain and nervous system, and the intracranial
pressure should be determined in all cases of delirium,
stupor, or where general arterial pressure' is high.
Status . epilepticus will yield to complete spinal drain-
age. Withdrawal of cerebrospinal fluid should not be
limited to diagnosis and intraspinal medication, but
should be employed in all cases, save perhaps those
presenting lesion of the posterior fossa, in which in-
tracranial pressure is increased; and in these cases,
drainage should be complete.
1000 PRESCRIPTION BLANKS, $2.50
(Uneo flnlib bond. 100 In pad
1000 ProlnilonkI Cnrdi .... «4.n
1000 NoUhMdl 4.60
1000 Drag BtiTelopa* 3.00
irOO SUtementi iM
1000 " ActntI" I'lrMwrUMn Letter! 6.M
PHet Inelud* Pareml Pott Charm—
A Jew samples free
A. H. KRAUS. 407.40»ChMtDalSt.. MOwaokM, Wb.
Wanted. — To purchase a general practice in Peniv-
sylvania. Address Box 501, c|o Pennsylvania Med-
ical Journal.
TABLE OF GONTENTS-Goncluded
Fbbdbbick L. Van Sickle, M.D.,
BxecuUve Becretary, Harritburg, Pa.
Senate and House Committees on Public Health and
Sanitation 346
nr KEXOBIAM
B. C. Bullock, M.D 346
CO-OPEBATITE MEDICAL ADTEBTIUHG BTT&EAV 346
COXTHTT MEDIOAI, SOCIETIES
Adams — January 347
Allegheny — January 347
Armstrong — January 348
Blair — December 348
Clinton — December 348
Cumberland — January 348
Dauphin — January 349
Elk — December, January 349
Franklin — November, December 350
Huntingdon — January 350
Jefferson — December 350
Lawrence — December 350
Luteme — December, January 351
McKean — January 351
Mercer — January 351
Northampton — December, January 352
Susquehanna — January 352
Warren — December, January 352
Wayne^December 353
Wyoming — December 353
STATE MEWS ITEMS 353
GENEBAL KEWS ITEMS 367
BOOKS BECEIYED 358
BOOK BEVIEW 369
TBTTTH ABOTTT MEDICnTES 361
INDEX TO ADVERTISERS
Aloe, A. S., Company 11
Armour & Company cover p. 4
B. B. Culture Laboratory 11
Bauer A Black Ill
Brady, Geo. W., A Company xvi
Bum Brae avl
Crest View XT
Deutsch, Max, The Oravld Shoe xvi
Devltt's Camp Xt
Felck Brothers Company xvll
Ooodell, J. E., Laboratory tI
Horllck's Malted Milk Co Tit
Hynaon, Westcott A Dunning xvil
JacobI, Edward xll
Jefferson Medical College xlll
Kenwood Sanitarium : ... xvi
Kraus 366
Langner Laboratory, The iv
Mcintosh Battery A Optical Co vll
Maltble Chemical Co x
Manhattan Bye Salve Co Til
Massey Hospital, The xii
Mayo Foundation, The It
Mead Johnson A Co. x
Medical Protective Co vll
Mercer Sanitarium xvi
Mett, H. A., Laboratories, Inc XTl
Moore's Hospital xr
Mutual Pharmacal Company, Inc Ix
Park Tailoring Co XTl
Pomeroy Company coTer p. It
Physicians & Surgeons Adjusting Association Tl
Radium Company o( Colorado It
Radium Laboratory xtII
Saunders, W. B., Company front coTer
Scherlng A Olatz, Ind Ix
Storm, Katherlne L., M.D cover p. 4
Sunnyrest Sanitarium xvi
Taylor Instrument Co XTii
United Synthetic Chemical Corporation xli
UnlTerslty of PennsylTanIa xlll
UnlTerslty of Pittsburgh kll
Victor X-Ray Corporation T
Woman's Medical College of PennsyWanla xlll
Zemmer Company, "The ! . . , . v^ Ix
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Owned, Controlled and Publiihed by the Medical Society of the Sute of Pennsylvania
Issued montUly under the sopervision of the Publication Committee
VoiuMK XXIV
NvUBM 6
212 North Third St., Harrisburg, Pa., March, 1921
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ADDRESS
CONSIDERATION OF SOME OF THE
PROBLEMS OF GLAUCOMA*
WILLIAM H. WILDER, M.D.
CHICAGO, lU.
My observation that the condition .of glaucoma
is frequently overlooked and, even when recog-
nized or suspected, is frequently neglected or im-
perfectly treated, has prompted me to offer a few
remarks on this subject that has been such a
favorite theme for the study and writing of oph-
thalmologists. There is so much to say on this
important topic, and all that is known of it has
been presented in the literature so much more
ably than I can hope to do, that it is with some
hesitation that I venture to offer it as the sub-
ject of a paper which your chairman has digni-
fied on the program as an address. It is only
because of the hope that some observations on
the subject which have been impressed upon me
after considerable study of such cases and expe-
rience in their treatment may stimulate some of
the younger men to more careful study and ex-
amination of this really difficult subject, that I
feel justified in presenting it before this section.
In considering the subject of glaucoma we
should get away from the idea that has so long
obtained, and is still held in most textbooks, that
we are dealing with a disease entity. While
glaucoma is indicative of an abnormal condition
of the eye, it is more accurately a syndrome, a
symptom complex, the chief feature of which is
intraocular pressure.
The accumulated experience and observation
of many students of this subject demonstrate the
complexity of the pathologic condition that may
underly glaucoma. The division of the subject
into inflammatory and noninflammatory, acute,
subacute and chronic or simple forms is the nat-
ural sequel of considering the condition as a
disease per se and is confusing. Much to be
preferred is the simpler nomenclature of conges-
tive and noncongestive forms adopted by Elliot
and other writers on the subject.
•Delivered before the Section of Eye. Ear, Nose and Throat
Diseases of the Medical Society of the State of Pennsylvania,
ittsburgh Session, October, 1920.
Hypertension, increased intraocular pressure
is universally recognized as the dominant feature
of this condition and the one that demands the
closest attention in our study and treatment, but
underlying this may exist pathologic changes and
conditions so diverse and complex as to defy our
efforts to elucidate them.
PROBLEMS OF ETIOLOGY
In the study of the etiology of glaucoma we
are confronted with difficulties from the outset.
A knowledge of pathological anatomy assists in
the study of pathogenesis. In this subject, the
lack of material for studying the earliest stages
of glaucoma increases our difficulties. Most of
the glaucomatous eyes that come to section are
those in the latest stages, and we may not be
warranted in concluding that the conditions
found are those of cause and not of effect.
I assume we are all familiar with most of
these changes, or at least with the most promi-
nent ones. The shallow anterior chamber, the
filtration angle blocked by the root of the iris, the
atrophied iris, the swollen ciliary processes, the
edematous cornea, the engorged ciliary vessels,
the cupped optic disc, the cavernous atrophy of
the optic nerve, all these and more have been ac-
curately and carefully observed. But it is diffi-
cult to answer the question, "Are these the cause
or the effect of the increased intraocular pres-
sure?"
There is little doubt that age is an important
factor in the etiology. It is a common observa-
tion that most cases of glaucoma occur in middle
and late life, and statistics confirm this. For in-
stance, in the analysis of a series of 1,032 cases
of primary glaucoma Haag found 4 occurred in
the first decade of life, 16 in the second, 26 in
the third, 74 in the fourth, 176 in the fifth, 288
in the sixth, 329 in the seventh, 116 in the eighth,
and 3 later. These figures are in accord with the
observations of Priestley Smith on a series of
1,000 cases collected from til practice of a num-
ber of surgeons.
But in what way does age influence the intra-
ocular pressure? Priestley Smith, one of the
most profound students of this subject, has
shown that the lens grows larger with advancing
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368
THE PENNSYLVANIA MEDICAL JOURNAL
March, 1921
life while the size of the eyeball remains the same
or possibly becomes somewhat smaller. He claims
to have demonstrated that the ciliary processes
are more prominent and bulky in the old than in
the young. With the increase in size of the
processes and the lens, the circumlental space is
correspondingly narrowed so that fluids cannot so
readily pass from the vitreus into the aqueous
chamber. In consequence the lens and swollen
ciliary processes are pushed forward against the
iris, the root of which blocks the filtration angle
and thus impedes or stops the outflow of fluids
through the spaces in the pectinate ligament. Of
course this would explain the shallow anterior
chamber, which is one of the well recognized
signs of an established glaucoma. Thickening or
sclerosis of the fibers of the pectinate ligament
as pointed out by Henderson may contribute to
this result. As a consequence of such thickening,
which may be one of the manifestations of fibro-
sis incident to advancing life, the spaces in this
structure may be seriously contracted so as to be
inadequate for the circulation of lymph.
Valuable as is the knowledge of these factors
in the production of glaucoma, the ultimate cause
is not yet known. What brings about the en-
largement of the ciliary processes? Is such an
enlargement in the nature of an inflammatory
condition? Is there associated with it an in-
creased secretion of fluids which the circulatory
system of the eye is unable to take care of, thus
raising the intraocular pressure? If there is an
increase of fluids in the eye, are they in any way
changed in their physical or chemical nature?
What role do vasomotor disturbances and nerv-
ous irritations, so common in the period of life
when glaucoma occurs, play in the problem ? Do
degenerative changes in the uveal tract, particu-
larly the ciliary body, bring about increased or
altered secretions in the eye ? What influence do
various morbid states that result in auto-intoxi-
cation have in bringing about such degenerative
changes in the ciliary body ? These and various
similar questions are engaging the attention of
students of the subject and have not yet been
satisfactorily answered. Possibly they may never
be answered, associated as they are with some of
the most intricate problems of metabolism.
In truth, the etiology of glaucoma is hydra-
headed. In the last few years writers on the
subject seem to have found reasons for denying
any causative relation between arteriosclerosis
and glaucoma. One cannot escape the thought,
however, that a condition like arteriosclerosis
that so profoundly affects the welfare and nutri-
tion of tissues, may play a role in bringing about
degenerative changes in the eye, particularly if
the ocular vessels are so affected, which may lead
to the results that we are considering, viz:
hypersecretion of fluids and alteration of such
secretions. Of course, this is at present, mere
speculation.
Elliot in his book on Glaucoma, quotes the ad-
mirable words of S. D. Risley on the subject of
Etiology. "Glaucoma is a disease, coming on
at an age when wear and tear, harressing vicissi-
tudes, misfortunes, exposures, overwork and
vicious living have sapped the physiologic foun-
dations of life; when infections have found en-
trance to the structure of the organism through
the ddorway of the epithelium ; and when a vari-
ety of toxic, auto-intoxic and other influences
have set up vascular and cardiovascular disease,
associated nephritis, uveitis, high blood pressure,
etc. Glaucoma, in fact, rarely occurs in indi-
viduals in good general health."
DIAGNOSIS
The diagnosis of congestive glaucoma should
not be difficult even in the early stages, when we
consider the distinct signs that it presents. And
yet we can all recall deplorable cases that have
been overlooked by the optometrist, and also by
the general medical practitioners in which the
eye has been greatly jeopardized or possibly lost
in consequence of such an error. Ignorance in
regard to this dreaded condition should not exist.
General physicians should be impressed with the
importance of the early recognition of it, and al-
though they may do no ophthalmic work should
be able to recognize it, or at least in more in-
sidious cases to suspect it and to refer the case
to the specialist for exact diagnosis.
Errors of recognition are not necessarily due
to ignorance, but may result from oversight be-
cause of the multifarious duties the general prac-
titioner must assume. I recall a recent case
under the care of a physician of no mean at-
tainments, which was being treated for persistent
vomiting. The eyes had distinct congestive
glaucoma but were not painful, although the
sight was much impaired. Such experiences are
not uncommon and suggest the importance of im-
pressing upon the general physician the necessity
of examining the eyes as a part of his general
examination of a case. This would be borne
home to him if he realized that at least one per
cent, of the cases in an eye clinic or in private
practice are glaucoma.
No difficulty should be encountered by the spe-
cialist in the diagnosis of congestive glaucoma
especially if it is once established or is in an
acute stage. The signs and symptoms, all pro-
duced by the increased intraocular pressure are
so familiar to us that they scarcely need more
than enumeration on this occasion. Steamy, in-
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March, 1921
PROBLEMS OF GLAUCOMA— WILDER
369
sensitive cornea occasioning rainbow phenomena
around lights; faint ciliary congestion in acute
stages and engorgement of ciliary veins that
penetrate the anterior portion of the cornea;
shallowing of the anterior chamber and oval en-
largement of the pupil ; more or less haziness of
the media, in consequence of which and also in
consequence of the pressure on the retina, there
is impairment of central and peripheral vision ;
if the condition has existed for any length of
time, more or less cupping of the optic disc is
noticeable, with possible pulsation of veins or
arteries or both ; (in the acute stages, because of
the haziness of the media, one may not be able
to see the details of the fundus) ; pain of vary-
ing degree, according to the intensity of the
acute attack, sometimes in the eyeball, sometimes
simulating a facial neuralgia, or occasionally dull
and ill defined, or of a nature to reflexly excite
'nausea and vomiting ; marked hardness, and in-
creasing tension of the eyeball as determined by
palpation or with instruments. All of these signs
and symptoms form a clinical picture that the
specialist readily recognizes as acute or conges-
tive glaucoma. There may have been prodromal
signs before the attack, but the glaucomatous
condition even then must have been present. •!
like the classification of stages used by Elliot of
early glaucoma, established glaucoma, and late
glaucoma, instead of prodromal, acute, chronic
and absolute of most writers.
It is the noncongestive forms of glaucoma that
present problems of diagnosis often difficult to
young practitioners in ophthalmology, particu-
larly in those cases of so-called simple glaucoma,
in which the intraocular pressure is not at all
times measurably increased. These are the cases
that frequently puzzle us in diagnosis and raise
questions as to treatment. Frequently they pre-
sent little or no impairment of central vision;
the onset of increased intraocular pressure has
been insidious and its progress slow. . The first
intimation of anything wrong may be the dis-
covery in the routine examination of a cupped
disc, and then further examination elicits the
glaucomatous condition. Or the patient may
complain of dull pain, and again of neuralgic
pains in and around the eyes at times, or of
blurring of the vision when reading as if his
glasses do not fit. Such symptoms may indicate
disturbances of accommodation from congestion
of the ciliary body, or disturbance in the refrac-
tive power of the lens from increased pressure.
It may occur in myopes as well as hyperopes.
Probably in these cases of so-called simple
glaucoma the increase in tension is not constant
but intermittent. Before the days of more ac-
curate testing of tension with the tonometer, it
was a question as to whether many of these sim-
ple glaucomas manifested any increased tension,
it being too slight to be noted by digital examina-
tion, but careful tests with the tonometer re-
vealed that, at times, they do. It is in such
cases that we must arrive at the diagnosis by a
study of the visual fields, the central vision, the
appearance of the optic disc and a record of the
tension as taken with the tonometer at various
times.
The fields for white and colors, particularly
red and green, should be taken, not once but fre-
quently, to record the progress of the case. They
should be taken by the same observer each time,
and as far as possible under the same conditions
as to light, environment, background, etc., for
there is no examination that admits of a greater
chance for error on the part of both patient and
observer than a perimetric examination of the
visual fields.
We are all familiar with the various irregu-
larities and contractions of the fields that are
present in simple glaucoma, but certain features
stand out prominently enough to make definite
characteristics. The contraction of the field is
usually, although not invariably, found on the
nasal side. It may be more marked above or be-
lo,w depending upon the pressure upon the optic
nerve. I have thought that the position of the
physiologic cup, whether central or temporal,
might determine in the beginning the character
of the shrinking of the visual field. With the
continuance of the intraocular pressure, the con-
traction of the visual fields proceeds until final
blindness is reached. The color fields usually
contract concentrically with the field for white,
but atrophic processes in the optic nerve may
alter this rule.
The blind part of the field, sooner or later is
found to be in contact with the blind spot of
Mariotte as first pointed out by Bjdrrum, and
both relative and' absolute paracentral scotomas
of Seidel may be demonstrated merging with the
blind spot of Mariotte.
To map out these defects one must use small
objects of I or 2 mm. on a Bjerrum screen or
the excellent instrument devised by Dr. L. C.
Peter, the campimeter, which I find most con-
venient. The discovery of Bjerrum's sign and
the scotomas of Seidel doubtless furnish valuable
testimony in the diagnosis of early glaucoma but,
as has been said, it is a method of examination
that must be accurately done to avoid error.
TONOMETRY
We must always hold to the central feature of
glaucoma, increased intraocular pressure. With-
out increased pressure there would be no glau-
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THE PENNSYLVANIA MEDICAL JOURNAL
March, 1921
coma ; with it all the manifestations of glaucoma
may be present, depending upon the degree and
the continuance of the pressure. In simple glau-
coma, the pressure may not be great, but it may
be continuous. In some cases it may not be
continuous, but may be intermittent. The tono-
meter enables us to determine this with more
accuracy than can be obtained with the fingers.
Furthermore, a record of observations can be
kept so that comparisons can be made from time
to time as to the condition of the pressure, which
could not well be done with digital examinations.
In this lies one of its great values.
With any form of tonometer, errors may arise
from inaccuracy of technique, and with any of
them, however carefully calibrated they may be
on the basis of manometric measurements of
normal intraocular pressure, there will be varia-
tions in results arising from such conditions as
rigid or flaccid coraiea, mild kerato conus, high
astigmatism, regular or irregular, corneal scars,
etc. Its value is a relative one. It may or may
not give us an accurate reading of the intra-
ocular pressure in terms of millimeters of mer-
cury, but it will from day to day, or week to
week, if properly used, give us on the same pa-
tient, the relation of impressibility of the eye to
intraocular pressure.
My preference is for the Schiotz instrument
because of its lightness and accurate construc-
tion. The patient should be lying flat on the
back, so that the face may be in the horizontal
position. One per cent, holocain solution is used
to cause anesthesia of the cornea. The patient
is asked to fix some object on the ceiling so that
the instrument can be placed exactly vertical on
the cornea, the foot plate occupying the exact
center of the cornea. Failure to do this will give
inaccurate readings. I have noticed that two
may work together to good advantage, one hold-
ing the instrument and keeping the patient's gjize
in the right direction while the other makes the
reading.
The instrument should be tested on the arti-
ficial metal cornea frequently to be sure that the
indicator arm registers accurately at zero on the
scale. The instrument must be kept in perleci
condition, so that the plunger glides easily. Nu-
merous observations seem to indicate that the
normal limits of pressure seem to be between 15
mm. and 26 mm. on the Schiotz scale, but there
may be individual cases where 28 mm. or even
30 mm. is normal.
PROBLBMS OF TREATMENT
Here we are confronted with difficulties that
arise from our lack of definite, accurate knowl-
edge of the etiology. Assuming the correctness
of the statement of Fuchs that "genuine glau-
coma develops only in an eye which has a pre-
disposition to it," a dictum with which many will
agree, the question naturally arises, what con-
stitutes such a predisposition? If we knew ex-
actly, we should be on the way toward a rational
prophylaxis. Lacking this definite knowledge
we are forced to fall back on therapeutic meas-
ures that are largely empiric. Most of these
measures aim at combating some of the body
conditions that are supopsed to contribute to the
development of glaucoma. In general they are
reasonable, for they include such measures as
avoidance of excesses in diet and drink, avoid-
ance of worry and hurry, prolonged hours of
work and exhaustion, etc., etc. — ^prescriptions
that are not easily filled by many patients.
Few people realize the sagacity of the advice
of the old medical philosopher that the best phjfc-
sicians to call in are Dr. Diet, Dr. Quiet and Dr.
Merryman. As to local therapeutic measures
they are all directed toward the main feature of
the condition, the increased intraocular pressure,
and are intended to facilitate and promote drain-
age from the eye. We use myotics such as eserin
and pilocarpin and they have unquestionably
shown their efficiency in a degree. The salicylate
of eserin seems preferable to the sulphate, for it
is less irritating, and for continuous use in sim-
ple glaucoma, pilocarpin muriate or nitrate is to
be preferred because of its less irritating effect
on the iris.
The stretching of the iris resulting from the
marked contraction of the sphincter muscle must
draw the root of the iris away from the filtration
angle and allow better circulation through that
part. For the same reason the spaces of the iris
are opened up and are supposed to be better able
•to absorb fluids from the anterior chamber.
One of the most important problems of treat- '
ment is that concerning operation, and particu-
larly concerning operation on noncongestive or
simple glaucoma. In congestive cases the evi-
dence is clearer, for the accumulated experience
of the masters in ophthalmology from Von
Graefe down to those of present times speaks
loudly in favor of operative means to counteract
the increased intraocular pressure. The debate
waxes warm at times in regard to which method
has the greatest value, and iridectomy still seems
to have the best of it, but there seems to be little
dissent from the view that some operative meas-
ure is necessary to bring about an artificial
drainage.
It is different in the case of simple or non-
congestive glaucoma. Here we have a condition
that does not present the immediately dangerous
features of the congestive type, and- Ujere aie
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March, 1921
PROBLEMS OF GLAUCOMA— DISCUSSION
371
those with great experience and skill who main-
tain the inefficacy of operation and rely upon the
powers of myotics and general measures to
maintain the proper pressure equilibrium. How
are we to direct our way in the midst of such
disagreement ? It seems to me that the study of
our cases by means of the tonometer and the
visual fields must furnish the guide. It may not
be amiss to refer to my own rule of practice in
such cases.
If the case can be controlled and general meas-
ures and regular applications of pilocarpin will
keep the tension within normal limits, if the con-
traction of the fields does not continue (the cen-
tral vision remaining normal), operation is not
urged, but the patient is informed of the impor-
tance of regular observation of the case and reli-
giously regular treatment. My observation is
that cases that can be controlled in this way are
few. If, in spite of general treatment and regu-
lar use of myotics, the records of the tonometer
show increased tension at times, even if not
great, and the fields slowly contract, or show en-
,larging scotomas, even if central vision is nor-
mal, operation is advised and urged, the patient,
so far as his intelligence will permit, being made
acquainted with the condition and its dangers.
As to the method of operation to be employed
to accomplish this artificial drainage, the time at
my disposal will not permit a discussion. As in
the past many roads led to Rome, so here many
methods of operation properly performed have
brought kbout the desired result and will do so
again if proper conditions obtain and they are
properly performed. The operations that have
been proposed and championed for this deplor-
able condition are so numerous as to indicate
that the perfect one has not yet been devised.
DISCUSSIOl^
Dr. William Campbell Posfiv (Philadelphia) : The
section is grateful to Doctor Wilder for his splendid
resume of this very important subject and for his own
personal •views regarding treatment,- etiology, etc.
He has dwelt upon the difficulties in diagnosing early
cases of chronic noncongestive glaucoma and empha-
sized the desirability of frequently taking the tension
with the tonometer and of studying the fields of vision
in this class of cases. I believe with him that many
cases of chronic noncongestive glaucoma are not rec-
ognized until they are so far advanced that treatment
is very problematical.
Referring at once to the important subject of treat-
ment, and leaving out of the question the inflammatory
types, what are we going to do in noninflammatory
cases ? Doctor Wilder has given, you his own views in
regard to that— employing myotics and continuing their
use as long as they keep the tension down, watching
the fields of vision deteriorate or a scotoma or limi-
tations appear in the peripheral field of vision. I think
every sane man must agree with him in following such
a line of treatment. I agree with him that myotics will
rarely exercise such a control, because chronic glau-
coma is a progressive disease and notwithstanding the
use of the drug the eyeball gets gradually harder and
the field of vision more and more compromised. But
each case must be studied by itself before deciding
upon the treatment to be followed.
Quite recently I saw a lady who had lost the left
eye as the result of chronic glaucoma. While the cen-
tral vision in the right eye was still normal, she had
a large reentering angle in the temporal field, a vision
of about one-fifth of normal; tension 33°. She was
sixty-nine years of age. What are you going to do
with a case of that kind? We realize that operation
is not unattended by danger in cases of that nature.
At sixty-nine years of age, the probability is that she
will not live a great many years, four or five, perhaps,
or eight or ten at the longest. Having followed a
good many cases of this kind, I feel pretty sure that
myotics may hold her vision pretty much as it is for
such a period. Indeed I have seen similar cases hold
their vision for a great many years under the use of
myotics, whereas if an operation is performed, I do
not care by whom or by what procedure, not infre-
quently vision fails immediately after the operation.
So in this particular case I said I thought operation
would be unwise and advised the continuation of
myotics. On the other hand, I have in mind a case, a
married woman of about thirty, who had lost the
vision of her left eye by glaucoma and the vision in
the remaining eye reduced to one-tenth of normal by
the same disease. Tension 45° and a much compro-
mised field of vision. Realizing that something radical
had to be done and the unlikelihood of the patient's
being willing to continue the use of myotics for the
remainder of life, even if they continued to be eflica-
cious, an iridectomy was performed, and greatly to
my surprise and gratification, there has been a steadily
improving vision ever since, five years or more now
having elapsed since the operation. Therefore the age
of the patient must guide you very largely in regard
to your treatment, and as a general rule, in subjects
under forty-five or fifty I would prefer operation,-} re-
serving myotics for older patients.
Dr. EuwArd StierEN (Pittsburgh) : I, too, wish to
express my appreciation of Dr. Wilder's excellent
paper. He has left little to be said. Of course all of
us in our experience with glaucoma make individual
observatiotis. One thing that has struck me in record-
ing the vision, is the effect of the sympathetic nervous
system on the glaucomatous condition causing a re-
duction in visual acuity. Time and again old people
come in, usually from some miles out of the city, and
when you first take their vision it will apparently be
much lower than it was before. But allow those pa-
tients to rest for a while, to enable them to regain
their equilibrium, and you will be surprised how much
their vision improves. '
In regard to the therapeusis of glaucoma, I find it
to be a distinct advantage to instruct the patient in
massaging the eye. We all know that when taking the
tension with the finger you can feel the eye become
softer after a minute or two of palpation of the globe,
and it is my custom to instruct patients in daily and
regular palpation of the globe.
Dr. J. Ferdinand Klinedist (York) : Doctor
Wilder has given us an excellent and clean-cut expo-
sition of the two forms of chronic glaucoma that are
most common. In regard to the treatment of the non-
congestive form, I want to call attention to a treat-
ment that has been effectual in many af my^c^e^lh^i^
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372
THE PENNSYLVANIA MEDICAL JOURNAL
March, 1921
is the method of using myotics as suggested by Dr. W.
C. Posey. Begin with weak solutions and increase
them gradually, continuing as long as the vision and
fields do not decrease, and the disease is held in check.
I have used this method for three years and propose
to stick to it until we find some better treatment.
Dr. William H. Seaks (Huntingdon) : I want to
ask Doctor Wilder one question: Have you difficulty
in the management of patients who come to you with
but one eye affected with simple glaucoma; that is in
getting them to appreciate the fact that without proper
care and continued treatment, they will inevitably lose
the sight of this eye and that the other eye will even-
tually be affected by the same process?
Dk. William H. Wildes (in closing) : I am very
glad indeed, that your chairman threw this address
open for discussion, for an address accomplishes its
greatest purpose only when it excites interchanges of
views and opinions. Of course, I could not in the
time allowed to me, or the time I thought should be
properly allotted to me, do anything more than bring
out some of the features that seem to stand out rather
more prominently than others.
In regard to tiie question of Doctor Sears, it will
depend altogether on the degree of intelligence of the
patient how he will react to any suggestions made to
him in regard to treatment. Of course, if his intelli-
gence pennits, one can explain to him something of
the nature of the case and take him into one's confi-
dence. But there will be difficulty, even with a person
of intelligence; it is really more of a matter of tem-
perament
I think we must take the attitude in regard to glau-
coma that we are not dealing with a disease entity,
but with a symptom complex, the pathogenesis of
which has riot yet been brought to light When we are
treating one prominent part of a symptom complex,
that is, hypertension of the eye, which is another word
for intraocular pressure, we must relieve that pres-
sure in some way. It may be some of us will live to
see the day in this wonderful age when new things are
constantly coming to light, when we will understand
what it is that lies at the bottom of this intraocular
pressure which we call glaucoma; but until that day
comes, we must simply treat the symptoms.
And so we have a condition that is at present a
difficult one, and we must call in every possible aid.
T purposely refrained from going into the discussion
of the merits or demerits of certain operations. We
all have our preferences. We get somewhere with one
kind of operation in one case, and it may not fit the
next case. The chief reason is that as yet we do not
know the pathogenesis of the condition.
ORIGINAL ARTICLES
BLOOD PRESSURE GUIDES DURING
ANESTHESIA AND OPERATION*
ALBERT H. MILLER, M.D.
PROVIDENCE, RHODE ISLAND
The condition known as shock is an acute
prostration of the vital functions. Such a con-
dition resulting from surgical traumatism is
'Read before the Joint Meeting of the Medical Society of the
State of Peonqrlvania, the Interstate Association of Anesthesists
and the National Anesthesia Research Society, Pittsburgh Ses-
sion, October 7, 1930.
designated surgical shock. In view of the con-
fusion attending our ideas of surgical shock, it
is well to restrict the use of this term to the lim-
its of the definition, employing other designa-
tions for the effects of hemorrhage or of anes-
thetic drugs.
From a review of the reports of several hos-
pitals, it appears that from 15% to 45% of the
postoperative mortality is ascribed to surgical
shock. These fatalities occur not only among the
serious cases but following such trivial opera-
tions as incision and drainage, minor amputa-
tions, the reduction of simple fractures, and un-
complicated appendectomies. We cannot con-
tinue to be satisfied with our diagnosis of sur-
gical shock in these cases without a more careful
study of the subject than has been made in the
past.
Considering the frequency with which the
diagnosis of surgical shock appears, in trivial as
well as among serious cases, it seems reasonable
to require that routine blood pressure examina-
tions be made in every operative case.' The sys-
tolic and diastolic pressures are to be taken by
the ausculatory method and recorded at the pre-
liminary examination, at five- or ten-minute in-
tervals during each operation, and as frequently
following operation as may be indicated by the
condition of the patient at the termination of
operation. The topics for investigation include
the effects of surgical traumatism, and of other
factors found to modify the blood pressure dur-
ing operation — as the temperature of the operat-
ing room, the posture of the patient, an obstruc-
tion of the air-way, the patient's organic defects,
the effect of hemorrhage or of anesthetic drugs.
EFFECTS OF SURGICAL TRAUMATISM
Accepting the blood pressure as a reliable in-
dex to shock, if the usual conception of surgical
shock were correct, we should expect to find a
distinct fall in blood pressure attending every
severe surgical operation and the effect should
be more pronounced in case the patient had not
the protection supposed to be afforded by deep
anesthesia. On the contrary, routine blood pres-
sure work shows that if the factors other than
surgical traumatism be favorable, the most se-
vere surgical manipulations may regularly be
performed without marked change in either the
blood pressure or the pulse rate. Given a
smooth, light anesthesia, an operating room at a
temperature between 70" and 80° Fahrenheit, an
organically sound patient, the dorsal position,
protection from hemorrhage and from obstruc-
tion to the respiration; gastroenterostomy, in-
testinal resection, cholecystectomy, complete
proctectomy, and major amputations are rega-
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March, 1921
ANESTHESIA AND OPERATION— MILLER
373
larly accompanied by no marked change in the
blood pressure. This is a statement not of the-
ory but of fact and can be demonstrated from
the blood pressure charts of hundreds of opera-
tions. It is not the intention to state that shock
cannot be produced by surgical manipulations
but that, in the present development of surgical
technique, the condition diagnosed as surgical
shock usually results not from surgical trauma-
tism but from other factors which if understood
might be controlled.
EFFECT OF HEMORRHAUE
In the presence of considerable hemorrhage,
the blood pressure may fall steadily with a corre-
sponding increase in the pulse rate or both pulse
and blood pressure may remain stable for some
time and then suddenly give way. In a case of
persistent hemorrhage from the hepatic vein, the
pulse and blood pressure were unaffected for
thirty minutes. During the next ten minutes the
systolic pressure changed from 150 to 90, the
diastolic from 1 10 to 80, the pulse pressure from
40 to 10, and the pulse rate from 92 to 132. In
such a case, a knowledge of the circulatory con-
dition, as shown by the blood pressure readings,
is of inestimable value to the surgeon.
INFLUENCE OF THE PATIENT'S CONDITION
While the blood pressure of vigorous patients
is more stable, in the cases in which resistance is
seriously lowered from any cause, a progressive
drop in the systolic, diastolic and pulse pressures
results from factors which ordinarily would not
affect the blood pressure. The patients suffering
from tradhiatic or surgical shock are especially
susceptible to the effect of the anesthetic. These
cases may be safely and satisfactorily anesthet-
ized with a very small amount of the anesthetic,
but under the usual dosage rapidly develop a
dangerous drop in blood pressure.
The blood pressure of stout patients, espe-
cially those with damaged hearts, is susceptible to
changes in posture and to protracted abnormal
postures. The blood pressure readings are a re-
liable guide to the hmit of safety in such cases.
A number of patients suffering from exophthal-
mic goiter or from cardiovalvular defects, espe-
cially those of the aortic valves, exhibit a phe-
nomenon which has not been explained. While
under the anesthetic and for some hours follow-
ing, the fifth blood pressure phase, which may
previously have shown the usual relation to the
fourth, sinks to zero. As the diastolic pressure
in these cases is obviously not zero, we here find
a powerful argument for reading the diastolic
pressure at the fourth rather than the fifth phase.
EFFECT OF RESPIRATORY OBSTRUCTION
The systolic pressure varies during the respi-
ratory cycle, being less during inspiration and
greatest at the beginning of expiration. If the
air-way is obstructed from any cause, the varia-
tion becomes greater, amounting in some cases to
50 mm., the" systolic and pulse pressures being in-
creased, with little variation in the diastolic pres-
sure. If the obstruction persists, there is a steady
fall in the systoHc and diastolic pressures. Respir-
atory obstruction is not always immediately no-
ticeable and the cause is sometimes difficult to lo-
cate. In these cases the blood pressure is a guide
of great value. A frequent cause of a partial ob-
struction of the air-way is the neckband of the
patient's shirt, which becomes tightly drawn across
the trachea as a result of moving the patient on
the table. A falling blood pressure may quite fre-
quently be traced to dyspnea due to the weight
of a surgical assistant resting on the patient's
chest. The steady decline in blood pressure dem-
onstrates that this is a vicious practice which
must be immediately and effectually corrected.
EFFECT OF TEMPERATURE
In an operating room at a temperature of 50°
Fahrenheit, with the exposure of viscera required
for an intestinal resection, the systolic pressure
declines steadily at the rate of a millimeter a min-
ute. If the condition is recognized and the room
is quickly heated, the blood pressure soon recov-
ers. A drop in blood pressure, usually but not
always transient, results from hot or cold appli-
cations to extensive visceral or muscular surfaces
or from irrigation of body cavities with hot or
cold solutions. In these cases the blood pressure
is a warning and a guide.
EFFECT OF POSTURE
A sudden change in the position of the anes-
thetized patient results in a distinct drop in blood
pressure. In several instances the change from
dorsal to Trendelenburg position has been imme-
diately followed by a fall of 60 mm. in the sys-
tolic pressure. This change was not accompanied
by an immediate effect on the pulse rate. The
change from the dorsal to the prone position has
an even greater effect on the blood pressure.
Usually but not always, this fall in blood pres-
sure is quickly rectified. In one instance, a pa-
tient who had undergone a breast amputation was
propped up in the sitting position for the appli-
cation of the bandage and immediately died.
Protracted use of abnormal postures may re-
sult in serious blood pressure changes. The dor-
sal is the position of choice for the anesthetized
patient. In the lithotomy position the systolic
pressure is increased. There is a further increase
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374
THE PENNSYLVANIA MEDICAL JOURNAL
March, 1921
if the hips are elevated. In the Trendelenbufg,
the reverse Trendelenburg, or the pfoHe pOsittoH
the systolic ptessut'e steadily declines, 'fhese
bhanges are more pronounced in case the patient
is profoundly anesthetized. As a result of the
routine use of the Fowler postoperative position,
many patients with resistance already otherwise
impaired, have undoubtedly died. The use of
this position must be condemned unless the pa-
tient's condition is first proved satisfactory by
blood pressure tests.
During the induttian of general dnesthesii)
there Is frequently i rise in the systolic pi-essufe;
iiohietimes aniOunting tb 36 nini. "this chailge is
transieht dtid withirt twenty Winutes f i-oni the be-
ginning of anesthesia the average pressure should
irest at the usuial level. As the anesthesia prog-
resses, there is a steady decline in the systolic
pressure but, under a light degree of anesthesia,
the fall in blood pressure during an operation of
the customary duration is so slight that it is not
generally noted. A profound anesthesia is ac-
companied by a marked decline affecting the
systolic, diastolic, and pulse pressures.
Anesthesia may be considered under three
headings according to the effect on consciousness,
o«i the muscular system, and on the vital func-
tions. The classical signs of so-called surgical
(inesthesia depend upon the effects on conscious-
ness and on the muscular system and disregard
the effect on the vital functions. As a result, it
happens that a patient who is suffering from an
overdose of the anesthetic, with a falling blood
pressure, a cold skin, a profuse perspiration, and
Cheyne-Stokes respiration may still show the
signs of insufficient anesthesia. Often enough a
patient has died of anesthetic overdosage when
the surgeon was complaining of insufficient mus-
cular relaxation and urging the anesthetist to get
the patient under. In such cases, the blood pres-
sure tests, closely measuring the effect of the
anesthetic upon vital functions, become the most
valuable indication of overdosage or approaching
overdosage of the anesthetic. The strenuous pa-
tient may survive a tremendous overdosage but
in the cases of vital depression, as from trauma-
tic shock or hemorrhage, a shght overdosage tips
the scale to the side of failure. The fatality is
attributed to surgical shock but the blood pres-
sure evidence indicates that the effect of the sur-
gical traumatism is usually negligible in com-
parison with anesthetic overdosage.
VALUE OF BLOOD PRESSURE IN OPERATIVE SURGERY
Besides opening the interesting and important
field of study which has been described, the blood
pressure tests are often of great immediate value
in operative surgery. Itl the preoperative ej«aml»
nation in detecting nephritis or cardiovalvulaf
lesions, in estimating the gravity of Cardiac de-
fects and in determining the degree of vital de-
pression from hemorrhage or traumatic shock,
these tests are of incomparable usefulness. The
rule of C. W. Moots for estimating the vital re-
sistance in terms of the blood pressure ratio is
of considerable value. "If the pressure ratio, a
fraction having the pulse pressure as numerator
and the diastolic pressure as denominator, is high
or low there is reason to apprehend danger. If
the pressure fitio lies between 35 per cent, and
75 per tent.i the tkse is probiblv operable} if
outside these llmitsj it is probibly inoperatlle."
During the operatiotlj blood pressure reudingS
warn us of the presence of injufious fdetdrs
which we aim to avoid and, in unavoidable vital
depression from shock or hemorrhage, furnish a
reliable index to the degree to which the depres-
sion may, with a fair amount of safety, be al-
lowed to progress. In these cases, the rule of E.
I. McKesson may be confidently accepted and
followed. "With a diastolic pressure of 80 mm.,
a pulse pressure of 20 mm., and a pulse rate of
120, a critical point has been reached. After a
half hour of sustained low pressure and rapid
pulse has been passed, almost every patient suc-
cumbs either shortly or within three days."
CONCLUSIONS
Despite opinions to the contrary, a working
definition of the condition of surgical shock can
be made and followed. The blood pressure is
our most certain guide to the condition of the
circulatory system.
Most of the fatalities attributed to surgical
shock are due to factors other than surgical
traumatism which, if understood, might be con-
trolled.
The fact that a majority of surgeons and an-
esthetists overlook the importance of blood pres-
sure tests in their work is difficult to explain.
131 Waterman Street
DISCUSSION
Dr. E. I. McKesson (Toledo, O.) : We have gen-
erally neglected the use of blood pressure during sur-
gical operations, except in a few localities and, as Dr.
Miller said, the reason is not apparent. It seems in-
credible that such a valuable guide and aid to both
surgeon and anesthetist in his work should have been
neglected. Nevertheless we hear some who say that
they have no time to take the blood pressure. The
change in posture to which Dr. Miller has referred is
a very important factor in promoting circulatory de-
pression, so that in my present work I prefer and in-
sist upon keeping the patient fairly in the same posi-
tion in which he has been anesthetized. For instance,
if the patient has been anesthetized in the recumbent
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March, 1921
THIRD STAGE ETHER ANESTHESIA— GUEDEL
375
posture, a sudden deep Trendelenburg position is a
thing against which I cannot too strongly advise, be-
cause in many cases I have seen very serious circula-
tory depression follow. Now the depression may not
occur instantly, but as a rule it does follow shortly.
It may come on a little later as the result of embar-
rassment, especially in a fat patient.
There are many factors which influence the blood
luessure, and one who is interpreting blood pressure
changes in a surgical operation must be keen, he must
be watchful, he must know what the anesthetist is
doing from the anesthetic standpoint, he must know
what the surgeon is doing and must have a clear con-
ception of the patient in order to properly locate causes
of depression. Heat applied to large areas, such as
applying a large hot pack to an amputated breast area
for the purpose of contracting the arteries, or small
blood vessels, stopping the oozing, is one of the most
productive causes of depression of which I know. I
have many times seen a fall of blood pressure from a
good pressure to a complete shock inside of five min-
utes. The patient may not die because he may have
enough comeback or reserve power in the heart muscle
to bring the pressure back up in the course of a few
minutes. In other cases if you have already exhausted
that power, or the reserve, you can expect trouble.
The depth of the anesthesia in its relation to blood
pressure is also a very important subject and if we do
not take blood pressure during our operations we have
closed our eyes to one of the most important guides as
to the depth of anesthesia and what we are doing to
the patient. We can run a patient in a light smooth
anesthesia and have the patient in good condition at
the end of the operation; or we can run a patient in
a deep anesthesia and initiate shock which will result
in the death of the patient inside of three days. It is
possible to do that if we do not observe the blood pres-
sure. I believe it is being done more frequently than
we can imagine. So I cannot too strongly urge the
general observation of blood pressure, especially in
the class of cases we call major operations.
Dr. Joseph E. Lumbard (New York City) : I un-
derstood Dr. Miller to say that shock can well be de-
fined? If so I would like him to define it. Many doc-
tors have increased their blood pressure when attempt-
ing to define shock in court.
Dr. C. C. McLean (Dayton, O.) : You asked the
blood-pressure experts to discuss the paper. If the
experts are through I should like to say a few words.
I do not want to be classed as an expert on blood
pressure. I feel that I know nothing about blood pres-
sure and I am only on my feet to urge that the anes-
thetists who are here will begin taking the blood pres-
sure of their patients under anesthesia whether they
know anything about it or not, or whether or not they
can interpret the fine points of the diastolic and sys-
tolic sounds. Begin and learn ; learn to use it. I have
been using blood pressure for only a short time — too
short, I am sorry to say, and the knowledge I have
gained has been wonderful, both to myself and the
surgeon. My plea to the surgeons who are present is
that the next case they operate that they insist on the
anesthetist putting on a blood pressure outfit and fol-
lowing that through the work. Whether or not he
understands the diastolic or systolic interpretation, it
will mean something to them. Keeping a record will
be a help both to the anesthetist and surgeon.
Dr. F. H. McMechan (Avon Lake, O.) : In behalf
of the National Anesthesia Research Society I should
tike to inform those in attendance of the existence of
a new uniform anesthesia record which has been drawn
up by a special committee of experts to assist all those
who wish to protect their patients imder anesthesia
with blood pressure guides. This uniform record was
originated and based upon the suggestions of perhaps
the most noted surgeon that Pennsylvania has ever
given to the world. I allude to Dr. W. W. Keen, of
Philadelphia. In correspondence with Dr. Keen, Dr.
A. H. Miller, of Providence, R. I., secured the basic
facts and conditions upon which such a uniform chart
should be established. Then Dr. Miller, in collaboration
with Dr. E. I. McKesson and Dr. A. F. Erdman, de-
vised a chart which the National Anesthesia Research
Society has approved and is distributing to hundreds
of hospitals that are cooperating in its use and in tabu-
lating the recorded results.
This record is calculated to do three things: It de-
mands first of all that the condition of every opera-
tive patient be primarily determined as to the surgical
risk involved. Then that every patient operated tmder
a general, or even a local, anesthetic shall have five-
minute blood pressure readings throughout the course
of operation to determine whether that patient is still
in the zone of safety, or whether there is a demand
for therapy to counteract shock or any variable degree
of circulatory depression. Third, this chart is cal-
culated to find out in what condition the patient leaves
the table, whether in the first, second or third degree
of circulatory depression, so that that patient may be-
given all the benefits of medical and surgical knowl-
edge in promoting recuperation. We hope in coop-
erating with himdreds of hospitals, surgeons and anes-
thetists, that by these uniform records, .when collected
in large series and tabulated, we will be able to present
to the profession some of the most wonderful studies
in blood pressure guides and the results of protecting
patients. Thus we will have initiated and carried
through a tremendous safety-first movement for anes-
thesia. In order that you may all understand this plan
and appreciate the value of the record we will have
samples of these records distributed so that you may
see exactly the work that we are doing in the Research
Society.
Ds. Albert H. Miller (closing) : Shock is defined
in the dictionaries as a condition of acute prostration
of the vital functions. In traumatic shock the pros-
tration is caused by injury or violence. Surgical
shock is such a condition resulting from surgical trau-
matism. It seems to me that we should accept the
definition of shock as stated in the dictionaries and
that those conditions which do not agree with the defi-
nition should be put under some other heading.
THIRD STAGE ETHER ANESTHESIA*
A SUBCLASSIPICATION, WlTH SIGNIFICANCE OF POSITION
AND Movements op the Eyeball
ARTHUR E. GUEDEL, M.D.
MINNEAPOLIS, MINN.
This paper has been delivered in the form of a
lecture before the Interstate Association of Anes-
thetists, Cincinnati, 1919; before the Indiana
State Medical Association, Indianapolis, 1919,
and the Indianapolis Medical Society, April,
1919. The paper and the accompanjring scheme
'Read before the Joint Meeting of the Medical Society of the
State of Pennsylvania, the Interstate Association of Anesthesists
and the National Anesthesia Research Society, Pittsburgh Ses-
sion, October 7, 1920.
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376
THE PENNSYLVANIA MEDICAL JOURNAL
March, 1921
of illustration were used by the writer many
times in teaching anesthesia with the A. E. F. in
France.
The objects in presenting the paper are two:
first, to encourage lighter and more even ether
anesthesia ; and second, to present some tangible
form for the didactic teaching of better anes-
thesia to students. The literature up to date
mentions four stages of anesthesia: the first
stage, during which the patient 'experiences
analgesia but does not lose consciousness; sec-
ond, the stage of excitement ; third, the surgical
hour in the deepest part of the third stage widi
sifety so far as immediate anesthetic accident is
concerned, but the postoperative toxemia vill be
great. Light anesthesia, if it be acceptable to the
surgeon, is infinitely better than deep aneshesia.
We have known this for a long time, but have
not known that there is a light stage of surgi^j
anesthesia which affords the surgeon as mudi
ease and comfort in operating as the state of
deepest third stage anesthesia. We have often
stumbled on to this stage, which is one of quie-
tude and tranquility, but being usually alarmed
soRniTic cHiXt saovvo the sicatrictfci or
CERT AIM txnxaa mm vuiioos staots
or ZTBER AIESTBESU.
Stkgas of
R*ntr«iiOB
trnrmx
Vp aad Soak
MovMant
Third-stage Btber An«Btbesia
stage, and fourth, that stage beginning with ces-
sation of respiration and ending with cardiac
paralysis and death.
Modem anesthesia requires more than this.
The knowledge that the patient is in the third
or surgical stage is now not sufficient. We
should be able to determine at any time in just
what part of the third stage we are carrying the
anesthesia. The latitude of third stage anesthe-
sia with ether is great, so great that the patient
may easily be given more than necessary without
being in any immediate danger. Post operative
toxemia is usually in direct proportion to the
amount of ether administered. The patient may
be carried lightly with good relaxation and
quietude and suffer but light postoperative tox-
emia from the ether, or he may be carried for an
by the apparent respiratory depression, would
withdraw the ether, and lose its effect.
Many of our anesthetists, even to-day, slate
that it is necessary to watch only the respiration
of the patient in order to determine the d^;ree
of anesthesia present. However, our better
anesthetists realize that they must take note of
every available sign in their work if they are to
do it well. In my experience, which include
over 10,000 cases conducted personally and by
my assistants in France, the eyeball with its posi-
tion and movements has afforded a sign which,
in proper classification, is reliable. Oscillation
marks the stage of ideal anesthesia after the fir^
ten or fifteen minutes of administration has
elapsed.
I have divided third stage ether anesthesia into
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March, 1921
THIRD STAGE ETHER ANESTHESIA— GUEDEL
377
four strata. The accompanying chart presents
a correlation of the various signs found in the
different strata of the third stage. Attention is
called in this paper only to the third stage, inas-
much as there is nothing new to be said of the
first, second and fourth stages. The chart con-
sists of columns A, B, C, D, E, and F, and takes
into considerati<Mi various signs separately and
in conjunction with each other.
Column A, showing respiration with anes-
thesia GOING DOWN
There is no regularity or rhythm to the res-
piration of the second stage, or the stage of ex-
citement. From experience we recognize the
transition from the second to the third stage. by
the inauguration of respiration that is rhythmical
and exaggerated. The exaggeration is marked
and continues so almost without change, pro-
vided there is a continuance of sufficient ether
to carry the anesthesia progressively downward
throughout the first, second and third strata of
the third stage. However, as the fourth or deep-
est stratum of this stage is entered, the respira-
tion shows beginning depression. This depres-
sion continues progressively downward through
the fourth stratum until its complete cessation
marks the transition into the fourth stage.
Column B. respiration with anesthesia
COMING UP
After respiration has ceased as the fourth
stage is n^lected, the ether is removed and res-
piration started by artificial means. It will begin
as it left off, with shallow movements. As the
patient unloads his excess of ether cc»ning up,
the respirations grow in depth progressively, the
rhythm being maintained, until the upper border
of the fourth stratum is reached. Here there is
an exaggeration corresponding to that in Column
A at the same level. As the patient continues
to come out, this exaggeration continues as in
Column A, throughout the third and second
strata. As the lower border of the first or upper
stratum is reached there occurs the beginning of
a quieter respiration. Why respiration should
become quiet at this point with anesthesia com-
ing up, I do not know ; but it does. It becomes
progressively quieter as the first stratum is tra-
versed upward, until at the upper border it
apparently almost ceases. This is just before the
patient comes out to the coughing or vomiting
state. This respiratory state of great" quietude
has often alarmed us and not infrequently has
caused the surgeon to pause in his work to in-
quire the condition of the patient. True, to one
who has not been watching closely the progress
of the anesthesia, one who judges the degree of
anesthesia by the respiration alone, the finding
suddenly of this quiet respiratory stage is apt to
be alarming. Under the old rule of "When in
doubt, wait," which by the way is always a good
rule to follow, the ether would be removed and
the patient soon found vomiting or becoming un-
quiet. However, there need be no doubt about
the degree of anesthesia here. The question to
be decided is a simple one. Is the patient just
ready to come out, or to go out ? In other words,
is he in the first stratum of the third stage, or in
the fourth stratum? The answer to this lies in
the eyeball.
Column C. the eyebali,: its movement or
its position
The eyeball offers one of the most important
signs in anesthesia to-day. As long as the eye-
ball is oscillating or is in an eccentric position,
though stationary, there is no danger that too
much anesthesia has been given. Aside from ex-
traneous circumstances, such as positional as-
phyxia, hemorrhage, shock, etc., if the eyeball is
moving or is stationary but eccentric, the patient
is safe and in good condition.
As the patient enters the first or upper stratimi
of the third stage, either from above or below,
there is manifest a partial paralysis of the motor
occuli muscles. Either there will be an inter-
mittent contraction and relaxation, or variations
of these, causing a rhythmical oscillation of the
eyeball, or there will be a stronger tonic contrac-
tion of one set more than of another, resulting
in a stationary but eccentric globe. Occasion-
ally in the alcoholic, or the individual of high
reflex nervous tension, in place of the above
there will occur a peculiar slight twitch of the
globe, usually in a lateral direction. This twitch
may not occur until from three to five seconds
after the lid has been raised for inspection,
therefore this inspection should not be momen-
tary. When this twitch does occur, whether late
, or early, it means tl^^ same thing as above,
namely, that there is only a partial and not a
complete paralysis of the motor occuli muscles.
Whether there be a rhythmical oscillation, an
eccentric stationary globe, or the twitch just
mentioned, the meaning is the same : the patient
has not had too much anesthetic and, other things
being equal, he is in the ideal stage of surgical
anesthesia.
As seen in the accompanying chart, the motion
or eccentricity of the eyeball is greatest at the
extreme upper border of the first stratum of the
third stage. As anesthesia progresses downward
from here this motion or extreme position de-
creases progressively until the second stratum of
the third stage is reached. The transition from
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378
THE PENNSYLVANIA MEDICAL JOURNAL
March, 1921
the first to the second stratum is marked by the
cessation of the eyeball movements, or by the
change from eccentric stationary to centric sta-
tionary position of the globe. This is the point
at which the paralysis of the motor occuli muscle
becomes complete. With anesthesia going down
there is no further movement of the eyeball, no
further contraction of any of the motor occuli
muscles.
With hospital anesthesia as it is conducted to-
day, with the hurry to have the patients ready
for the waiting surgeon, they are forced under
rapidly, either with straight ether or with the
nitrous oxide, or ethyl chloride, or other ether
sequence. They are usually taken to the knife
before there has been time to "even them up,'*
or before they have settled down to an even ether
saturation. Consequently at first there is a
deeper degree of anesthesia necessary to quiet
relaxation than that indicated by the partial
paralysis of the motor occuli muscles. Here it is
up to the anesthetist to put the patient, in the be-
ginning, down to the second or even the third
stratum as herein illustrated, but to allow him
to come up to the first stratum, that of the oscil-
lating or eccentric eyeball, as soon as possible,
and to maintain him there. In this stage the pa-
tient presents a better operative general condition
than in the second or third stratum, because of
the tranquil respiration. As a rule it is as sat-
isfactory to the surgeon as the fourth or deepest
stratum.
In anesthesia with ether, carried for an hour
or more, if the eyeball be kept oscillating the pa-
tient will usually emerge shortly from the anes-
thetic and there will be less nausea and depres-
sion than we have formerly experienced. By
watching the eyeball, internes are conducting
better anesthesia than before.
If it were always possible to use as much time
as one desired in the induction of ether anes-
thesia, the patient could, in the course of fifteen
minutes or so, be carried gradually to this first
stratum of the third stage and anesthesia be there
maintained throughout the operation. But for
some inexplicable reason in most hospitals the
idea of saving time is to start the operation. Its
finish may come when it will.
In finishing the consideration of Column C of
the chart, it is important to say that when the
respiration is found very quiet and seemingly
depressed to a considerable degree, the eye must
be inspected. If the eyeball is oscillating or
eccentric the stage of anesthesia is right and
ether should be continued. If the eyeball is sta-
tionary on center with the pupil dilated, the anes-
thesia is too deep, and ether should be discon-
tinued at once.
Column D. pupil without morphine
Morphine is so universally and properly used
as a preanesthetic narcotic, either alone or in
combination with other drugs, that this column
is of only relative importance. Before the gen-
eral advent of the use of morphine for this work
we were taught that the pupil may be dilated, but
that it must react to light. Without morphine the
pupil in the average case does not begin its dila-
tion until the lower part of the second or upper
part of the third stratum is reached. Therefore
the dilated pupil, even without morphine, is an
indication of anesthesia too deep.
Column E. pupil with morphine
The statement has often been made that when
morphine is given in combination with atropin
in the usual proportions of 1/4 and 1/150, the
pupillary reflex will be the same as when no
morphine is given. This is not true. With this
combination the pupil will not as a rule dilate as
early in anesthesia as when no morphine has
been given. ,
It is safe to assume that when morphine hjis
been given, no matter in what combination, a
dilatation of the pupil in the conduct of anes-
thesia is a manifestation of careless technique on
the part of the anesthetist.
Note: Neither Column D nor E of the chart
can be considered accurate for all cases. But
though they may not be accurate, they are suffi-
cient to show that in neither case is it necessary
to have any dilatation of the pupil in order to se-
cure quiet and relaxed anesthesia.
An apropos note is here in order. No anes-
thesia can be safely relaxed and quiet, no matter
how much ether is given, if the respiratory pas-
sages be not kept freely open, or if the patient
be suboxygefiated. Where the respiratory pas-
sages cannot be kept constantly open, pure oxy-
gen should be administered, whether through the
ether or separately. Only thus in certain cases
can the patient be relaxed.
Column F. the larynx ; its movements
Although an ancient sign, this movement of
the larynx is not to be ignored, especially in this
classification. With the eyeball moving or eccen-
tric the danger in conduct of the anesthesia is
not that the patient may "go out," but that he
may "come out." There is usually at all times
a rhythmical movement of the larynx up and
down with the respiration. There is always the
exaggerated movement of this organ up and
down with swallowing. The latter is well mani-
fest in the induction period.
This movement of the larynx in swallowing
is of importance here in that it assists the anes-
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March, 1921 THIRD STAGE ETHER ANESTHESIA— DISCUSSION
379
thetist in guarding against vomiting during the
operation. With anesthesia coming up, at the
extreme upper border of the first or upper
stratum of the third stage, just before the patient
comes out to the vomiting or second stage, there
will occur in the average case an exaggerated
up-and-down movement of the larynx, half a
minute or so before vomiting takes place. If the
little finger of the mask-holding hand be allowed
to rest over the larynx, this exaggerated move-
men may be detected immediately it begins.
There is yet time to increase the amount of ether
gradually, sufficient to carry the patient back
where he belongs without permitting retching or
vomiting. I say gradually, because if at this
stage a concentrated ether vapor be suddenly ad-
ministered, there will uspally follow laryngeal, or
pharyngeal spasm, with coughing.
Although this paper is intended primarily to
cover the third stage of ether anesthesia, the sig-
nificance of the eyeball in this classification is not
limited to ether alone. These signs hold good
with any anesthetic agent now commonly in use,
no matter what attention has been paid to pre-
anesthetic narcoticfs. Morphine in any combina-
tion does not influence them. Neither does chlo-
ral or its allied drugs. The eyeball signs are con-
stant.
Nitrous Oxid-Oxygen. — With this mixture
alone, I have never been able to get a patient
anesthetized beyond the stratum of the oscillat-
ing or eccentric eyeball where the anesthetic was
properly conducted. Proper nitrous oxid-
oxygen anesthesia requires a pink or rose-colored
patient. As long as this color is maintained it is
quite out of the ordinary, if not impossible, to
carry the anesthesia beyond the first stratum as
herein illustrated. In improper anesthesia with
this agent, the asphyxial element being allowed
to enter, it is of course quite possible to so intoxi-
cate the patient with carbon dioxide that there
will occur a complete paralysis of the motor
occuli muscles and a complete dilatation of the
pupil. This is inexcusable technique.
Ethyl Chloride. — Properly handled, this agent
is an excellent substitute for nitrous oxid and
therefore deserves mention. There is much that
is new in the way of observation of the action
of this agent that cannot be considered here.
Suffice it to say, that with ethyl chloride, admin-
istered slowly, as long as there is maintained
only a partial paralysis of the motor muscles of
the eyeball, the anesthesia is quite safe. Ethyl
chloride should not at any time be given beyond
this point.
CONCLUSIONS
1. This is a plea for lighter and better anes-
thesia.
2. It is a plea for better teaching of anesthesia
in our medical schools and hospitals.
3. As long as we note any movement or eccen-
tric position of the eyeball, aside from that which
might be normal for the occasional patient, that
patient has not had too much anesthetic; but
after anesthesia has been well inaugurated, he
has had quite enough.
4. The upper part of the third stage, namely,
the first stratum, is anesthesia entirely as satis-
factory to the surgeon as the second, third or
fourth stratum of the third stage.
DISCUSSION
Dr. Albert H. Miuer (Providence, R. I.) : Dr.
Guedel's excellent paper is very refreshing and de-
serves as much discussion as is possible. His observa-
tions on the changes in respiration are especially inter-
esting. There is one special point to which I wish to
call Dr. Guedel's attention because it is a point that
has not been noted and one which we can work up in
the future and use with great benefit as an added sign
of sufficient anesthesia ; that is, the type of respiration
which we find under an anesthetic.
I am accustomed to consider the respiration under
two headings : first, the thoracic type, in which a large
part of the respiration is carried on by the thoracic
muscles and; second, the purely abdominal type, in
which the thoracic muscles are quiet and the dia-
phragm carries on the entire respiration. If we watch
carefully the type of respiration under ether we find
that as the patient goes deeper and deeper imder anes-
thesia, the respiration is at first of the thoracic type,
but as a rule, as the patient becomes deeply anesthet-
ized, we find a beginning paralysis of the thoracic
respiration. In practically every case which is deeply
anesthetized we find complete paralysis of the thoracic
respiration and the patient relies entirely upon the
abdominal or diaphragmatic respiration. If this con-
dition comes on gradually we find that the thoracic in-
spiratory effort comes a little later in the respiratory
cycle each time imtil finally the thoracic respiration is
completely lost. If the paralysis of the thoracic mus-
cles is allowed to progress further we have retraction
of the chest instead of expansion during inspiration.
In this condition we have a sign of too deei> anesthesia
and the anesthetic dosage should be immediately
lowered. Although this point has only recently been
noted it seems to be of such importance that I find out
every five or ten minutes whether the patient is breath-
ing with the thoracic muscles or if the thorax is so
paralyzed that there is retraction rather than expan-
sion of the chest during inspiration. The reason that
this sign has not been previously noted is that the
chests of the patients have generally been covered dur-
ing operation.
Dr. C. C. McLean (Dayton, O.) ; I wish to say that
this is the second time that I have heard Dr. Guedel's
paper. He brought it to the attention of the Interstate
Anesthetic Association last year. It was new to me.
Since that time I have read Dr. Guedel's paper not
once but several times. To-day I have enjoyed Dr.
Guedel's paper as I have never enjoyed it before. I
have learned something new from his paper to-day.
It is one of the greatest helps in administering an anes-
thetic that I have learned in many years and I only
hope that the anesthetists will ponder well and try at
least to remember some of this P^per. /If thet wilk
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380
THE PENNSYLVANIA MEDICAL JOURNAL
March, 1921
make these observations I believe that everyone will
become a better anestheist, giving better service, to the
surgeon and the patient.
Db. Asthus E. Guedel (closing) : One thing that I
wish to bring out and that has been brought out by my
conferes in the past year and emphasized, is that the
oscillations of the eyeball may sometimes be sluggish
and of different types. There will be the rhythmical
oscillation varying in degree laterally practically always.
There will be certain other types particularly those of
a high strting nervous temperament, alcoholics, etc.,
there may be very little oscillation and the anesthetist
at his first look at the globe will see nothing. Some-
times a view of lo or 15 seconds is necessary before
the movement is seen, but I have not yet found a case
in which the movement was not there. The move-
ment in that type of individual is merely a light twitch-
ing one way or the other. The eccentric position of
the globe means nothing excepting that the eyeball
may turn in, out or any direction, meaning the same
thing. I have our interns at our hospital and the
method of teaching them induces them to take more
readily to their anesthesia after having something tan-
gible to look for. Watching the respiration alone has
never been satisfactory. It requires experience to
know what the respiration means. It does not require
experience to know that the motor oculi muscles are
paralyzed. In reference to the question of Dr. Miller,
I have never noticed the difference because 1 have
never looked for it, that is, the place in which abdom-
inal and thoracic respiration occurs. I have noticed
and many others have noticed, the expressions of res-
piration. I think I have learned something from Dr.
Miller.
THE ANESTHESIA PROBLEM IN LUNG
SURGERY*
JAMES T. GWATHMEY, M.D.
NEW YOBK, N. Y.
Certain fundamental principles regarding
anesthesia for lung surgery have been definitely
settled, but are not so widely known as they
should be.
Misunderstandings have occurred from a lack
of definiteness in the meaning of the following
terms which it is necessary to state very clearly
before proceeding to a discussion of the subject.
I.. "General anesthesia" means less of all
forms of sensation, affecting the whole body, and
with unconsciousness,
2. "General analgesia" means absence of sen-
sibility to pain but does not include the loss of
tactile sense, the sense of heat and cold, or pres-
sure and traction.
Strict adherence to these definitions compels
us to admit that we have not a perfectly safe in-
halation anesthesia, that is, one in which the
brain is as completely isolated from the field of
operation as in spinal analgesia.
■ With inhalation anesthesia, when there is
'Read before the Joint Meeting of the Medical Society of the
State of Pennsylvania, the Intersute Association of Anesthesists
and the National Anesthesia Research Society, Pittsburgh Ses-
sion, October 7, 1920.
movement or response of any kind (such as in-
creased respiratory effort) to the surgeon's knife,
it means that stimuli are getting through to the
brain and there is only partial anesthesia.
Likewise, in so-called analgesia (for painful
dressings), with nitrous oxid and oxygen where
the patient is constantly moaning and the anes-
thetist assuring him he is all right, though upon
completion of the dressings he remembers noth-
ing of the occurrence, the state is not one of per-
fect analgesia, but partial analgesia, with com-
plete amnesia.
Finally, the so-called local anesthesia, where
the surgeon is constantly assuring the patient
that he is not suffering, although painful reflexes
are manifestly present, the condition is neither
analgesia, nor anesthesia, but a crude attempt at
hypnotism.
With these definitions in mind, the purpose of
the present paper will be more readily under-
stood as we proceed. A paper of a title similar
to this was published for me in the Medical Rec-
ord, June 12, 1920. This paper outlined the
work in lung surgery in the A. E. F. and the
laboratory experiments upon which that work
rested.' It gave in detail directions for using
the army apparatus (500 of which were ordered
for the army in France). I propose now to re-
view briefly the salient points of the previous
paper and to show how anesthesia for lung sur-
gery can be given in the simplest, safest and best
possible way with any nitrous oxide and oxygen
apparatus, also that certain fundamental princi-
ples outlined in the previous paper are applicable
to all surgery.
THE ANESTHETIC AGENT
In the former paper I showed, by a process of
elimination, that nitrous oxid and oxygen was
preferable to ether and air. Marshall'* had pre-
viously shown that while during the operation the
blood pressure is sustained equally well under
ether vapor and with nitrous oxid and oxygen,
within a few hours later a lowered blood pressure
succeeded the ether administration, which did not
obtain when nitrous oxid and oxygen were ad-
ministered. Furthermore in our laboratory work
it was established that 1 5 to 35 per cent, of oxy-
gen could be used with the nitrous oxid -(instead
of the usual 5% -8%) if an analgesic state was
obtained by the previous administration of the
largest possible physiological dose of morphin
(in our experience average for adults 3/8 of a
grain by hypodermic). The combined effect of
these two agents was analgesia with uncon-
sciousness. The unconsciousness was produced
in about two minutes (without the aid of holding
straps or orderlies) and disappeared with the re-
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ANESTHESIA IN LUNG SURGERY^GWATHMEY
381
moval of the mask ; but the analgesia remained,
thus leaving the patient in the best possible con-
dition. It is a remarkable fact that while the
amount of morphin used could not alone produce
sufficient analgesia for the operation, nor could
nitrous oxid, with the large amounts of oxygen
used, alone produce unconsciousness, yet the
synergistic effect of these two agents meets all
requirements — easy and quick induction, safe re-
laxation, and speedy recovery with a minimum
reaction.
THE ADMINISTRATION
A face mask (with a rubber bag reservoir for
the gases close to the mask) is held gently but
firmly on the face, and the first three or four ex-
halations are allowed to escape through the ex-
piratory valve, after which the expiratory valve
is turned off and part of each exhalation is al-
lowed ,to escape between the face and mask.
The rubber- bag is then allowed to fill to slight
positive pressure, which is easily maintained by
more or less close approximation to the face. A
pressure of from 5 to 12 mm. of mercury had
already been decided upon as a result of the ani-
mal experiments.^ If over 12 mm. of mercury
is used, air may be forced into the stomach. If
this should happen, the passage of a stomach tube
will correct it. A pressure of 7 to 10 mm. of
mercury meets all requirements, and with this
pressure no such accident will occur.
This pressure was first determined by means
of a mercurial manometer placed in the circuit,
but this was discarded as unnecessary when it
was found that the required pressure could be
estimated easily by the following observation:
When the rubber bag is slightly over-distended
with the gases, to such an extent that upon full
inspiration the seams of the bag are still slightly
distended, there is a pressure of from 5 to 7 mm.
of mercury.
The positive pressure method used involves:
(i) A constant supply of fresh gases ; (2) a con-
stant escape of some of the) gas; (3) a slight
amount of rebreathing. Yeates* states that
"Positive pressure control makes examination of
the lung and operation much easier and elimi-
nates the necessity for dangerous traction. It
offers a simple test of the air tightness of the
closure and of satisfactory hemotasis ; the neces-
sity for undue haste is eliminated."
Thus by positive pressure time is conserved
and the traumatized tissue is more quickly re-
paired than if pressure were not used. Positive
pressure is also a factor in maintaining anes-
thesia. This pressure commences immediately
but is slight at first, increasing to from 5 to 10
mm. of mercury during operation and gradually
reduced as the operation is completed.
We have now a perfect method of anesthesia.
With this method, first-stage anesthesia is main-
tained throughout, as indicated by the pink color,
active lid reflex and rolling eye. The muscles are
usually well relaxed, but if not, one or two drams
of ether are added. This occurs about once in
every eight cases. This small addition of ether
is much safer than saturating the patient with
nitrous oxid, which means lowering the blood
pressure and diminishing the distance between
safe anesthesia and the toxic dose.
Most physiologists are agreed that the sequence
in which the parts of the nervous system are in-
volved in the production of general anesthesia is
as follows :' the cerebral cortex is first involved,
the basic ganglia and cerebellum second, the sen-
sory centres of the cord which connect the brain
with the periphery third, the cerebrospinal motor
tracts and centres fourth, and the respiratory,
vasomotor and cardiac centres of the medulla
fifth. Inhibition of all functions and death fol-
low.
The first effect of nitrous oxid upon the nerv-
ous system is usually a pleasurable sensation,
during which time the senses are rendered more
acute.* This is followed by analgesia, and then
by anesthesia. In this last condition, the patient
is profoundly unconscious and insensitive to
pain. If the anesthesia is pushed beyond this
point, the respiratory, vasomotor and cardiac
centres of the medulla are affected, with possibly
fatal results.
With the method outlined in this paper, the
nitrous oxid and oxygen involves the cerebral
cortex fully, the basic ganglia and cerebellimi
only slightly, while the morphia completely
analgizes the sensory centres of the cord, the
cerebrospinal motor tracts and centres, thus thor-
oughly eliminating all danger from anesthesia in
lung surgery.
The light anesthesia or unconsciousness main-
tained as described, is separated from the danger
zone by the second and third stages of anesthesia
and is therefore much safer than the full surgical
anesthesia maintained with the gases alone. For
this very reason endotracheal and endopharyn-
geal anesthesia, requiring preliminary saturation
with ether in order to abolish laryngeal reflexes
before insertion of the tubes, may now both be
considered obsolete. The patient is saved with
ether saturation with the accompanying lowered
blood pressure and temperature and possible re-
action afterwards.
DANGER OF THE METHOD
This lies in ignoring the anesthetic value of the
morphin and administering the gases as if this
preliminary had not been used. The highest pe«-^
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382
THE PENNSYLVANIA MEDICAL JOURNAL
March, 1921
centage of oxygen compatible with good breath-
ing should be given and the patient should not be
allowed to become cyanosed at any time. But
the oxygen should not exceed 35%, for other-
wise all physiological requirements will be met
and the patient may stop breathing. While under
the circumstances this is not dangerous, the aim
should be to keep the pulse, respiration, and blood
pressure normal. Stertor, abolition of lid re-
flexes, or cyanosis should not at any time be
permitted.
SAFEGUARDS
Artificial respiration, when necessary, can be
easily maintained with the face mask method by
lifting the mask slightly for expiration and hold-
ing it tightly for inspiration. The supply of car-
bon dioxid is better maintained in this way than
by either the endotracheal or endopharyngeal
method of artificial respiration. Since carbon
dioxid is the normal stimulant of respiration, it
would seem that natural breathing would be
more readily reestablished by this method than by
any other. At the completion of the operation the
pink color, with good pulse and quiet respiration
may temporarily mask the true condition of the
patient; it is best, therefore, to treat all chest
cases ' as shocked patients. General analgesia
with morphin, supplemented vvith nitrous oxid
and oxygen under slight positive pressure pro-
vides a more complete brain block than can be
obtained with any other inhalation method or
combination. Having thus outlined a simple and
safe method of anesthesia for lung surgery, it
only remains to show how this method can be
used with any nitrous oxid and oxygen appara-
tus. This can be stated in a very few words, the
fundamental principles being the same, i. e., the
preliminary medication, first-stage anesthesia
with nitrous oxid and oxygen, and positive pres-
sure, remain the same. How can the pressure be
determined? Simply by employing a mercurial
manometer attached by a yoke to the respiratory
bag.
kEFERENCES
1. Gwathmey: Medical Record, June 13, 1920.
la. Marshall, Geoffrey: Anesthetics at a Casualty Clearing
Station, Proc Roy. Soc. of Med., 1917, Vol. X, pp. 17-36.
2. Cannon: Historical Record of the Services of the Labora*
tory of Surgical Research, American Army at Dijon, 1918.
3. Gwathmey: Anesthesia, p. 61.
4. Gwathmey: Anesthesia, p. 131.
40 East Forty-first Street
DISCUSSION
■ Dr. Johk R. McCurdv (Pittsburgh) : Unfortu-
nately, we in this part of the country do not have very
much experience with major chest surgery. As Dr.
Gwathmey has said, a great deal of his study and ex-
periments have been done in the war zone and in war
work. If we may be allowed to include in chest sur-
gery what we anesthetists meet with in this part of
the country, chiefly rib surgery, resections and abscess
. conditions in the lung (I mean excluding accident sur-
gery of the lung itself), then I should like to ntake a
few points in discussion. It has seemed to me the
most potent element, if one can be picked, in Dr.
Gwathmey's technic is the preparatory medication. I
was very glad to hear him state, and if I may I would
emphasize the point, the importance of the morphiniza-
tion of the patient before any procedure is begtm.
Every one of us knows the analgesic properties of mor-
phin as well as the sedative properties. Three-eighth
of a grain or morphin administered in divided doses,
as Dr. Gwathmey has advised, is not a dangerous dose
in these cases. Some of you who are not accustomed
to administering morphin routinely might be a little
timid in giving three-eighths of even one-half a grain,
but anesthetists often see marked advantages in using
full doses of morphin. Especially in rib resections it
seems not only of great advantage, but an absolute
necessity to successful anesthesia and successful opera-
tion. The depressant power of morphin upon the res-
piratory centers should not be disregarded, but may be
discounted, I think. You have all seen the character-
istic breathing of an empyema. If you have watched
the anesthetization of such a patient you have seen still
greater stimulation, exaggeration and irregularity of
that breathing. The morphin undoubtedly produces a
much better respiratory condition; moreover, it gives
the patient comfort and relief from pain, irrespective
of the anesthetic agent administered, that is not only
humane, but assists very materially both the anesthetist
and the surgeon. The only other point which has oc-
curred to me in the paper which might not be clear to
your minds, and is not entirely clear to my mind, is
that of being at all times aware of the amount of posi-
tive pressure. I will ask Dr. Gwathmey to explain
that a little more definitely.
Dr. Rea Proctor McGee (Pittsburgh) : It was my
privilege, during the war, to serve in the same For-
ward Hospital in which Dr. Gwathmey administered
much of the anesthesia in chest surgery of which he
has here spoken. The work that he did was very re-
markable because, before he came with Major Yates
to do this work we had to give the ordinary ether anes-
esthetic for chest cases. There was a great deal of diffi-
culty in handling chest cases and the consequence was
that all of us who were with that hospital took great
interest in Dr. Gwathmey with his big gas cylinders
and mercury valve machinery. He gave the anesthetics
for the most extensive chest surgery that has been
done in modern times. He gave nitrous oxid-oxygen
day after day in the St. Mihiel sector and in the Ar-
gonne, in a hospital that received only nontransportable
battle casualties and in every instance his patients
seemed to sleep easily and to stand the operation with
the very tiest results. In fact when Major Yates made
his report upon the very low death rate that he had
with his chest operations it took a good deal of faith
for many surgeons to believe that the work could be
done so well, but I think that Dr. Gwathmey deserves
a very large share of praise for what was accomplished
in saving the lives of wounded soldiers with chest in-
juries. I have also seen him give analgesia, particu-
larly in one of my own cases of face injury — a man
struck with a shell fragment and hi^ face split so wide
open, you could look into the pharynx. He kept this
man in the upright position in the state of analgesia
for two and a half hours. The patient was able to
answer questions intelligently at any time during that
period. The face was completely rebuilt and the pa-
tient evacuated in good condition. I believe when, a
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ANESTHESIA IN OBSTETRICS— DANFORTH
383
man is able, not only to devote the study and time to
produce the machine that gives these results, but to
give anesthesia himself in such a remarkably satisfac-
tory manner, he deserves a careful hearing and a rea-
sonable adherence to the ideas that he has presented.
Dr. E. I. McKesson (Toledo, O.) : In calling upon
me to discuss this paper in reference to primary or
secondary saturation, I want to say that deep anes-
thesia is not required in chest surgery. I agree heartily
with Dr. Gwathmey's idea of maintaining a very light
analgesia in lung surgery. There is no necessity I
know of, from the few cases I have had, for maintain-
ing a deep anesthesia. In fact I think it is quite dis-
tinctly more dangerous to do so.
• I have found one thing — if I may be allowed to
digress slightly from the subject into the inflammatory
conditions of the chest — that after the rib has been re-
sected and the first gush of pus evacuated, if the posi-
tive pressure is maintained in the inhaler so as to fill
out the lung again that much of the pus will leave the
chest. Of course one must, use judgment in not using
too mtKh pressure in the inhaler, else seme damage
may possibly be done to the lung. In favorable cases
it is possible to make the lung completely fill out the
chest again. I think that perhaps wjeeks of convales-
cence can be cut off for that patient.
The effect of morphin on blood pressure consists
in merely lowering the level. A good sized dose of
morphin is of more value to the patient than the dam-
age it might possibly do by lowering the blood pres-
sure, because after all we are not so much interested
in or worried about the exact level of the blood pres-
sure as we are in the efficiency of the blood movement.
So if we have a good heart stroke, if our pulse pres-
sure is approximately half the diastolic pressure, our
patient is usually not in danger and even though we
may step our blood pressures down with a good stiff
dose of morphin by possibly 5 to 10 mm. I think the
patient is distinctly better off than he would be to give
small doses of morphin, maintain blood pressure and
attempt to carry the patient in deeper anesthesia. I
agree absolutely with Dr. Gwathmey's idea of running
a patient in light anesthesia or analgesia for this class
of work.
Dr. F. H. McMechan (Avon Lake, O.) : I would
like to make an announcmeent of interest to all those
who have heard Dr. Gwathmey's and Dr. Geudel's pa-
pers. Both these papers are based on research work
that was conducted in the midst of strenuous cam-
paigning in war. When this meeting was scheduled,
the National Anesthesia Research Society offered a
series of prizes for the best papers that would be pre-
sented on research subjects. At this time I would like
to inform the society that the Committee on Prize
Award has awarded a prize to Dr. A. E. Guedel, his
paper being based on 10,000 anesthesias administered
in France, and also that a prize has been awarded to
Dr. James T. Gwathmey for his wonderful work in
anesdiesia for lung surgery, which Dr. Yates, of Mil-
waukee, said reduced the mortality to practically one-
third or less than what it had been before Dr. Gwath-
mey arrived upon the scene of action.
NEOCINCHOPHEN.— The ethyl ester of methyl-
phenylquinolin-carboxylic acid. It was first introduced
as novatophan. The actions and uses of neocinchophen
are the same as those of cinchophen (New and Non-
official Remedies, 1920, p. 224), only it is tasteless.
NITROUS OXID-OXYGEN ANALGESIA
AND ANESTHESIA IN NORMAL
LABOR AND OPERATIVE
OBSTETRICS*
WILLIAM C. DANFORTH, B.S., M.D., F.A.C.S.
EVANSTON, ILL.
In June, 1918, the results of the use of gas
as- an agent for the production of analgesia and
anesthesia in a series of 663 cases of labor were
reported. Since that time there have passed
through our maternity wards a little more than
1,000 cases. As nitrous" oxid is our routine
method for the relief of pain except in certain
of the pases in which complete surgical anes-
thesia is requisite, this would give a series of
about 1,700 cases in which nitrous oxid has been
used.
Since the publication of my last report no de-
tailed notes have been kept upon each case with
reference particularly to the character of the
analgesia as we have since that time regarded
the use of gas as routine, a method which was
no longer in the experimental stage and there-
fore not subject to the exact and comparative
observation which would be given to a method
which is still on trial.
The technique is very simple. At the begin-
ning of the second stage of labor the administra-
tion of gas is begun. In multiparse we usually
begin a little before the beginning of the second
stage and this may also be done in case of an
intolerant primipara. The mask is placed over
the face and the patient instructed to breathe
deeply and rather quickly. The number of
breaths which are needed may vary from three
to six or eight. Occasionally it may be given
throughout the length of the pain. The num-
ber of breaths which are needed in any indi-
vidual 'case may quickly be ascertained by the
aiiesthetist and that number be given from that
time on. After the number is ascertained, the
mask may be removed after having given that
number, when it will be found usually that the
relief of pain continues throughout the length
of the contraction.
A very essential point in the administration of
gas is that it should be begun immediately upon
the onset of a pain. If the pain gets well under
way before the administration of gas is begun
the best results cannot be expected.
Oxygen should be added to nitrous oxid in
percentages of from 5 to 15 according to the
necessity of each individual patient. Usually
one is able to obtain satisfactory results with a
•Read before the Joint Meeting of the Medical Society of the
State of Pennsylvania, the Interstate Association of Ancsthcsists
and the Nationnal Anesthesia Research Society, Pittsburgh Ses.
sion, October 7, 1920.
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THE PENNSYLVANIA MEDICAL JOURNAL
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percentage of from 5 to 8. They do not re-
breathe prior to the time of delivery. Those
who are beginning the use of nitrous oxid as
an agent for the production of analgesia must
distinguish between anesthesia and analgesia.
Should the patient be permitted to pass over
into the zone of anesthesia the cooperation of
the patient cannot be maintained and stru^ling
is quite likely to occur.
Cyanosis should always be avoided and this is
perfectly possible with due attention to the per-
centage of oxygen and to the amount of the
anesthetic that the patient is permitted to take.
As the end of the second stage is approached
it is of decided advantage to add thrpugh the
medium of an ether attachment on the gas ap-
paratus, a little ether during the last three to
five pains. This increases muscular relaxation,
including the muscles of the perineum, and also
thereby decreases to some extent the violence
of the contraction of the uterine muscle, thus
rendering the head more easy of control and
minimizing the likelihood of laceration. This
also makes possible if necessary the perform-
ance of a small episitotomy without pain. Fur-
ther, the patient may be rendered entirely un-
conscious at the moment of delivery and awake
without any appearance of it. This amount of
ether rarely produces any nausea and is devoid
of any disadvantage so far as I have been able
to observe.
Obtaining analgesia appears to be a simple
process, yet satisfactory analgesia cannot be
produced without a certain amount of at-
tention to proper technique and without suf-
ficient intelligence and training upon the
part of the administrator as will enable him
to appreciate the different degrees of sensi-
bility to the anesthetic and to be able therefore
to vary the amounts given in a proper manner.
I am quite at variance with the opinion which
has been expressed at times in discussions of
this subject that analgesia requires no training.
We have almost invariably found that the first
attempts of a new individual at analgesia were
far from satisfactory. An intelligent nurse or
interne can, however, learn to give a satisfac-
tory analgesia if a little time and effort is de-
voted to the acquisition of its technique. .A.fter
an experience of five years in the use of gas
analgesia, I am quite emphatic in saying that
this method has given us the best results of any
method we have tried of relieving pain.
As to the influence of gas upon the character
of the labor we have found that the labor does
not tend to be slowed after the administration
of gas. A properly given analgesia does not
diminish the force or frequency of the pains.
A carelessly given anesthetic which permits the
patient to be anesthetized part of the time may
do so. This, however, is not the fault of the
method but is due to a defective technique. We
have found on the contrary that the effective-
ness of pains in the second stage is increased
because, as the pain is so largely relieved, pa-
tients are more likely to assist voluntarily than
if their sufferings are acute. During a properly
given analgesia consciousness is not lost and an
intelligent patient will cooperate, bearing down
when asked to do so and stopping immediately
upon request.
With the use of methods of pain relief which
cannot come into play until the second stage is
nearing its end, one is sometimes obliged to in-
tervene because of the suffering of the patient
or because of her refusal to continue. These
cases may be carried forward much more ef-
fectively with gas and it is quite striking at
times to see a nervous and excited patient who
is complaining- loudly, become quiet tmder the
administration of gas, thus making it possible
for the labor to continue to a point at which a
simple forceps may terminate a labor which
otherwise might have demanded a difficult high
forceps extraction. The effect of this upon
fetal mortality is of course at once apparent.
The relief of nervous exhaustion after the
most painful portion of labor has been under-
gone under the influence of analgesia is worth
noting. The number of completely exhausted
patients which we see at present is much smaller
than we were accustomed to observe under less
satisfactory modes of pain relief. It must not
be forgotten that pain itself causes a greater
drain upon the nervous system of the patient
than the actual work which she is called upon
to perform and in relieving pain we are taking
away the most potent cause of nervous exhaus-
tion. This, of course, has its effect upon the
puerperium, and the patient is in far better con-
dition to begin her convalescence.
I believe that nitrous oxid decreases to some
extent the danger of postpartum hemorrhage
as it does not relax the uterine muscles to the
same degree as the other anesthetics. We have
not been able at any time to note any deleterious
effects upon the mother. In toxic cases it is of
great advantage to avoid the irritating effects
of ether and chloroform upon the parenchy-
matous organs. In operative work in this class
of patients it is of great value and adds con-
siderably to the safety with which operative
procedure can be carried out.
As to the effects of nitrous oxid on the child
during labor we have been greatly pleased. We
have not noted any untoward results which we
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ANESTHESIA IN OBSTETRICS— DANFORTH
385
have been able to charge to the use of gas.
Cyanosis of the new-born child has not been
more frequent than before we began its use.
There have been no fetal deaths chargeable to
it. Perhaps a brief review of the fetal deaths
of the year 1919 might be of interest.
In a little over 530 labors there were 17 cases
in which the child was lost. Nine of these died
shortly after birth and eight were dead when
bom. Of the nine which died shortly after
birth, six were premature babies ranging from
six to eight months gestation. One of these six
was one of a pair of twins, the other being born
dead. One of the premature children, born at
seven months, had also a cleft palate. Another
had a congenital heart lesion, living only part of
a day. Another child had an abdominal tumor
at birth. This turned out to be an immensely
dilated large bowel. The autopsy showed the
child to have an obstruction of the sigmoid due
to a peritoneal band caused by a peritonitis
which had occurred in utero. The mother had
had a severe attack of influenza during preg-
nancy. Whether any relationship existed be-
tween this illness of the mother and the intes-
tinal obstruction of the child cannot be posi-
tively stated.
Another child, delivered by cesarean section,
because of a large fibroid in the lower uterine
segment, died two days after birth, cause un-
known. This mother, however, had had no gas,
the section having been done under ether.
Of the stillborn children one was a child of a
syphilitic mother, the child showing evidences
of syphilis at birth. Another was the other one
of the pair of premature twins alluded to above.
One was lost as a result of prolapse of the cord ;
version was done at once but failed to save the
child. Two died as a result of difficult high
forceps extractions done under ether. Another
was an anencephalic monster.
In the field of operative obstetrics we ap-
proach an entirely different problem. Here we
have to do only occasionally with analgesia and
usually with surgical anesthesia. Gas anes-
thesia, however, finds a distinct field of useful-
ness in operative obstetrical work. It must be
emphasized, however, that here as in other sur-
gical work nitrous oxid, to be of real service, de-
mands the same care in its administration as in
any other field of surgery. He who expects to
have his gas anesthesia given for an obstetrical
operation by some intelligent member of the
family or a neighbor or by a nurse untrained in
anesthesia or even by a physician who has not
been at some pains to familiarize himself with
the technique of anesthesia in general and gas
anesthesia in particular, is doomed to failure.
There is no anesthetic which is safer or more
satisfactory within its proper field of use than
nitrous oxid. Without proper administration
there is none, I think, which is more unsatisfac-
tory. Without proper administration also we
must admit a certain percentage of danger.
There are a number of ingenious and satis-
factory forms of apparatus for the administra-
tion of gas anasthesia upon the market. None
of them, however, is able to think and there is
incorporated in the mechanism of none of them,
so far as I know, a knowledge of the physiology
of the circulation and respiration. The failure,
therefore, by an inexperienced person to give
good anesthesia cannot be charged against the
apparatus. Possession of a gas machine does
not cause one to become an anesthetist, neither
does the possession of a microscope immediately
cause to exist in the mind of its possessor an
exact knowledge of pathology. He who is to
obtain good results, therefore, from gas anas-
thesia in operative obstetrical work or from gas
anesthesia in operative gynecological or surgical
work must first see to it that the anesthesia is
given by an individual who is possessed of a
knowledge of the subject of anesthesia.
The interest which has been manifested in an
increasing degree in the subject of anesthesia in
recent years is an extremely hopeful sign, espe-
cially so when a great meeting such as this de-
votes itself to the consideration of its problems.
Primary perineal repair is probably the most
frequent surgical operation in the obstetrical
field. This can, in a great majority of instances,
be carried out under gas anesthesia and there is
no objection to rebreathing if necessary. In
cases in which it is requisite a little ether may be
added for a few minutes to obtain relaxation.
A good anesthesia is needed for the proper
carrying out of a repair operation, for the at-
tempt to do it with the patient partly asleep and
struggling makes it impossible to do good sur-
gical work. Nitrous oxid has the advantage of
allowing the patient to wake up with but little
or no nausea. Further, it does not tend to cause
the uterus to relax.
The next most common operation for which
anesthesia is necessary is that of low forceps.
We find that we are able satisfactorily to carry
out the majority of our low forceps deliveries
with gas in some cases supplemented by a little
ether for the purpose of securing relaxation. In
a prior report I stated that we had become a
little discouraged in the use of gas in these cases
but since that time we have, perhaps by a little
greater effort and attention, succeeded in ob-
taining good results in the majority of cases.
Whenever, however, the requisite amount of re-[p
386
THE PENNSYLVANIA MEDICAL JOURNAL
March, 1921
laxation is not easily obtainable under gas one
should not hesitate to add some ether, or to
change to ether entirely if needed.
For the induction of labor by the use of a
hydrostatic bag, nitrous oxid finds very useful
application. This operation in my experience
is invariably painful in primiparse and fre-
quently so in multiparas An ether anesthetic
with subsequent nausea is unpleasant after the
introduction of the bag when one expects and
hopes that labor will begin at once. This is
largely or entirely avoided by the use of gas.
The patient, however, should be given no break-
fast on the morning on which the induction is
expected to occur.
The introduction of a bag may often be done
under analgesia rather than anesthesia. This
. requires a certain cooperation on the part of the
patient to whom it must be explained that all
knowledge of what is being done will not be
abolished, but that pain will not be felt. A
highly nervous woman will not always make the
needful effort to render this process a success.
When possible, however, it is of value, as any
nausea or other discomfort is entirely avoided at
a time when it is usually hoped that labor will
promptly start.
Another very frequent operation for which
gas is exceedingly useful is that of evacuation
of the uterus in incomplete abortion or for the
introduction of packing in inevitable or thera-
peutic abortion. We have for years used gas
routinely in these cases and almost invariably
with success.
The operation of version I believe is best car-
ried out under ether. Exceptions to this may
be cases in which the child is small and easily
movable and the amniotic fluid not drained
away. As a rule it is vsafer to have thorough
muscular relaxation of the uterine wall which
facilitates manipulation and allows the child to
turn more easily and minimizes the risk of lac-
erating the uterine wall. The danger of rupture
of the uterine wall during this procedure, par-
ticularly if the uterus be firmly contracted about
the child is well recognized. Thorough relaxa-
tion of the uterine muscle must be a prerequisite
to safe operating, and this, in my experience is
not as well secured by nitrous oxid as by ether.
Any operative procedure requiring full muscu-
lar relaxation whether of uterine or abdominal
musculature, in the great majority of instances
must be done under ether anesthesia.
In cesarean sections, we have since the pub-
lication of my last report, been using gas to a
greater degree than formerly. It finds an ex-
ceedingly valuable place in eclamptic or toxic
patients in whom delivery by section has been
chosen. Its effect upon the parenchymatous
organs ordinarily is so much less than either
ether or chloroform that its advantages in this
field must be conceded. We have among our
sections this year so far had two of this class in
which gas was used. Both of these were primi-
parse who were sent into the hospital in convul-
sions and without any dilatation. One of these
was done by my associate, Dr. R. A. Scott, and
the other by myself. It seems no longer neces-
sary to add the damage done by a lipoid solvent
anesthetic to that already wrought by the tox-
emia of eclampsia or nephritis when nitrous
oxid or local anesthesia are at hand.
These cases, however, unless the patient is
extremely stuporous, demand a careful giving
of the anesthetic. The untrained interne will
not attain success. Care must be taken that
cyanosis does not occur, for one must not run
a chance of causing injury to the child by over-
carbonization of the blood, yet the patient
should be sufficiently asleep that the operation
may proceed without danger of bowel extru-
sion, although extreme relaxation of the ab-
dominal wall is not essential. The operation
may be done without preliminary morphine
medication. It must be emphasized, however,
that real acquaintance with the science of anes-
thesia and painstaking care are needed for suc-
cess. Success is perfectly attainable, however,
and is within the reach of any well-organized
hospital. It is my experience that the contrac-
tility of the uterus is better in a cesarean done
under gas than in one done under ether.
One other class of cases I wish to mention,
one which we do not frequently encounter but
which demand careful management. These are
the women in whom the uterus must be quickly
emptied, the patient not being in good condition.
This situation may arise in the rather rare case
of pernicious vomiting of the severely toxic
type where the patient has been allowed to get
into bad condition. The best mode of pro-
cedure, if the ovum is of any size, as in a two
and a half to three months pregnancy, is an
anterior vaginal hysterotomy, which can be rap-
idly done and permits of evacuation of the
uterus at one sitting. This can be accomplished
under nitrous oxid anesthesia, and this mode of
anesthesia is highly preferable to any other.
It is to be hoped that the last word has not
yet been said upon the subject of the relief of
pain for the woman in labor, and that in the
future some method may appear which will be-
stow upon her that complete relief which it was
hoped by some would be provided by the sO-
called twilight sleep. We have, I believe, at
present in gas a most valuable agent for the safe
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March, 1921
ANESTHESIA IN OBSTETRICS— DISCUSSION
387
alleviation of some of the worst, at least, of this
suffering, and one which is free from the dan-
gers of dainage to the parenchymatous organs
which may ensue either at once or later from
the use of chloroform and ether and which ap-
pears to have been demonstrated by the work of
Graham and C. H. Davis.
Until some means of safe relief of pain
throughout the entire length of labor appears,
we should not, because we can assuage the suf-
fering of the second stage and that of operative
procedures, allow ourselves to forget that relief
which the older measures allow us to afford.
Attention to the simple things during the first
stage, making sure that bladder and rectum do
not remain filled, seeing that the laboring woman
receives easily assimilable food and sufficient
water, these are time-honored measures the im-
portance of which is as great to-day as ever.
Especially the timely dose of morphine in the
case of a slowly progressing and suffering
primipara, particularly one whose nervous en-
durance is becoming taxed and who still has
hours of labor before her, is a measure of the
greatest worth. And may we not add that many
times a simple word of encouragement and ex-
planation from the obstetrician makes the road
easier to travel. Attention to these things, par-
ticularly the use of an opiate when needed, will,
I am quite convinced, enable us to carry through
and into the second sta^e many cases which
otherwise would require intervention at an un-
favorable time. Indeed it is quite probable that
not a few cesareans have been done which
might have been avoided by no more compli-
cated means than those of which I have just
spoken.
While I am quite positive as to the value of
nitrous oxid as an agent for the relief of pain
in labor I wish to make it quite clear "that I do
not consider that its use will enable us entirely
to discard ether. We must remember that anes-
thesia is a process to be adapted to the patient,
not the patient to the anesthetic. Great mus-
cular relaxation is not easily obtainable by gas.
Therefore when relaxation is needed ether
should be added. I have gone through the
period of attempting to adapt gas to everything
in gynecology and obstetrics and recovered
therefrom several years ago. Gas anesthesia
has suffered perhaps somewhat at the hands of
its friends. Crile tells us, if relaxation is needed,
and not at once obtained by gas, to add ether
sufficient to produce relaxation. Should this re-
quire that much ether be added we may have a
situation which has been characterized by
Deaver "as an ether anesthetic masquerading
as a gas anesthetic," the ether doing the work
and the gas getting the credit.
Therefore, while recognizing fully the great
value of nitrous oxid in obstetrics, we must not
allow ourselves narrowly to restrict ourselves
to one drug to the disadvantage of the patient.
A little ether at the moment of delivery with gas
will aid us in controlling the head in many cases
and should be used. The fact that many low
forceps and perineal repairs may be done under
gas must not prevent us from adding some ether
if needed. Good operative work requires a
quiet patient and it is of greater importance
than a proper repair or forceps operation be
done than that a given medium of anesthesia be
adhered to.
The more skilful the anesthetist the more suc-
cessful will he be in maintaining good anes-
thesia with nitrous oxid in a large part of one's
operative obstetrics. And surely the relief af-
forded by nitrous oxid and the safety of its use
during normal labor as an agent for the produc-
tion of analgesia should entitle it to wide accept-
ance.
CONCLUSIONS
1. Nitrous oxid is of very great value as a
means of relieving pain in normal labor.
2. We may give a greater degree of relief of
pain in a normal labor by means of gas than by
any other means except twilight sleep. The
safety of gas, however, is greater.
3. Successful analgesia requires a certain
technic, not difficult of acquisition, but essential.
4. Many operative procedures may be done
under nitrous oxid, provided the anaesthesia be
given with a reasonable degree of skill.
DISCUSSION
Dr. Sauuei, Johnston, (Toronto, Canada) : I have
just a word to say in connection with this paper. I
have been using nitrous oxid and oxygen in obstetrical
work for some time. It has been my privilege to
administer a good many anesthetics. The point I
would like to mention is (I am not sure that Dr. Dan-
forth has mentioned it) that we do not have cyanosis
very often in a child and the way to avoid it is this :
just as the head is about to be born, turn on a breath
or two of pure oxygen — probably a little more than a
breath or two. At all events when the child is born
the child is a good color. There is one objection to
this — the child will not make the same effort to
breathe for a few moments as though it had not been
given, but will survive. I think this is a very safe
and valuable method. Then in cesarean sections, just
the moment that the gynecologist picks up his knife to
make his incision in the uterus, I turn on the oxygen
in the same way and by the time the child is delivered
the child is a good color. In cases where previous
medication has been given, where you expect probably
a child will be cyanosed, a little more oxygen will be
required and then switch back to nitrous oxid. In this
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THE PENNSYLVANIA MEDICAL JOURNAL
March, 1921
way we find we have not as many children bom cy-
anotic as under ether anesthesia.
Dr. Joseph E. Lumbakd, (New York City) : I
would call attention in eclampsia cases to the great ad-
vantage of using oxygen in large quantities with the
anesthetic — never use chloroform in eclampsia.
Dr. C. C. McLean, (Dayton, Ohio) : There is just
one thing that I would like to say, not as an ob-
stetrician but as an anesthetist. In a few cases I have
administered gas in obstetrics, especially for the pur-
pose of analgesia where I did not desire to put the
patient into the stage of anesthesia, or a light anes-
thesia for the application of forceps. After the for-
ceps have been applied you can lighten the anesthesia
and as the uterus contracts increase the anesthetic.
With the patient in analgesia, if the obstetrician begins
traction before the uterus is contracting or continues
traction after. the uterus has ceased to contract, fail-
ure will be the result. I believe that this is the reason
why gas has been in disrepute. If the obstetrician
will study gas with the idea of using it in his work
and will commence traction as the patient begins bear-
ing down, and continue traction until the uterus ceases
to contract and then gradually letting up, I think a
great deal of the objection to the gas will be obviated.
Dr. Danfcmith, in closing: In regard to the point
Dr. Johnston mentioned regarding oxygen, that is a
good point It is not in my paper. I mentioned it in
a paper a year and a half ago. I think the oxygen has
a decided value. As to the point brought out by Dr.
McLean in regard to the forceps, my haste in begin-
ning to operate before anesthesia was complete was
the reason I did not get good results at first. One
must wait until the patient is pretty well under before
forceps are introduced. It is the same haste which
was spoken of in connection with anesthesia in general
surgery. We all want to get to work before the
anesthetist is entirely ready.
ORAL AND SINUS SURGERY IN THE
FORWARD INCLINED SITTING
POSTURE, UNDER N,0-0
ANESTHESIA*
IRA O. DENMAN, M.D.
TOLEDO, OHIO
I once heard a lecture on salesmanship in
which the speaker stated that every successful
business career, not only in mercantile lines but
in the professions as well, owed its success to
efficient salesmanship. This first struck me as
being rather farfetched when applied to pro-
fessional work, but he showed that the minister
sells his services to the congregation when he
goes and preaches a trial sermon. The attorney
sells his services to his client, not only by his
preliminary advice but by his reputation as well.
Physicians and dentists must also sell their serv-
ices that is, the patient must be convinced that
what the physician offers in the way of advice,
must be for his welfare, and this acceptance of
'Read before the Joint Meeting of the Medical Society of the
State of Pennsylvania, the Interstate Association of Anesthesists
and the National Anesthesia Research Society, Pittsburgh Ses.
sion, October 7, 1920.
the advance constitutes the consummation of
the sale.
Furthermore a good salesman must of neces-
sity have confidence in the goods he offers. It
is my experience in my surgical work, that im-
mediately upon proposing a surgical procedure,
I am at once confronted with numerous in-
quiries, and it often requires much tact, patience
and ingenuity to iron out all the difficulties
which oftentimes appear to the patient to be
unsurmountable. TMiey want to know the in-
dications for the operation, the conditions which
make me deem an operation advisable, the result
of the operation, the time required in the hos-
pital and for the convalescence. They want to
know whether they will have pain during the
operation or soreness or discomfort afterwards,
whether any complications may appear during
or afterwards, whether they will bleed much,
or if they bleed whether it can be controlled.
Last but not least, they want to know about
the anesthetic. And in this connection I beg to
state that it is just as important to my own con-
science to be able to recommend an anesthetic
in which I have confidence, as it is to recom-
mend the surgical procedure to the patient. We
must realize that the anesthetic is a mental
hazard to both patient and surgeon, and is
usually one of the sticking points in the "sale"
of an operation. That it is a real danger can-
not be disputed truthfully. It is equally true
that other factors are often the actual causes of
operating room fatalities which are laid at the
door of the anesthetist. In general surgery, we
may mention an incomplete diagnosis, faulty
and incomplete preparation of the patient, ill-
chosen time of operation, long drawn out or
slow operative technique, or lack of good tech-
nique, too many operative procedures at the
same sitting, etc. All of these are often the real
cause of fatalities, which are laid to the anes-
thetic. Some of these may apply also to sinus
and oral surgery, but in addition, in my opinion,
the position of the patient counts for much so
far as .safety is concerned.
It will readily be admitted upon a moment's
reflection that hemorrhage, always a danger
factor, assumes an added significance when it
occurs from areas adjacent to the ingress of
air to the lungs. Hemorrhage to the general
surgeon has but one menace to the patient;
that is, the loss of the vital fluid. To those of
us whose surgical field lies adjacent to the
larynx, we must also learn to recognize not only
the immediate danger of suffocation, but the
added remote complication of pulmonary sepsis,
should the invading blood carry infective ma-
terial. In tonsil and nasal surgerj^ thereSore
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March, 1921
ORAL SURGERY— DENMAN
389
an additional problem is presented for solution ;
namely, the question of preventing the ingress
of mucus, froth and blood with the air into the
lungs. This has been attempted by many means,
notably the various prone positions of the
patient in which the head is lowered below the
line of the body, head dropped over the table
downward, the use of various suction apparati,
siphons and sponges, which aid materially in
this direction, but all of which must meet the
actual condition that gravity and inhalation
carries the blood towards the larynx, and if
these means are effective at all they must be so
by their ability to absorb or carry away the
blood before it enters the larynx.
Local anesthesia for tonsil work and for
some nasal operations has found much favor
because of the fact that under local anesthesia
the patient is conscious, maintains the erect pos-
ture, and may by his own efforts prevent the
ingress of these secretions into the trachea.
But while effective in this regard there are so
many other unpleasant features connected with
it, not to say some real dangers, that it is far
from desirable as a routine measure.
About ten years ago the writer devised the
forward-inclined-sitting posture, attempting
thereby to combine the advantageous features
of the erect sitting posture, such as is found
under local anesthesia, and at the time eliminate
as far as possible the objectional features of
local anesthesia and the prone position under
general narcosis. I will later show you illus-
trations of this position. My first thought in
connection with the anesthetic was that of the
similarity of the requirements of my position
with those which the dental profession had long
since met with nitrous oxid and oxygen. I
therefore called to my assistance Dr. McKesson
and we at once began to work out our tech-
nique, and for the past nine or ten years have
used this position and this anesthetic exclusively
in my work. Based upon this experience I am
of the opinion that the forward-inclined-sitting
posture is the most natural, convenient and
safest position for oral and sinus surgery. In
this position blood takes care of itself by grav-
ity, aided by the flow of gases out of the mouth
in a much more effectual manner than is pos-
sible by suction apparatus or in any other posi-
tion in which the operation may be thoroughly
done. The danger of asphyxia by inspired
blood or froth is absolutely eliminated. Our
hospital records show no fatalities for nine and
a half years.
In the renewal of our old friendships one
often discovers desirable qualities and admira-
ble traits which are not apparent upon the more
casual earlier acquaintance. So it has been
with the use of nitrous oxid and oxygen. I
have been able to discover additional reasons
for the use of this anesthetic during this period,
and for many years past it has seemed to me to
be so far superior to all other anesthetics that I
cannot refrain at this point from giving it my
unqualified endorsement.
Nitrous oxid was, as you know, the original
anesthetic, first administered in 1844. Its ad-
ministration in the crude state met with com-
petition by the discovery of other agents, nota-
bly chloroform and ether and their combina-
tions, which permitted longer anesthesia than
did the pure nitrous oxid. It remained for the
second decade of the twentieth century to bring
nitrous oxid to its own again by the successful
combination of oxygen gas therewith. The ad-
ministration of these combined gases by an ef-
fective mixing machine, under the guidance of a
skilled anesthetist, in my opinion constitutes the
ideal narcosis and instead of being a deadly
anesthetic as was commonly supposed) it is in
reality the safest of all methods of rendering
the patient oblivious to pain. After placing the
patient under complete anesthesia by a few in-
halations of pure nitrous oxid, the oxygen is
admitted sufficiently to maintain even anes-
thesia, closely approximating a perfectly normal
sleep. If at any time an emergency occurs, the
best of all pulmotors is on tap and already at-
tached to the patients mouth and nose — pure
oxygen under pressue. The absence of nausea
after operation is one of the especially desirable
features. The quick induction period without
suffocation is an experience to the patient which
is invaluable. I am not an anesthetist, there-
fore it is presumptuous to dwell upon these
points before this body. However I must men-
tion one more factor which is to my work in-
valuable, and that is the mistakable action of
oxygen in coagulation of the blood. The nor-
mal coagulation period as it is found by ex-
posure to the air prior to the operation is re-
duced one-third to one-half under the influ-
ence of pure oxygen which is administered to
the patient when the operation is finished. In
one case by actual count the coagulation test
prior to operation was ten and one-half minutes,
and following a tonsillectomy all hemorrhage
had ceased in four and one-half minutes upon
administration of oxygen. Secondary hemor-
rhage is almost tmknown in our work, having
had but nine cases in nine and one-half years
and several thousand operations; the explana-
tion is the fact that the oxygen restores the
tone to the blood vessels, thereby causing them
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390
THE PENNSYLVANIA MEDICAL JOURNAL
March, 1921
to contract into a firm clot in conjunction with
the rapid coagulation of the blood.
This combined technique has enabled me to
work out a method for complete dissection in
tonsillectomy which can easily be accomplished
in from one to two minutes. The details of this
technique have been published twice and dis-
tributed by reprint so that I will not repeat them
here. But to generalize, I will state that the
position affords such an unobstructed view of
the operative field as to make it unnecessary to
lose any time in clearing it in order to see what
one is doing. This position also admits in every
case of a double application of the snares, that
is both tonsils are removed simultaneously by
two snares. I use a dull dissection with a back-
ward application of the snare which permits of
the posterior pillar dissection by the closure of
the snare wire. Should there be those present
who are interested more particularly in this
technique I will be pleased to mail to them a
reprint upon application.
I attribute our low percentage of hemorrhage
to the combination of three elements, viz, the
dull dissection without sharp instruments, the
nitrous oxid and oxygen anesthesia which leaves
the blood vessels not in a relaxed state, but re-
stores their tone, and last of all to the absence
of nausea and vomiting following the opera-
tion which in many instances I am convinced
brings on a secondary hemorrhage which would
otherwise not occur. The dull dissection makes
it impossible to injure the pharyngeal muscles
upon which the tonsil rests, and it is my belief
that injury to these muscles constitutes the most
prolific source of hemorrhage. I believe it to
be a very rare circumstance for hemorrhage to
occur from the tonsillar artery when crushed by
the snare, provided the blood current is in suit-
able condition for operation, that is the coagu-
laticMi point normal. It is also apparent that
absence of injury to the pharyngeal muscles
make for a much shorter and much more com-
fortable convalescence, the patient being able
to eat in twenty-four or forty-eight hours.
I use this same technique in all my sinus
work. The same reasons apply here for utiliz-
ing gravity to keep the field clean and prevents
inspiration of blood as in tonsillectomy. In
nasal and sinus work anesthesia is accomplished
by means of the mouth inhaler. The nasal pas-
sages are therefore free and unobstructed for
dissection in the anterior nares, such as sub-
mucus resection of the inferior turbinates or
septal spurs and radical maxillary sinus pro-
cedures. If desired the postnasal spaces may be
tamponed to prevent the gas from blowing out-
ward through the nostrils and disturbing the
field.
After an infected sinus is opened and irriga-
tion is desired this position is especially valu-
able. In irrigating the sinuses after they are
opened, the forward inclined position allows the
pus to flow directly out of the anterior nares,
thus not endangering the patient by inspiration
during the narcosis.
Comparing gas with local anesthesia in nasal
work, I think its greatest claim for superiority
lies in the thoroughness in which surgery of the
ethmoidal labyrinth can be performed. Skill-
ful application of a local anesthetic may accom-
plish complete insensibility of practically all of
the nasal area except ethmoid and sphenoid
sinuses. It is a well-known fact that many
operative measures on ethmoids have proved to
be only partially successful and others are a
total failure. The discharge persists and the
patients are dissatisfied. These patients consti-
tute a great majority of the knockers on nasal
surgery as I find it. They are the ones who ad-
vise their friends never to start operations on
the nose as they may submit to three, four or
five operations and at the end be in no better
condition than they were in the beginning.
IN PURULENT ETHMOIDITIS
When it has gone to necrosis and the forma-
tion of granulation tissue and polypi, with hy-
perplasia, oftentimes closing in the infection, it
then becomes a physical impossibility to anes-
thetise the area locally any farther than merely
the outlying wall. Thus far it can be done and
the operator and the patient start in with a
great deal of confidence that the operation is
going to be painless. However, as soon as the
outer anesthetised crust is penetrated, one of
two things happens: either the operator must
stop short of thoroughness or continue with the
patient writhing in pain. Of course the former
will more often occur and the operation is
stopped with only part of the chronic area re-
moved. The patient can do nothing less than
have a continued supperation and postnasal dis-
charge. By and by the operator may persuade
him to have another sitting, and perhaps another
sitting, each time getting farther into the eth-
moidal sinus. There are a sufficient number of
patients who refuse to subject themselves to suf-
ficient repeated operations to have their entire
diseased ethmoidal cells removed and their dis-
charge dried up. I give it as my opinion that the
thorough ethmoidal exenteration should never be
attempted, except under profound general nar-
cosis. I find in my work under nitrous oxid and
oxygen gas, as I have described, rfiat a^thorough
March, 1921
POSTOPERATIVE COMPLICATIONS— DECKER
391
ethmoid operation is very easily done without
any pain or consciousness on the part of the pa-
tient.
Another point which I consider of great value
in this position is orientation. I need not re-
mind you that in sinus surgery landmarks and
direction count for much as regards the safety
of the patient. In an erect posture these direc-
tions are most natural and manifest. More-
over, the various structures are in their normal
position and relation as they are found during
the examination of the patient prior to the
operation. In such delicate procedures as enter-
ing the naso-f rental duct or the maxillary sinus,
or avoiding the penetration of the cranial cav-
ity through the cribriform plate of the ethmoid
bone in frontal sinus and ethmoidal surgery, the
direction of the instrument in probing the sphe-
noidal orifice or enlarging the same are all much
more easily and safely accomplished with the
patient sitting.
A general surgeon in Toledo is now using
my chair in performing gasserian ganglion op-
erations chiefly because of better orientation.
DISCUSSION
Dr. E. I McKesson, (Toledo, O.) : I have admin-
istered a great many anesthetics for tonsil work with
the various forms of anesthesia, but none gives me the
pleasure and the confidence and the control of the
patient that nitrous oxid does, particularly in this po-
sition. One of the most serious complications for the
anesthetist is the inhalation of blood because it is not
just blood after the patient inhales it; it is soon froth.
I have been very much exercised several times in try-
ing to resuscitate a patient who had inhaled a pharynx
full of blood, just ahead of the ability of the surgeon
either to suck it out with suction apparatus or to get
a sponge there in time. Oncfe down, it stays down,
especially so if the patient is deeply anesthetized, and
it chums back and forth into froth. Oxygen cannot
go through that froth. There is no efficient way to
save life if there is inspirated a teaspoonful that may
froth sufficiently to completely asphyxiate a patient.
Therefore, any means by which we can avoid this will
be a means of saving life. I have had several cases
under ether in the recumbent posture where I have
had to resort to oxygen under pressure to inflate the
lung, and then suddenly remove the mask to let the
bubbles stretch and burst to get rid of froth. By such
a procedure I have been able to save two of them.
So, if there is nothing else to recommend the forward
inclined sitting posture, this is quite sufficient for me.
There are many others from the surgeon's standpoint
— the orientation of his patient. We learn our anat-
omy in the upright posture. Your anatomy is mentally
fixed in those relations. The operative field is more
accessible to the surgeon. I am quite sure better tonsil
operations may be uniformly and more easily per-
formed in the forward inclined sitting position.
POSTOPERATIVE COMPLICATIONS OF
THE RESPIRATORY TRACT*
H. RYERSON DECKER, M.D., F.A.C.S.
PITTSBURGH
The surgeon with a conscience is constantly
seeking to lower his postoperative morbidity
and mortality. With this in view his patients
are subjected to a most careful examination to
determine the operative risk from the stand-
point of the heart, arteries and kidneys. The
respiratory tract, however, is apt to be neglected
or examined in such a cursory fashion that
often there develops after operation a complica-
tion such as pneumonia, which a postponement
of operation or some prophylactic measure
might have prevented. The indifference to the
respiratory tract springs, it may be, from a feel-
ing that these complications after an operation
are infrequent, or when they do occur, are in-
consequential and not attended with a consider-
able mortality. One has only to consult any
published statistics such as Table I to appreciate
the error of this viewpoint, and to see that post-
operative respiratory tract lesions are suf-
ficiently frequent and grave as to constitute a
real menace to the patient.
TABLE I
«
0
Author.
1
0
-3
1
0
.&8
•00
1^
1
1^
lis
Cutler & Morton (i).
Mass. Gen'l
3.490
6s
1.8
33
.94
50.7
Armstrong (a), Mon-
treal Gen'l
3.500
55
a. 2
32
1.28
58. 1
Mayo Clinic (3)
16,317
220
i.3»
«5
.11
9.6
Von Lichtenberg (4).
a3,673
440
1-9
Cutler & Hunt (5),
Peter Brigfaam, . . .
■ ,s6a
55
3.52
It
0.7
20
Decker, Pittsburgh, .
5.976
69
1.3
29
0.5
4a
Morbidity varies in the various clinics from
1.2% to 3.5% and the mortality from o.i% to
over 1%, which means that on the average one
case in every forty-five operated upon develops
a respiratory tract complication, and that one
case in every two hundred dies from some such
complication. But even if the complication does
not result fatally, it is true that the lesion often
protracts the convalescence to the point that a
considerable economic and sociologic loss is en-
tailed by patient and hospital alike, or leads to
sequelae which add the same burden. We have
studied the respiratory complications that have
developed in a series of 5,976 consecutive cases
in the services of Drs. R. R. Huggins, R. T.
Miller and W. O. Sherman at St. Francis Hos-
pital, and my own at Presbyterian Hospital,
•Read before the Section on Surgery of the Medical Society
of the State of Pennsylvania, Pittsburgh Session, October 6,
1920.
Digitized by
Uoogle
392
THE PENNSYLVANIA MEDICAL JOURNAL
March, 1921
as well as the experience of other clinics, to
answer for ourselves certain questions: i.
Whether the incidence of respiratory tract com-
plications is greater in this locality than else-
where. 2. What, if any, factors are essential to
the production of the complications. 3. What
are the factors in mortality. 4. What cases
may be considered potential risks. 5. What, if
any, measures may be taken to reduce the re-
spiratory tract morbidity. In our series of 5,976
cases there were seventy-one respiratory tract
complications after operation in sixty-nine pa-
tients, an incidence of 1.2%. On the basis of
these figures and making due allowance for in-
dividual equation, imperfect records, etc., it is
apparent that lesions of the respiratory tract do
not occur more frequently in this community
than in other clinics. This negatives the theory
that is sometimes expressed that the cUmatic
and industrial conditions in Western Pennsyl-
vania, predisposing to anthracosis and acute re-
spiratory tract diseases, are factors in the devel-
opment of the postoperative morbidity.
Numerous classifications are proposed for
the respiratory tract complications, but we have
chosen simply to list our complications as patho-
logical entities in Table II.
TABLE n
Lobar pneumonia 45
Broncho pneumonia 7
Bronchitis 7
Pleurisy :
Dry 7
Serofibrinous 2
Empyema i
Pulmonary embolism 2
71
It will be seen that pneumonia is by far the
most frequent complication with a great pre-
ponderance of lobar over bronchopneumonia.
Lesions of the upper respiratory tract such as
coryza and pharyngitis, if they have occurred
at any time, have been considered too inconse-
quential to record. The same might be said of
cases of mild bronchitis, so that the figure of
seven cases represents really only severe lesions.
The limits of this paper proscribe more than a
brief summary of the clinical aspect of our
cases.
Pneumonia. — Lobar pneumonia, forty-five
(one in association with pleural effusion),
bronchopneumonia seven. The onset of thirty-
two of these cases was within a forty-eight hour
period, a group of cases often but improperly
called "ether pneumonia" for we know that
while many of these early cases belong to an
irritation class they are not necessarily the re-
sult of anesthesia. The remainder of the pneu-
monia cases developed in periods ranging from
three to thirty days. Two of these cases were
very definitely terminal pneumonias. No cases
were of the definite embolic type of the disease
leading to well-marked infarction. Onset was
marked with cough and with sputum of muco-
purulent type, but rusty only twice. Forty per
cent, had pain in the chest. About twenty per
cent, had no subjective symptoms.
Physical signs at onset were usually only a
few rales, and diminished voice and breath
sounds, with an occasional friction rub, but
sooner or later went on to partial or complete
consolidation and could be differentiated as the
broncho or lobar types. There was always a
definite elevation of the temperature, pulse and
respiration which was not higher oftentimes
than the usual postoperative reaction. An un-
usual elevation of the respiratory rate was sug-
gestive of pulmonary involvement. Whipple'
has raised the question as to whether or not
many of the sharp temperature rises in the
48-hour postoperative period, and ordinarily
considered simply as normal "postoperative re-
action" are not really cases of postoperative
pneumonia. They are not recognized as pneu-
monia because they are not examined carefully
or because they do not have frank physical
signs. Whipple finds the x-ray helpful in lo-
cating lesions of this sort, and the characteristic
appearance in the lung as a wedge-shaped
shadow with a base directed downward and out-
ward toward the periphery of the lung and the
apex toward the hilum.
Defervescence occurred in our cases by lysis
in all but three and in the majority of instances
within a twelve-day period. The right lung was
involved more than the left in the ratio of 3 to i
and the same rate held in reference to the lower
and upper lobes. In about 12% of the cases
more than one lobe was involved.
Pleurisy. — We noted ten cases all told, seven
of which were of the dry type and two cases of
effusion (one of these associated with bron-
chitis and the other secondary to pneumonia),
and one case of suppurative type. In this case
a very small abscess was found at the operation
and a good recovery resulted. One point of
interest to be noted is the infrequency with
which empyema follows a postoperative pneu-
monia. Most of the dry cases developed in the
second week of the postoperative period when
the patient was entirely convalescent and were
manifested simply by pain in the chest with or
without friction rubs and usually without eleva-
tion of the temperature, pulse or respiration.
It is not unlikely that they are the result of
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March, 1921
POSTOPERATIVE COMPLICATIONS— DECKER
393
small emboli set free from the operation site.
Pleurisy, with effusion and empyema, on the
other hand occur most commonly when there is
a localized or general upper abdominal peri-
tonitis, affording an immediate source of infec-
tion via lymphatics.
Bronchitis. — Many cases follow immediately
upon the anesthesia and for this reason would
seem to have some definite relationship to the
irritation produced by it when inhalation anes-
thesia is used. It is a complication which can
be predicted with certainty if there is evidence
before the operation of inflammation in the
bronchi. It is quite exceptional for cases of
bronchitis to result fatally, but in our series of
six cases there was one suppurative case which
died. This followed a cholecystectomy for
cholecystitis and cholelithiasis under ether anes-
thesia of one hour's duration. The patient ran
a high temperature immediately after opera-
tion, had a hard cough and a rather thick yellow
sputum containing pneumococci of Group 4, but
at no time, however, were there signs of pneu-
monia. Death occurred on the tenth day.
Embolism of the Pulmonary Artery. — This is
a complication grouped usually with the respira-
tory tract lesions. In our series there were two
cases, first a woman of forty-six, with varicose
veins of both legs in which a double Trendelen-
burg operation was done under local anesthesia.
On the ninth day the patient developed pain in
the chest, temperature of 100° F., pulse 120,
respiration 24, which subsided quickly. On the
seventeenth day, pain in the chest recurred with
temperature 98° F., pulse 150, and respiration
60. The pulse continued very weak for about
forty-eight hours and did not regain normal rate
or force for a week. In this case the condition
was probably primary thrombosis of the veins
of the extremities with very likely on two sepa-
rate occasions splitting off of emboli, in the
first attack causing pulmonary infarction, and
in the second a partial blocking of the pulmon-
ary artery itself. The second case was a woman
of 57 with cholelithiasis and suppurative cho-
lecystitis. A cholecystostomy was done under
spinal anesthesia. On the twenty-ninth day
after the operation out of a clear sky she com-
plained of considerable pain in the chest and
shortly went into collapse and died in a very
few minutes. Here, it is very likely that there
was rather extensive thrombo-embolism of the
pulmonary artery. Etiological factors in her
case were not certain though there had been an
infection in the gall bladder which, however,
had practically cleared up through drainage.
The question of the effect of operative pro-
cedure upon pulmonary tuberculosis is an im-
portant one. All clinicians seem to be in ac-
cord that a latent tuberculosis may be lighted
up or an active lesion may be aggravated by
operation, especially if inhalation anesthesia is
used. One case of our series with apparently
normal physical signs before operation devel-
oped bronchopneumonia associated with pleu-
risy, and subsequently ran a temperature course
which strongly suggested tuberculosis, though
the tubercle bacilli were not demonstrated in the
sputum. Certainly if pulmonary tuberculosis is
suspected inhalation anesthesia should be
avoided.
This rather brief summary and comment on
the clinical aspect of our cases bring us to the
discussion of the etiology of the respiratory
tract complications. One is impressed at once
that the factors are numerous and various. We
have chosen to consider them in two categories,
first predisposing and second exciting. The pre-
disposing factors may be grouped as exogenous
or endogenous, depending upon whether they
act from without, or are due to the physical con-
dition of the patient. The important exogenous
factors are: i. Anesthesia. 2. Exposure. 3.
Type of operation. 4. Factors increasing the
virulence of the bacteria. The important endo-
genous iactors are: I. Recent infection of the
respiratory tract. 2. Local or general sepsis
elsewhere. 3. General physical condition of the
patient. 4. Condition of the cardio-vascular
system, predisposing to stasis in the lungs. 5.
Thrombosis and those etiological factors upon
which it depends.
Inhalation anesthesia is undoubtedly respon-
sible for the production of a certain number of
postoperative complications. This is especially
true of ether, owing to its irritating properties
on the mucous membrane of the respiratory
tract. The mucus which is secreted in abundant
quantity is churned up in the patient's throat,
mixed with any food contents that may be pres-
ent, and the bacteria of the mouth and throat,
which often include streptococci and pneumo-
cocci. This charge is carried directly to bronchi-
oles or alveoli whose resistance is lowered be-
yond a successful barrier point. Of the general
anesthetics it is a consensus of opinion that
ether is the most irritating, nitrous oxid less so,
and chloroform the least. With a history of
physical signs of recent respiratory tract in-
fection, both ether and nitrous oxid, in my ex-
perience, are to be avoided. Local anesthesia,
or spinal anesthesia or chloroform are much to
be preferred. It is interesting to note that many
complications follow local or spinal anesthesia.
Gottstein'* and Henle", for instance, reported
in a series of abdominal operations liiat more i
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394
THE PENNSYLVANIA MEDICAL JOURNAL
March, 1921
pneumonia occurred with local than general,
though with less mortality. In a consideration
of statistics of this sort, however, it must not be
forgotten that in many of these cases local anes-
thesia may have been chosen because of the
grave condition of the patient or because of evi-
dence of respiratory tract infection, either one
of which could have been responsible for the
pneumonia. In our series of sixty-nine cases,
fifty-six occurred with ether, five with novo-
cocaine, six with spinal, and one with chloro-
form. Aside from the kind of anesthetic, the
duration of anesthesia may be an influence, but
this in turn is not nearly as important a factor,
it seems to me, as the method of administration.
Open methods of administration with avoidance
of cyanosis, vomiting, and excess of mucus are
the desiderata. In six of our cases the ether
was badly taken. On the other hand it was
badly taken in a number of cases which did not
develop any complication, which tends to show
with other evidence that anesthesia per se is not
an etiological factor of great moment.
Exposure of the patient to chilling before and
after operation is in our judgment a very im-
portant predisposing cause. In the average hos-
pital, patients are subjected to conditions of
ventilation, bed clothing, and wearing apparel
to which they are not accu-stomcd. It is quite
usual after a hot admission bath for patients
to be allowed up and about a cool ward inade-
quately clothed, and then in the course of phys-
ical examinations and preoperative preparations
to undergo further exposure. The result is that
they become chilled to the point of vasomotor
depression and the opportunity for bacterial in-
vasion is enhanced. After operation "when the
vasomotor system is at the lowest ebb of tonicity
they are wheeled, it may be, in cold wet night-
gowns through cold, draughty corridors to cold
recovery rooms. It is careless handling of this
nature that is as prolific of respiratory tract
complications as any other predisposing cause.
Whether the type of operation is an etio-
logical factor is a matter of opinion. Statistics
would seem to show that occurrence is much
higher in abdominal cases than others, even
four to five times greater. (In our series, ab-
dominal 51, hernia 8, head and neck 3, and ex-
tremities 7.) While this may be due to the fre-
quency of intra-abdominal sepsis, further ex-
planation is found in the limitation of respira-
tory excursion that is apt to follow the trauma
of rough retraction, the application of tight ab-
dominal binders and dressings, or is incident to
the pain of incisions close to the ribs and to
postoperative distention, any one of which may
interfere with aeration of the lungs or ability to
cough out mucus.
It has been noted that a greater number of
cases of postoperative complications occur in
the winter and spring months, and in this par-
ticular follow the increased frequency of pri-
mary respiratory tract disease at these seasons,
which, however, was not true of our series
where the cases were evenly distributed. Ex-
planation of this is easily found in the conges-
tion and crowded housing conditions that ob-
tain then, but a more interesting theory has been
suggested by Cole' and others to the effect that
in these months there is an increased virulence
of organisms especially the pneumococcus, the
result of being passed rapidly from one host to
another.
In a consideration of endogenous predispos-
ing causes, local infection in the respiratory
tract stands out foremost. That an infection
such as coryza, laryngitis, or bronchitis recently
subsiding or acute, could be a source of compli-
cation after operation needs no discussion.
Chronic inflammatory conditions, such as
chronic bronchitis and emphysema with circu-
latory stasis in their train also, without doubt,
predispose to complications, but less frequently.
Some cases result from infection elsewhere in
the body, which is then carried to the lungs by
the blood stream or lymphatics, particularly when
there is an infection in the upper abdomen.
Then the route is a most direct one through the
lymphatics from the mesentery and liver, which
in turn pass through the diaphragm into the
anterior and posterior mediastinal nodes, and
thence into the bronchial lymphnodes. By no
means the least important factor, is concerned
with the general physical condition and resist-
ance of the patient. Those who are debilitated
through shock, hemorrhage, toxic conditions, •
especially of malignancy or through old age fall
an easy prey to pulmonary infection.
That any cardio-vascular lesion such as myo-
carditis, which results in a pulmonary hypo-
static condition predisposes to infection needs
no discussion. And finally there are thrombosis
and embolism, and the numerous factors in turn
which favor their development, such as: local
infection, anaemia, slowing of blood stream, sub-
normal physical condition, inefficient hemostasis,
traumatization of tissues, injury to blood ves-
sels, and excess of calcium salts in the blood.
Individual opinion varies in the diflferent clin-
ics with reference to the importance of these
several factors. Thus Bevan* believes that
postoperative pneumonia is largely autogenous
and the result of attacks by bacteria at a time
when resistance and vitality are lowfredr^ AtiHf ^
Digitized by VjVJO^Ic
March, 1921
POSTOPERATIVE COMPLICATIONS— DECKER
395
strong,* in view of the predilection of the pneu-
monic process for the right base, thinks that
aspiration of foreign material is especially at
fault; Lord,* that infection exists at time of
operation; Herb,' that loss of body heat in the
operating room is most important; Beckman,*
that septic emboli are chiefly responsible. Cut-
ler,' in his recent paper, states that embolism is
the chief factor. In studying our series of
sixty-nine cases we were reasonably certain of
predisposing factors in only eighteen cases. In
six of these ether was taken rather badly, two
could be attributed to general infection, eight
had preoperative inflammation in the bronchi,
two had a history of recurrent winter cough.
In the remaining fifty -one cases there was no
definite cause determined. Many of these may
have been due to emboli, especially as they were
abdominal cases, the type that is prone to set
free emboli, and furthermore were associated
with a septic focus. Some undoubtedly were
the result of exposure, but there was no record
to point out how definitely this may have been
a factor. As a result of our study we have
come to believe that there is no constant or es-
sential predisposing etiological factor in the pro-
duction of respiratory tract lesions after opera-
tion, but that exposure of the patient and exist-
ing infection in the respiratory tract are quite as
important as the setting free of emboli from the
operative field.
Whatever may be the factor that predisposes
to lesions, it is certain that pathogenic bacteria
are the exciting agents present either in the re-
spiratory tract or elsewhere in the body and in-
troduced from septic foci either by lymphatics,
blood stream, or by direct extension. There has
been no bacteriological study of pulmonary in-
fection as a whole, though Whipple* and Cleve-
land" have investigated postoperative jpneu-
monia. Their findings with reference to pneu-
monia are registered in Table III.
TABLE III — SPUTUM EXAMINATION
Pre- Post-
operative, operative.
Cases examined by mouse inocu-
lation 8s 130
Cases not examined ^^ 32
Group I, pneumococcus 2 4
Group II, pneumococcus S S
Group III, pneumococcus 8 10
Group IV, pneumococcus 30 (35%) 80 (62%)
Groups III and IV 0 i
B. influenzx I 5
B. mucosus capsulatus 3 7
B. mucosus capsulatus and pneu-
mococcus IV o I
Streptococcus 3 10
As we have already suggested the seriousness
of postoperative pulmonary complications is
well understood when the mortality is consid-
ered. The rate is particularly high where there
is infection. In our series of twenty-nine deaths
there were eighteen with acute pyogenic foci.
In three, shock and hemorrhage were associ-
ated; in three, cachexia, and in three, advanced
years. The question might be raised whether
the respiratory lesions in themselves are respon-
sible for the mortality. It would seem in our
series that in sixteen of our cases the respira-
tory tract complication was. definitely the cause
of death and- probably in eight more was the
factor which tipped the scales against the indi-
vidual's chances of recovery. This was espe-
cially true of a group of three of typhoid fever
perforation cases which might have recovered
but for the onset of pneumonia in each instance.
In our series only five cases would have died
anyway. Pneumonia and thromboembolism are
the most prolific sources of mortality. Em-
pyema too is highly fatal. In Bumham's" re-
port of a series of six cases all were fatal.
We have raised the question as to what cases
are potential operative risks from the standpoint
of the respiratory tract. On the basis of our
study, there are three classes: i. Those with
history of recent respiratory tract invasion. 2.
Those with history or evidence of chronic le-
sions such as bronchitis and emphyema. 3.
Those with evidence of circulatory stasis
whether of cardio-renal origin or due to
cachexia and old age. Surely in these cases if
operation is necessary more than usual care
must be exercised in their handling.
This brings us to consider whether any meas-
ures may be undertaken to reduce the respira-
tory tract morbidity and mortality. It is our
belief that such can be done in a prophylactic
way. Careful history taking and physical ex-
amination should point out operative risks, and
lead one either to postpone the operation or
avoid irritating anesthesia or pass the opera-
tion by entirely.
It is a moot point whether special ante-
operative oral asepsis is of distinct advantage.
At least measures taken to cleanse the teeth and
throat can do no harm. In the matter of pre-
venting pulmonary thromboembolism, it would
seem well worth while to carry out the sugges-
tions of Ochsner against the specific etiologic
factors. These include perfection in aseptic
methods of operation, perfect hemostasis, trans-
fusion of whole blood to boost up anaemia or
cachexia and subnormal general physical con-
dition, avoidance of undue traumatization of
tissue especially by retraction, and of injury to
veins in the extremities by faulty positions on
the operating table. ^.^.^.^^^ by (^OOgle
396
THE PENNSYLVANIA MEDICAL JOURNAL
March, 1921
Inexpert administration of anesthesia may be
eliminated; extra precautions may be taken to
prevent chilling and exposure of the patient. In
Kronlein's" clinic, the incidence of pneumonia
fell from 9% to 2.10% in four years by taking
precautions to prevent chilling of the patient in
the scnib-up and operating room, and the sub-
stitution of open ether administration for closed
methods.
At the Presbyterian Hospital in New York a
•number of prophylactic measures have been
adopted. These include: i. Special care in
physical examination and history taking. 2.
Avoidance of ether in those operations of neces-
sity where the patients have any evidence of re-
spiratory tract infection. 3. The following
nursing rules: (i) The temperature for the
bathroom routine admission bath must be 70°
F. (2) No patient who has had his admission
bath and is to be operated on the following day
is allowed out of bed. (3) The hair of all fe-
male patients is to be thoroughly dried with an
electric blower. (4) Before leaving the operat-
ing room each patient shall be given a di^,
warm night shirt, arfd shall be carefully covered
with sufficient blankets. (5) On arriving in the
ward a cotton pneumonia jacket shall be put on
each patient. (6) Sufficient blankets shall be
provided and. all draughts avoided. (7) As
soon as patient is conscious a heavy woolen bed
jacket is to be worn. Blanket rules are not to
apply in hot weather. 4. On one ward, tincture
of digitalis was given in the preoperative period
in an effort to obtain a digitalis effect on the
heart to combat pulmonary congestion during
operation. On another ward, chests were
rubbed with turpentine and camphor liniment
immediately after operation. While there has
been no report as to the benefit of these meas-
ures, they seem to me to be a step in the right
direction, and many of them have been put in
force in my hospital service, where special stress
is being laid upon careful physical examination
of the chest, counter irritation with camphor-
ated oil both before and after operation and ex-
treme care in avoiding exposure of the patient.
At this time our statistics are too meager to
warrant any conclusions as to the worth of
these extra precautions, but we believe our
records several years hence will show that they
are justified.
In conclusion, I wish to reaffirm the menace
that exists to operative cases from respiratory
tract complications, to urge greater care in the
handling of cases from this standpoint, and to
emphasize my conviction that a large decrease
in the postoperative morbidity will follow a
painstaking prophylactic regime.
BIBLIOGRAPHY
- 1. Cutler, E. C, and Morton, J. J., Surg., Gynec. & Obst,
1917, XXV, 6ai.
a. Armstrong, G. R. Brit, H. J., 1906, i, 1141.
3. Beckman, Collected Papers Hnro Clinic, 1910-1914.
4. Von Lichtenberg, A., Centralbl, F. d. Grenzgeb, d. Med.
U. Chir, II, Jig, 1908.
5. Cutler, B. C, and A. M. Hunt, Archives of Surgery, Vol.
I, No. I.
6. Whipple, A. C, Surg.. Gynec & Obst., 1918, XXVI, 39-
7. Cole, Arch. Int. Med., 1914, XIV, s«.
8. Sevan, A. D. Tr. Am. Surg. Ass., 19IS. XXXIII, 31.
9. Lord, F. T. J. Am. M. Ass., 1916, LXVII, SS9-
10. Herb, I. J. Am. Ass., I9>6, LXVI, 1376.
11. Cleveland, Mather. Surg., Gynec. & Obst., 1919, XXVIII,
283.
13. Bumbam, A. C. Surg., Gynec & Obst., 19, 4^8, 1914-
13. Kroenlein. Verhandl. d. deutscb. Gesellsch. f. Chir.,
190S, XXXIV, I.I.
14. Gotutein, G. Arch. f. klin. Chie., 1898, LVII, 409.
15. Henle, Verhandl. d. deutscb. Gessellsch. {. Chir., 1901,
XXX, 340.
THE PROBLEMS OF CHEST SURGERY
AS MET BY PHYSIOLOGICAL
DRAINAGE*
LEVER F. STEWART, M.D., F.A.C.S.
CUiARFIEU), PA.
Some eight years ago while doing experiments
on animals, necessitating the opening of the
plural cavity, I was compelled to give up the
work on account of the invariable occurrence
of pleuritis and pneumonia. The chest surgery
done in the forward areas during the late war
was more successful but attended very fre-
quently by the same results. From my observa-
tions the mortality of operations done on these
cases varied from 30 to 60%. Pleuritis or
pneumonia or both were the usual causes of
death. They were the things to be avoided to
make this work successful. It has long been
known that the pleura has little resistance to in-
fection.
An interesting sidelight on the occurrence of
pneumonia in these cases comes with the contra-
lateral pneumonias or pneumonias seen on the
side opposite the injured side in cases treated
without operation. This condition occurs in the
absence of an anesthetic in the lung that has re-
ceived no trauma. My attention was first called
to this by Tuffier. The occurrence of contra-
lateral pneumonia may be influenced by the gen-
eral change in intra-thoracic pressure shown to
occur by Graham, E. A., and Bell, R. D., of
the Empyema Commission, writing on "Open
Pneumothorax; Its Relation to the Treatment
of Empyema" — (Am. J. M. Sc, 1918, Clivi,
839), in which they say :
"It would seem to follow from all this that in
the normal chest an open pneumothorax on one
side would produce graphically an equal amount
of compression of both lungs and that the
prevalent conception of collapse of one lung
with maintenance of respiration by the other
"Read before the Section on Surgery of the Medical Society
of the State of Pennsylvania, Pittsburgh Session, October J(,
Digitized by VjOOQIC
March, 1921
CHEST SURGERY— STEWART
397
must be incorrect. Again, direct experiment
seems to confirm the truth of this conclusion;
for determinations of the relative densities of
the two lungs after altering the pressure in one
pleural cavity show that, within the range of
experimental error, the densities are the same
and therefore that both lungs are practically
equally compressed. The extreme mobility of
the human mediastinum in the absence of ad-
hesions has been shown in x-ray studies by
Stivelmann and Rosenblatt. Their work tends
to confirm the truth of the general idea here
being developed, of the practical equilibrium of
pressure throughout the normal thorax."
I prefer to use nitrous oxid as an anesthetic
whenever practical and feel that its use in
skilled hands is attended by less risk to the pa-
tient than any other general anesthetic. I wish
to record that in my own observations on chest
cases in the use of intratracheal ether insuffla-
tions (ether by the drop method and nitrous
oxid) there has been no effect on the incidence
of pneumonia. I feel I may say the anesthetic is
a negligible factor in the occurrence of pneu-
monia.
In America during 1918-1919, army surgeons
at cantonments were confronted with an un-
precedented number of cases of empyema and
lung abscess following pneumonia. They were
treating them by immediate operation and hav-
ing an unprecedented mortality. Moschowitz
writing on Empyema ( S. J. & Obst., Jan., 1920,
XXX, 35) says:
"It is unwise to perform an operation in the
formative stage. The mortality is terrific be-
cause the accompanying pneumonia is still in
full bloom and furthermore there occurs an
acute pneumothorax with 'fluttering of the me-
diastinum' and consequent embarrassment of
the action of the heart."
In civil practice one rarely if ever encounters
wounds of the heart or lungs. Primary ma-
lignant disease of the lung is rare and when it
comes is too generally distributed from the root
of the lung outward to make operation prac-
tical. Operative intervention in pulmonary tu-
berculosis is not practical, because it is fre-
quently generalized and when localized to an
apex and giving sufficient symptoms to consider
operation, the patient's condition usually does
not permit of it. Lung resection for bronchi-
ectasis and similar conditions is still in an ex-
perimental stage.
Transpleuro-diaphragmatic splenectomy is
possible. I have done it in cases following in-
jury from a projectile, but it is not the opera-
tion of choice. Recently a Frenchman has sug-
gested an abdomino-thoracic incision where dif-
ficulty is encountered in doing splenectomy.
Transplural drainage of a subdiaphragmatic
abscess is occasionally necessary. This class of
work is decidedly Umited. Here we have in-
fection and pneumothorax as our chief primary
difficulties. A solution of these problems can
broaden the field beyond the treatment of em-
pyema, which in civil chest surgery has been our
limit to date.
Infection in the plueral cavity is aggravated
by exposure. That pneumonia can occur as a
result of exposure as well as infection is easily
understood when one considers the inrush of
cold air through a sucking wound of the chest.
The dictiun of surgery is to drain in the pres-
ence of infection. The dictum of lung surgery
is to keep the pleural cavity closed to air and
drained. In war work our greatest care was to
close sucking wounds quickly in order to avoid
the cardiac embarrassment, shock and infection
incident to them.
Drainage with the pleural cavity protected
from pneumothorax, permitting only the exit of
infected material and air, is made possible by
the use of the one way (expiration) valve used
on our army box gas mask and meets the physi-
ologicall requirements. This was first suggested
to me by Yates in 1918; at the meeting of the
Clinical Congress of Surgeons held in New
York, October, 1919, Yates described this valve
used in connection with a drainage tube. I have
attached this valve to the Brewer tube, modified
its application so as to continue indefinitely the
protection of the pleura from the air and at the
same time permit of the use of Dakin's solu-
tion.
To the distal end of the tube the gas mask
valve is attached. The shape of the valve is
better appreciated from the above cut. It is
really hexagonal in shape with the superior and
inferior sides shorter. The two sides adjoin-
ing the inferior side or base are open. These
openings permit the discharge of air and fluid
but any suction whatever causes approximation
of the edges and complete closure of the open-
ings. This was proved in the army where it
was shown safe in preventing gas from entering
the respiratory passages. Starting about three
c. m. from the flange of this same tube, openings
at right angles to the long axis of the tube are
made so that they extend some distance from
the flange and increase in length as they in-
crease the distance from the flange, but all start
from a straight line parallel to the long axis of
the tube. (See Fig. 3.) The cuff tube that fits
over the one already described has a perforation
parallel to its long axis. (See Fig. i.)
The above-described openings are^ about 8 j
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398
THE PENNSYLVANIA MEDICAL JOURNAL
March, 1921
mm. in width. The cuff can be rotated on the
inner or longer tube and where these openings
cross, Carrell tubes can be passed and yet pre-
serve an airtight apparatus by the aid of vase-
line gauze. The arrangement of the perfora-
tions is such that the thickness of the chest wall
cannot interfere with arranging perforations to
• receive the tubes. The cuff is made sufficiently
large to rotate properly when vaseline is ap-
plied. (See Fig. 2.)
the old line of closure in order to deliver the
flange. A pinch cock is then applied close to
the skin between the flange and first perforation
in the tube. Thus the space between the skin
and pleura is permitted to close of itself, whidi
it readily does. If further drainage is needed
it can be gotten with release of the pinch cod.
All of this manipulation can be done without
the entrance of air into the pleural cavity.
Closure by suture is not necessary. The last
w^ |.^;«i.«w.
^.V» - I tT«.
'fff
^•^.nUw
^^-■
The tube is inserted in the usual way, prefer-
ably after rib resection but instead of having the
outer flange outside the skin, it is placed beneath
the skin after the muscle has been sutured close
to the tube with cat gut. The skin is then su-
tured over the outer flange with cat gut. This
insures good position of the tube, guarantees
an airtight connection, and prepares a place for
the inner flange, for after the cavity is shown
to be sterile the cuff is pulled out from under
the skin and the inner flange is pulled outward
to occupy the former position of the cuff flange.
Sometimes it is necessary to open the skin along
flange is removed when closure of deeper struc-
tures is assured and there is no further drain-
age.
The results from the tise of Dakin-Carrell
treatment through this tube have been astound-
ing compared with our previous results in this
work. I believe the exclusion of air has helped
materially in the action of the Dakin solution.
We have injected the solution in amounts up to
20 cc. in each of two to four tubes every two
hours, the tubes are clamped after injecting the
fluid. A pinch cock has been kept on the tube
distal to the cuff. It has been released and ac-
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Uoogle
March, 1921
CHEST SURGERY— STEWART
399
cumulated fluid evacuated two or three times a
day dependii^ cm the virulence of the infection.
We have usually instituted the Dakin-Carrell
treatment in from twenty-four to seventy-two
hours following the introduction of the tube in
badly infected cases.
The advantages of the apparatus over the or-
dinary drainage tube are obvious. Empyemas
due to streptacoccus hemolyticus can be ap-
proached immediately on being diagnosed be-
cause the exposure is but a matter of moments
instead of the constant endless sucking in and
out of cold air over the surface of a lung, the
seat of pneumonia and covered by an infected
pleura. Cardiac embarrassment, circulatory
and lymphatic change, and lung collapse are
temporary. This tube can be inserted after a
resection of a rib in less time and with less diffi-
culty than by the use of troca and cannula, and
embodies many improvements over the troca
and cannula. Rib resection is not necessary
but is always a better procedure, especially m
obese pe(q)le. Postoperative shock and mor-
tality is reduced to a minimum. Ashurt's propo-
sition number two (Annals of Surgery, July,
1920, LXXII, 33) that "if the fluid found on
puncture is serious, or sero-purulent, thorac-
otomy usually may be postponed until frank pus
has formed, as this will permit the formation of
firmer adhesions and thus prevent complete
collapse of the lung when the empyema is
opened," should be disregarded. Following
such a policy can only increase the number of
mutilating operations such as decortication and
those of Schede and Eslander, all necessitated
by the presence of binding adhesions.
I have assumed that the application of this
airtight drainage immediately permits the ex-
pansion of the lung, as a result of observing
many open chests. It is easy to expand the col-
lapsed lung by increasing the pressure of the
nitrous oxid or oxygen. I have not verified
this by fluoroscopic examination immediately
following operation but have found it to be the
case when fluoroscopic examination was done
before the discharge of these patients from the
hospital at the end of from three to six weeks
with healed wounds. Immediately following
operation fluoroscopic observations should be
made, their importance had not impressed me
until I took up the preparation of this report. I
consider the fluoroscope the best single diagnos-
tic agent we have in chest conditiwis, and I trust
that where physiological drainage is used such
observations will be made and reported.
This method of drainage with the use of
Dakin's solution has permitted the cure of em-
pyema and lung abscess cases, some of long
duration, in from three to six weeks following
operation. Our mortality has been lowered.
The tube has permitted our wounds to remain
small, closure has been almost automatic with
the removal of the inner flange from its first
position. Secondary closures have not been
necessary. Where secondary closure of chronic
empyemas after the method of Depage and
Tuffier is practiced, with or without decortica-
tion, the use of this drainage tube should be of
the greatest value in caring for the frequent
hemorrhage and drainage occurring during the
ensuing twenty-four hours. It applies to any
thoractomy in which liemorrhage, drainage, and
infection are feared.
With an apparatus such as I have described,
drainage of the pleural cavity at the earliest mo-
ment infection is indicated can be instituted
with confidence. If there is virtue in early in-
tervention in an acute abdomen, it certainly is
more important to give immediate relief to the
pleura whose endothelium cannot wage the
battle against infection that peritoneal endoth-
elium is capable of waging. The worst possible
late result of early physiological drainage is an
expanded lung adherent to the parietal pleura.
Procrastination and an open drainage tube too
often result in a collapsed lung firmly held in the
costovertebral groove by adhesions. Our med-
ical chest conditions, including chronic em-
pyema, can be approached with assurance of the
immediate closure so much to be desired with
drainage in additicMi.
The primary use of this apparatus should
eliminate the later use of Perthe's water pump
and similar apparatus for causing expansion of
collapsed lungs. Reflecting on the findings of
Graham and Bell and considering that they as
well as others showed experimentally that the
danger from an open pneumothorax depended
on the size of the opening, there should be no
reason why the tubes I have described should
not be used simutaneously in both pleural cavi-
ties where double empyema exists. However, I
would suggest that the second tube be inserted
twenty-four to forty-eight hours after the in-
sertion of the first tube. These investigators
have learned that the increased pressure in the
pleural cavity is compensated for by an in-
creased respiratory rate up to the point of the
pleural openings approaching the size of the
trachea. Where the tube I have described is
used, you deal only with a temporary pneumo-
thorax in which the air pressure gradually dis-
appears. The size of the opening in the chest
is only large enough to prevent any possible leak
in the drainage tube or around its point of in-
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400
THE PENNSYLVANIA MEDICAL JOURNAL
March, 1921
Since using this tube I have had occasion to
do but ten empyemas. With these I include two
lung abscesses. One of the ten, a three-year-old
child, admitted to the Clearfield Hospital in a
moribund condition, died.
DISCUSSION
Dr. Frederick B. Utuy, (Pittsburgh) : I have lis-
tened to these two papers with very great interest, and
in addition I had the pleasure of reading Dr. Decker's
paper before it was presented. Dr. Decker's paper is
opportune at the present time. It is so common for a
physician on the medical service to transfer a patient
to the surgeon for operation and for the patient to ap-
pear in the operating room without either one of the
physicians concerned having given a thought as to the
ability of the patient to take an anesthetic or what
would be the best anesthetic. It is important to deter-
mine the type of anesthetic which should be used in
each individual case from the standpoint of the respir-
atory tract as well as from that of the circulatory
system. There are many surgeons who have come to
surgery through general practice and they are per-
fectly competent to determine what anesthetic is safe
and best to use. There are, however, many surgeons
who have worked throughout their hospital experience
entirely on the surgical side and it would seem to me
that they are not competent to pass on the medical
aspect of heart and lungs any more than the medical
men are to pass on a surgical condition in the abdomen.
The medical men are always at the call of the sur-
geons to render an opinion as to whether the anes-
thetic should be ether, chloroform, or some other type
of anesthetic.
Dr. Decker spoke of the bad taking of an anesthetic
where the mucus is churned in the back part of the
mouth and possibly aspirated into the lung. As has
been well shown, the mouth always contains pneu-
mococci. During the winter season, because the dis-
ease is more prevalent at that time, the pneumococci
are more virulent and the aspiration of the same might
result in pneumonia. Blake and Cecil pointed out that
as long as the pneumococcus remains in the mouth the
host is safe but when introduced into the trachea or
bronchi pneumonia is likely to follow. Hence the im-
portance of giving an anesthetic properly, which re-
quires the services of an experienced anesthetist. In
cases where more or less pulmonary stasis exists it
might be possible to overcome this in part by posture
after the operation. I am not competent to speak
with full authority, but I believe that there is seldom
a surg^icat case that could not have the head of the
bed elevated somewhat to take care of the pulmonary
stasis existing in that individual.
Dr. Decker pointed out that there should be a care-
ful and complete physical examination. That is the
crux of the situation in all medicine. It helps to make
a more accurate diagnosis and helps to treat the pa-
tient better. We should always have the welfare of
the patient in mind. If we find a pulmonary condition
does exist, the patient can either have the operation
postponed, omitted or perhaps another form of anes-
thetic used if immediate operation is imperative. It
would seem to me wise to have all patients in the hos-
pital a few days before operation if possible, in order
to give those who are to work with the patient a
better conception of his condition, and also to give the
patient an opportunity to build up resistance.
As to the use of a pneumonia jacket and covering
with blankets following operation, I think these pa- *
tients should be protected from draughts and exposure
to cold. It seems to me, however, that patients are
often weakened and their resistance lowerd from
drenching perspiration due to too much warmth and
clothing applied following operation.
I am not competent to speak of the technical char-
acter of Dr. Stewart's paper. I have seen two or
three chests this spring in which the method he has de-
scribed was used, and I was amazed to see how com-
pletely the pleural cavity had filled with the expanding
lung.
Dr. J. Ralston Wells, (Philadelphia) : I have been
very pleased to hear these papers of Dr. Decker and
Dr. Stewart. The prime thing in Dr. Decker's paper
was, to me, the importance he placed on the anesthesia
used. All inhalation anesthesia, of course, make the
lungs work to a greater extent. It would, therefore,
cause a passive hyperemia of the lungs with probably
lowered resistance and would therefore give you a
better opportunity for culture of any bacteria that
happened to be present. That nitroUs oxid is the least
harmful of all the inhalation anesthesias I think the
majority agree. Dr. Decker spoke passingly of spinal
anesthesia. 1 should like to impress upon the gather-
ing the advantages of a spinal anesthetic which is
moderately safe, although we have not had as much
opportunity to try it clinically as we would like. I am
speaking of cocaine anesthesia robbed of the toxic
properties that we all know and fear. If this becomes
established we would have a safe anesthetic approach-
ing the ideal. In a paper on which I spent considerable
time, read before the Academy of Surgery of Phila-
delphia, I elaborated on the cocaine whose preparation
and use was shown to me by a French physician and
surgeon in 1918, a preparation of cocaine that has been
dehydrated and put through a purifying process. In
his 400 and some cases he has never had a fatality nor
has he ever had any alarms on the table, aside from
slight sinking sensations, such as you get when open-
ing the abdomen and pull a little too hard on the in-
testinal mesentary, the nerve supply of which is a part
of the nervous control over which the spinal anes-
thesia does not seem to act. As far as spinal anes-
thesia per seis concerned it gives you a patient who
is in no way devitalized so far as resistance goes, the
prostration, weakness, the vomiting 24 to 48 hours fol-
lowing is absent. The diet has to be particularly
watched in all inhalation anesthesias, nitrous oxid
being among the least irritating, while in the cocaine
anesthesia the diet is practically uninterrupted. The
patient can have the same meal for dinner that he was
in the habit of previously, and metabolism goes on the
same. Ether anesthesia is more preferable than this
method of spinal anesthesia in cases where expert sur-
geons or men used to giving spinal anesthesia are not
present. With spinal anesthesia in the hands of a
person who is familiar with its use, it appears to me
that would overcome a great deal of the difficulty ex-
perienced in chest surgery.
Pneumonia may be explained by the sudden opening
of one side of the chest cavity, allowing of positive
pressure. Dr. Stewart overcomes this almost imme-
diately, which would make an engorged lung on the
other side and thus more chance of infection. The
drainage tube of Dr. Stewart is very apt and I think
will lessen our mortality to a great extent and hasten
our convalescence. I have been in the habit of using
a simple tube inserted into a water bonle.at the side
Digitized by VjOOQIC
March, 1921
HYPERTRICHIASIS— KNOWLES
401
of the bed which has in it a solution of bicarbonate of
soda. On inspiration the water is pulled up 14" to 18"
and on expiration very naturally drops and takes
considerable of the pus by the suction created. The
disadvantage of this tube is it has to be cleaned out
at least every 24 hours so in this point at least a valve
is an advantage over the old methods.
Dr. Decker, (in closing) : I did not mean to create
the impression that I was placing unusual stress on
anesthesia in the development of postoperative com-
plications. In some cases it is the factor ; in the ma-
jority it is not. I am sure that no matter how inuch
care we take to prevent postoperative complications,
in a certain number of instances they will develop, but
if we exercise precaution and pay as much attention to
the lungs as we have to the heart and kidneys in anti-
operative examination of patients, we are going to
have less morbidity and less mortality. In the reading
of my paper, for lack of time, I had to leave out a
number of details in reference to specific prophylactic
measures. There are certain things which I believe
are of importance. Counterirritation of the chest be-
fore and after operation is certainly of moment. In
one ward of the Presbyterian Hospital in New York
they used digitalis to prevent pulmonary stasis, but
there has been no report as to whether that therapy
has been -of any value at all. The nursing rules which
are detailed in the paper are certainly worth while and
so far as possible 1 think ought to be carried out by
all clinics.
Dr. Stewart (in closing) : I regret that the time
allowed for the papers does not permit one to present
a paper in a more logical and consecutive way. In
removing this tube your effort is first to take out the
outer flange from beneath the skin. Sometimes it is
necessary to incise the skin to do this. Then the outer
flange is pulled out and you still have the means of
drainage there, which is not going to interfere with
the closure of the muscle which you have sutured
around the tube. As already stated, the inner flange
is pulled from within the pleural cavity, through the
muscle to a point beneath the skin. The muscle tissue
falls together and healing takes place without doing
secondary closure. The advantage is that when you
attempt lung resections or operations on some of the
chronic types of empyema, or the operation of Depage
and Tuffier, you can place this tube with the assurance
that it will take care of the drainage for 24 to 48 hours
and then you can remove it in an airtight manner.
HYPERTRICHIASIS IN CHILDHOOD:
THE SO-CALLED "DOG-FACED
BOY"*
FRANK CROZER KNOWLES, M.D.
PHILADELPIA.
There came to the Children's Hospital of
Philadelphia, on July 22, 1916, a patient show-
ing the following curious anomaly: the head
was covered with a very heavy growth of coarse
black hair, extending over the forehead to the
eyebrows. The eyebrows were unusually heavy,
the eyelashes quite long, black and bushy.
There was a heavy growth of hair of a fine
•Read before the Section on Surgery of the Medical Society
of the State of Pennsylvania, Pittsburgh Session, October 6,
1930.
consistency extending over the cheeks. In fact,
all portions of the face showed this hirsute
characteristic, the bridge of the nose being least
involved. There was a heavy growth of soft
black hair, in many places an inch or more in
length, extending over all portions of the back,
the arms, the legs, the abdomen and the chest.
All evidence of pigmentary changes in the skin
were absent, aside from the normally racial
dark skin of the individual, thus absolutely ex-
cluding the possibility of a naevus.
The child was well developed, splendidly
nourished, and of an average mentality. The
thorax was well shaped, the heart and lungs
"Dog-faced" Boy, aged three years and eleven months.
Anterior view.
normal, spleen palpable and the liver not en-
larged. There was a tit-like prominence on the
upper lip; the tongue was normal, but the
palate showed a high arch ; the teeth were char-
acteristic of this early age. The musculature
was good and the reflexes normal.
The child was born August 28, 1912, making
the boy three years and eleven months old at
the time of the first visit to the dispensary. The
child showed this hairy characteristic at birth
but not to such an exaggerated degree. The
birth was normal without instruments. There
have never been any unusual features in the
cranium and all evidence of spina bifida was ab-
sent. The father and mother, both Italians, are
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402
THE PENNSYLVANIA MEDICAL JOURNAL
March, 1921
living and well. The five other children in the
family and no ancestor shows this hairy anom-
aly. The patient was presented to the Phila-
delphia Pediatric Society, October lo, 1916.
An apt definition for hypertrichiasis is a
growth of hair which is either abnormal in
amount or occurs in places where, normally,
"Dog-f«ced" Boy, aged three years and eleven months.
Posterior view.
only lanugo hair is present. This excessive
growth may be either general or partial, con-
genital or acquired. Hypertrichiasis universalis
is very rare, while the acquired form, or hyper-
trichiasis partialis, is very common, and is fa-
miliar to us all in the unfortunate examples —
bearded women.
In the universal form hair is found generally
excepting in these areas where this growth
never occurs such as the palms of the hands, the
soles of the feet, the backs of the last phalanges
of the fingers and the toes, the inside of the
labia majora, the prepuce or on the glans penis.
Subjects of this malady are usually bom cov-
ered more or less thickly with hair, which may
be light or dark in color. This does not fall, as
is usually the case in infants, but continues to
grow longer, coarser and darker until it reaches
its full development. As a rule, the long hair
covering the bo<ly is fine, resembling more that
of the head than the beard, this same charac-
teristic applies to the hair on the face of these
persons. It follows a general course in growing
which is away from certain well-defined cen-
ters. Thus on the back the growth is observed
on each side downward and outward from the
spinal column ; on the forehead away from the
middle line, following the lines of the eye-
brows; on the face, also, from a line running
down the middle.
Accompanying this excessive hirsute growth
there is usually combined a deficiency of teeth,
especially marked in the upper jaw. Michelsen
has seen a family which was very hairy, in sev-
eral members of which there was a defect of
all five back teeth, the alveolar processes for the
same being absent. The history of the Kes-
troma family from Russia, a father and son, is
interesting. The son was exhibited in this coun-
try in 1886, under the title of the "Russian Dog-
faced Boy." Jackson made a careful examina-
tion of this boy and found him well-developed,
though somewhat under the average size, mus-
cular, active and energetic in his actions and
acute in mentality. His head was covered with
a luxuriant growth of fine, glossy hair, blonde
in color, some six inches long, extending fur-
ther down on the neck than normally. The hair
grew well down on the forehead and over the
face, though of a finer texture and lighter ccJor
than on the scalp. There was only a scanty
growth on the central portion of the upper lip.
The hair of the face was some four inches in
length, while that on the back grew down the
spinal column and stood out not unlike a horse's
mane. The trunk and the extremities were
completely covered with this hirsute growth.
There was a cast in his left eye and he was
near-sighted. He had only five teeth, two upper
canine, two lateral and one middle incisor ; the
alveolar ridges showed no sign of there ever
having been other teeth. The teeth were dis-
colored and badly shaped. His father was said
to have had no teeth until seventeen years old
and then only four in the lower and one in the
upper jaw,
Barbara Ursler was reported by Strickler as
having had universal hirsuties in the seven-
teenth century. The body of this woman was
covered with blonde, soft, curly hair, and she
had a thick beard reaching to the waist. In a
book published in 1642, "Aldrovandi Menstro-
rum Histeria," there is a description of a hairy
family composed of the father, aged forty, a
son aged twenty, and two daughters aged eight
and twelve years. They came from the Canary
Islands, and were covered with hair, excepting
that the daughter's lips, nose, neck, breasts and
hands were uninvolved. In 1852, Chowne re-
ported a case of imiversal hypertrichiasis oc-
Digitized by VjOOQIC
March, 1921
HYPERTRICHIASIS— DISCUSSION
403
curring in a Swiss woman aged twenty years,
the breasts and chest alone being free of
growth. Beigel recorded several instances of
this abnormality, notably those of Julia Pas-
trana, a Spanish dancer, and of Shewe Maen
and his daughter Mapheen, in India. The lat-
ter's second child was hairy like his mother. In
the father and daughter there was an absence
of the canine and molar teeth.
Partial Congenital Hypertrichiasis. — There
are a large number of cases of this type on rec-
ord, many of them developed on nevi. In the
Lancet, 1869, is recorded the description of a
Mexican woman who had a nevus pilesus ex-
tending like a pair of bathing trunks from the
umbilicus anteriorly and the sixth dorsal ver-
tebra posteriorly to about one-half way down
the thighs, covering the buttocks. Cummins
mentioned a case of a woman who was noted
for her beauty of face, whose body from breast
to knee was covered with a profuse growth of
black, thick, bristly hair. Waldeyer reported
the case of a girl, aged nine years, who had a
lock of hair running from the first to the fourth
lumbar vertebra, and a smaller one from the
third to the fourth cervical vertebra.
These localized and partial cases of hyper-
trichiasis are most frequently met with in the
sacral or lumbar region, and not infrequently
are associated with spina bifida. Omstein
stated that sacral hypertrichiasis is common
among the Greeks and recorded two cases of
tails in Greek soldiers, one a quarter of an inch
long and cone-shaped, and in the other not quite
so long and stumpy.
Partial Acquired Hypertrichiasis. — Two ex-
amples of this might be mentioned. Chowne
speaks of a boy, aged eight years, who had the
whiskers of a man. Beigel saw a six-year-old
girl with pudenda like a woman of twenty, both
in shape -and hair.
Transitory hypertrichiasis, so-called, in which
hair develops following friction, in association
with derangement of the ovarian-uterine ap-
paratus, in various nervous affections, etc., dis-
appearing with the amelioration of the causative
factor, hardly comes into the domain of the
present paper.
Etiology. — The cause of hypertrichiasis in
many instances is extremely obscure. In uni-""
versal hirsuties heredity certainly plays an im-
portant part. This fact is attested by several
members of a family or direct antecedents
showing this anomaly. Virchow attempted to
account for these cases by the theory of nervous
influence, founded upon the fact, that the lack
of development of the teeth and jaws was in
the same zone of nerve control as was the over-
development of the hair on the forehead, nose,
cheeks and ears, all being supplied by the
branches of the trigeminus, or fifth cranial
nerve. This theory, however, does not offer an
explanation for the universal hirsuties. Atavism
has also been brought forward to account for
the occurrence of these cases. Derangement of
the ductless glands also has certain supporters.
The fact that the foetus is covered with hair
lends weight to the theory promulgated by '
Unna : "That it is due to the persistence of the
fetal or primitive hair; the change of type be-
tween the primitive and permanent hair not tak-
ing place." Ecker came to the conclusion that
because most of the hair in these hairy indi-
viduals remains soft and fine and follows the
lines of direction of the embryonic hair that it
was a restriction in development just Hke the
defect in the teeth. Other theories which have
been brought forward at various times are ma-
ternal impressions, fecundation of the human
female by a hairy animal and others of a like
weird genesis.
At the present writing, cases of this descrip-
tion from an etiological point of view, have to
be placed in that large, but fortunately decreas-
ing field of the "great unknown."
ReFSRSNces
DiKases of the Hair, Jackson and HcMurtry, 191 j.
The Histopathology of the Diseases of the Skin, Unna, Trans-
lation by Norman Walker, 1896, p. 11 51.
DISCUSSION
WaUAM H. Guy, M.D. (Pittsburgh) : If my mem-
ory serves me correctly, it cost me exactly fifteen cents
to see my first, last and only case of congenital hyper-
trichiasis in childhood. I was a fairly close observer
in those days and also considerable of a skeptic. I
have to confess that I was doubtful as to whether or
not this really represented a member of the human
fanuly.
In common with other conditions of unknown eti-
ology, the subject of hypertrichiasis, particularly of
the congenital variety of the type that Dr. Knowles
has reported, has been productive of a great many
different theories, particularly as to the etiology.
Unna taught that it is due to the persistence of
lanugo hair. This may explain how it occurs, but not
why. Unna's observation that such is occasionally
the case has been many times substantiated and also
some cases have been reported in which there has been
a persistence of lanugo hair of more than the usual
amount which disappeared spontaneously at varying
periods after the birth of the child.
Virchow's theory of the neurotic origin is worthy
of consideration because of the association of develop-
mental defects in certain cases. Also the observation
of Hamilton of certain cases of acquired hyper-
trichiasis with the same developmental defects.
Fortunately the condition is extremely rare. If it
were not, we would probably be hard put to finding
some method of satisfactory therapeutic attack.
Dr. Knowles is to be congratulated upon the able
presentation of an interesting and most unusual case.
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THE PENNSYLVANIA MEDICAL JOURNAL
March, 1921
PERavAL J. Eaton, M.D. (Pittsburgh) : I cannot
add anything more to the discussion as I never saw a
case, but some years ago I saw some pictures of a
tribe on some island in the northern Japaneses archi-
pelago, called "The Hairy Ainus", and most of them
were covered with hair. Dr. Knowles may know of
them.
Edwaw) L. Bauer, M.D. (Philadelphia) : Will Dr.
Knowles kindly tell us what part the ductless glands
play as an etiological factor in these cases? Will he
also tell us whether radium has played a helpful
part therapeutically or not?
Dr. Knowles (in closing) : Of course the entire
literature on the subject has not been covered and the
paper was purposely made as short as possible. Other
examples could be mentioned in regard to the tribe
that has been referred to.
Various glandular preparations have been tried and
this case has been under observation in the hospital
for two or three months without the slightest change,
except that the hair kept getting longer.
As to the possibility of removal with X-ray or
radium in a child of this age, it has ben decided best
not to attempt it on account of such large surface in-
volvement. Nothing can be done for a permanent
VACCINE TREATMENT OF PER-
TUSSIS*
ROBERT K. REWALT, M.D.
' Wn,LIAMSP0RT, PA.
Pertussis vaccine consists of the killed Bor-
det-Gengou bacillus. This bacillus is generally
recognized to be the exciting cause of pertussis.
Some elements of proof are lacking to show
that this bacillus is the specific germ causing
the disease. Frequently it is absent and more
often associated with other bacteria. Improved
methods of making a quick and accurate bac-
teriological examination, such as the method
for finding the diphtheria bacillus, are to be
greatly desired.
The lack of certainty in finding the Bordet
bacillus by present methods makes it very diffi-
cult to decide whether or not the straight vac-
cine or a mixed vaccine should be used. In
other words, if one should be guided entirely
by the results of a bacteriological examination,
a mixed vacciiie would be the one of choice in
a large majority of cases. To my mind this
procedure would be a mistake. I believe that
many, not all, of the so-called mixed infec-
tions found in undoubted cases of pertussis are
contaminated cultures. There is no doubt but
that if cultures were taken from normal sputa
a variety of bacteria would be found.
In 130 cases of pertiftsis where vaccine was
used, the straight vaccine, i. e., the one consist-
ing of the Bordet bacillus alone, was the one
*Read before the Section on Pediatrics of the Medical 'So-
ciety of the State of Pennsylvania, Pittsburgh Session, October
7, i9»o.
of choice, A mixed vaccine containing the
Bordet bacillus, the pneumococcus, the strep-
tococcus and the staphylococcus was used in
some cases, chiefly the ones complicated by, or
following pneumonia. My youngest case was a
breast-fed infant of seven weeks. My oldest
case was a boy of ten years. The 130 cases
extend over a period of seven years, all occur-
ring in private practice. In the earlier cases
treated the results were not so good, nor so
striking as in the later cases. This, I believe,
was due to the fact that the doses were too
small. As one should record failures as well as
successes, I may say that a child treated by per-
tussis vaccine in November, 1913, whooped and
vomited for five months, notwithstanding fif-
teen injections. Drugs were also resorted to
with absolutely no effect. This child belonged
to the exudative diathesis group, which may
have had some significance in prolonging the
disease.
In% total of six cases the treatment was an
absolute failure. In 45 cases benefit of more
or less degree was obtained. The other 79 cases
showed marked improvement. In some the re-
sults were little short of marvelous. A brief
resume of the youngest case treated may be of
interest. This breast-fed infant of seven weeks
was first seen after she had been coughing one
week. It was my good fortune to see her in a
paroxysm at my first visit. A culture was taken
and a leucocyte count made. Temperature was
99° F. by rectum. Chest contained a few large
moist rales. Paroxysms of coughing growing
more frequent. Culture showed Bordet bacil-
lus present in large numbers, together with
staphylococci. Leucocyte count was 10,000;
250,000,000 were given as first dose. Tempera-
ture rose to 101° F. that night but dropped to
normal next day. Paroxysms were just as hard
but there was no increase in number; Three
days later 500,000,000 were given. No reaction
noted after this dose. The effect was striking.
Two days later there were only two paroxysms
and in one week there were none. A third dose
of 500,000,000 was then given just as a precau-
tionary measure. The child remained cured.
The rapidity of the cure in this case would
make the diagnosis a great question were it not
'for three facts: i. The result of the culture.
2. The leucocytosis — 10,000. 3. Witnessing a
typical pertussis paroxysm.
Unfortunately not all cases respond so
quickly. An interesting case occurred in Sep-
tember, 1919. A boy of four whose sister had
pertussis was seen during the second week.
No culture was made in this case, but a leuco-
cyte count showed 12,000 cells. He was given
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March, 1921
VACCINE IN PERTUSSIS— REW ALT
405
vaccine at the beginning of the paroxysmal
stage. Three doses were administered without
apparent effect. The day after the third dose
the child became listless and lost his appetite.
He was given castor oil. The next morning,
after two paroxysms during the night, he was
found with a complete right hemiplegia. De-
glutition was interfered with to the extent that
he choked on water. Temperature which had
been below ioo° F. by rectum rose to 102° F.
The paroxysms were painful to witness, the
child being completely prostrated afterwards.
Three more doses of the vaccine were given at
two-day intervals with marked improvement.
The vomiting stopped in one week and the
whooping ceased during the second week. Un-
der rest, stimulation, and careful feeding, the
paralysis entirely disappeared in two weeks,
after the third week he was removed to the sea-
shore where he recuperated fast. This boy
passed through the entire winter without having
his usual winter cough.
An interesting case occurred in February,
1920. This was a boy of 14 months old who
developed a typical influenza complicated by a
central pneumonia. At least he had all the
symptoms of pneumonia without the physical
signs. His temperature was between 104° and
106°, respirations 60 to 80 and pulse 160 to 200
for six days. His leucocyte count was 30,000
and he had a bad cough. Repeated physical
examinations of the chest by a consultant and
myself failed to reveal any signs of pneumonia.
As this child was treated at home, no x-ray
pictures were taken. After having a distinct
crisis, I noticed that his cough was growing
worse and he finally developed typical pertussis.
He was given six doses of a vaccine consisting
of Bordet's bacillus, influenza bacillus, pneu-
mococcus, streptococcus and staphylococcus,
over a period of ten days. In two weeks he
ceased vomiting and in four weeks he stopped
coughing. No other treatment, aside from iron
and arsenic to combat anaemia, was given.
A number of more or less interesting cases
could be cited but time forbids. I regarded the
cases in which there was a complete cessation
of symptoms inside of four weeks as being
benefitted a lot. The criticism may be made
that many untreated cases of the mild type are
cured inside of four weeks. That is undoubt-
edly true. However, at the onset of the disease,
one can never be sure that a case will be mild
or severe and it is better to use vaccine.
As I stated before many of the cases treated
with vaccine five or six years ago, did not re-
spond so well as those treated in the past three
years. I believe this was due in a measure to
the small doses used. Fifty million to 100,000,-
000 doses as advocated by some observers are
entirely too small. In infants an initial dose of
250,000,000 to 500,000,000 was used and this
was increased to 1,000,000,000 or more as the
symptoms demanded. From three to eight
doses were given at intervals of 48 to 72 hours.
More than eight doses were not considered nee-'
cssary. In older children an initial dose of
500,000,000 was given and each succeeding dose
was doubled as was deemed necessary. In
other words, if after the second dose of 1,000,-
000,000 or the third dose of 2,000,000,000 there
seemed to be improvement the succeeding doses
were held at that figure. If no improvement
was noted, the larger doses were given.
Occasionally a reaction was noted by a tem-
porary rise in temperature or increase in par-
oxysms. No reaction lasted over twenty-four
hours. If there are any contra indications to
the use of vaccines in the treatment of pertussis,
1 do not know them. Even observers, who state
that in their experience, the vaccine treatment
is a failure, admit that the use of vaccines does
no harm to the patient. Four cases treated by
me had a nephritis from other causes. The
nephritis improved while the vaccine was being
administered. Several cardiac conditions were
seen. These were affected not at all. The vac-
cines used were all of the stock variety, being
obtained from the various manufacturers. No
autogenous vaccines were used in any of these
cases.
At a recent meeting of the American Pedi-
atric Society, Freeman of New York advocated
the use of fresh stock vaccines. His argument
was that vaccines deteriorated very quickly, that
is inside of two to three weeks. There is much
food for thought in this idea as it is well known
that the potency of vaccines, as well as serums,
decreases rapidly with age. Unfortunately, the
majority of us do not have access to such won-
derful laboratories as those of the Department
of Health in New York. However, if a con-
centrated demand were made of the various
manufacturers by physicians for fresh vaccines,
it would be but a short time until they would
be readily procurable.
CONCLUSIONS
1. The vaccine treatment of pertussis is the
most valuable treatment at the present time, re-
gardless of its failures.
2. No definite promise of a rapid cure should
be made, because as yet we have much to learn
concerning this treatment.
3. Larger doses and shorter intervals should
be employed. . , j
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THE PENNSYLVANIA MEDICAL JOURNAL
March, 1921
4. In the majority of cases, the symptoms are
made lighter and the course of the disease is
materially shortened.
5. A decided effort should be made to obtain
fresh vaccines to be used in the treatment of
pertussis.
DISCUSSION
L. Clvdb Bixler, M.D. (Pittsburgh) : Dr. Rewalt
has given us more evidence on a most important sub-
ject ; one that is alive, has been alive and will be alive
for a long time. All of us have felt our more or less
helplessness and hopelessness in the presence of
whooping cough and anything at all that offers a
shadow of hope I think should be looked into and in-
vestigated.
From my own personal experience I have been
rather neutral on the matter of vaccines. I must con-
fess that the three most severe cases I have seen have
been among those who received stock vaccines, the
age of which 1 do not know, and they were not given
in the {loses Dr. Rewalt uses. I have talked with my
conferees at different times and some of them use
vaccine and some do not, but only one of them used
stock vaccine, not the unmixed vaccine, and all of
them seem to be undecided as to the actual and positive
value. One man in particular, a pediatrician, does not
use any except in severe cases and he then uses mixed
vaccine in very large doses but not in billions as Dr.
Rewalt has mentioned.
1 find in looking over the literature that there is still
quite a diversity of opinion on the subject. We find
one man using unmixed with no result and we find
another using mixed with, he thinks, some result. I
will just quote you a few figures from them. In look-
ing up Reynolds of New Haven; we find he reported
thirty cases in which he used straight vaccine, the
fresh vaccine of the New York City Department of
Health, in which each c.c. represented one billion
organisms of the straight whooping cough bacillus.
His conclusions were that the average duration of the
disease was not shortened and he gives figures to
show that. The average duration was Asyi days and
the average dose given was 19 c.c. or 19 billions, so
evidently he gave his patients a sufficient dose. He
concludes his article with the remarks that the un-
mixed vaccine may have some value but the mixed
vaccine has more value, more particularly in prophy-
laxis in reaching those cases that have not been ex-
posed. Among those cases that have not been ex-
posed and that have not been vaccinated about 50%
escape ; that is if they are exposed to whooping cough
they fail to take it. The administration of the mixed
vaccines in large doses seems to add 20% to that
figure.
Barenberg (New York) in 1918 reported an epi-
demic that occurred in the Home for Hebrew Children
in New York and reports several hundred cases which
he had and he gives specific figures from them. I will
just quote briefly some of his groups. He vaccinated
41 early, even before they were exposed, and of the 41,
29 failed to take it (70%), and 12 contracted it. An-
other group that was exposed showed no symptoms.
Of these 161 failed to take it and 114 contracted it.
Among those unvaccinated 9 took it and 9 failed to
take it. Among 28 cases that he treated therapeu-
tically with the vaccine were 12 very severe ones.
These are his conclusions after he had followed his
cases, using fresh vaccine from the New York City
Department of Health: that he feels almost certain
"that pertussis vaccine, given even in large doses, not
only has no curative effect but does not tend to lessen
the severity of the disease."
"As regards the prophylactic value of partussis vac-
cine, the case is different. In both the former epi-
demic and in this one (of 1918) the percentage of vac-
cinated children who developed the disease was con-
siderably less than of those who were not vaccinated."
Edward L. Bauer, M.D. (Philadelphia) : Dr. Re-
walt has certainly presented us with a fair and un-
biased list of results that he has obtained from a
very definite standpoint. True, he does not settle the
question of vaccine therapy, nor do the figures or
facts as presented by other observers to date definitely
settle the value of vaccine therapy in pertussis. Two
main factors are still to be worked out, namely, the
technique of administration and the final decision of
dosage. The vaccine treatment is more efficient in
ohildren, generally speaking, than in adults, and in
that there is a ray of hope that the pertussis vaccine
will eventually prove to be a successful line of treat-
ment
Dr. Rewalt has been quite successful with the
straight Bordet vaccine. The question arises, do the
mixed vaccines, especially the mixed autogenous, help
to guard against complicating infections more success-
fully than the straight vaccines. I believe that they
do, and use them. In my work with the vaccine
treatment in pertussis I find that, generally speaking,
the child will run a four to six weeks' course, but the
paroxysms will be fewer and the degree of severity
will be lessened. I took charge of an institution in
Germantown, Philadelphia, in which practically one
hundred and thirty were infected. I divided them in
half and treated one-half with vaccine treatment and
one-half with the old-fashioned sodium-bromide-anti-
pyrine method. I felt that the degree of severity
would be balanced about evenly in so large a number
of children so that severity would not be a question in
estimating ultimate results. I found that the vaccine
treatment did help those children receiving it, and
complications were absent. These children received
their vaccine early in the course of the disease, which
I think is an important point. Certainly a fresh vac-
cine must be used, and in vaccine treatment, the same
as in any other methods that are scientifically refined,
the technique of administration and the preparation of
materials cannot be arrived at by any short cut.
It has not been definitely decided whether vaccine
treatment will ultimately be the final solution to the
whooping cough problem, but I am satisfied that it has
helped me, and I am encouraged by its results in my
cases. If I can find any other refinement in its use
that will help I certainly would be very glad to prac-
tice that too. The doses that Dr. Rewalt uses are
larger than I am accustomed to giving. I usually start
with four or five million of the Bordet bacillus, and
that I would be very glad to increase if other ob-
servers can assure me that my results will be better.
William N. BradlEv, M.D., (Philadelphia) : I
would like to say that Dr. Rewalt's paper accords with
my own ideas exactly in almost every particular. I
believe that vaccine treatment as it is employed today
is a wonderful advance in the treatment of pertussis.
I agree with Dr. Rewalt that the Bordet bacillus in
fresh culture is the best to use except in selected cases,
and that it must be used in large doses and at short
intervals. . , .
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March, 1921
DIABETES— BLODGETT
.407
Harry J. Cartin, M.D. (Johnstown) : I am pleased
at the enthusiasm with which everybody has spoken
in regard to the use of vaccine in the treatment of
whooping cough, but I must say, without intending to
throw any cold water on the thing, that the trail is
very seductive and the path has been strewn with en-
thusiasts.
One part of Dr. Rewalt's paper I want to call his
attention to, although he may not have meant is as it
sounded, and that is that he has the same access to
the laboratory in New York as Dr. Freeman has,
separated only by the distance between Williamsport
and New York in the delivery of the goods. The
goods manufactured by the Department of Health in
New York are on sale to any person in the United
States.
Henry "T. Price, M.D. (Pittsburgh): There is one
point in Dr. Rewalt's pap«r that I think needs em-
phasis, and that is regarding the children with whooping
cough under one year. I feel that with a mortality of
at least 50% in these children under one year anything
that offers any help is of value. Personally I have
been using the mixed vaccine. I feel this treatment
should be given until we find that some harm is being
done rather than improvement. I have never seen any
harm in any cases where it has been used and I feel
it is wise to use the vaccine in children under one year
practically routinely.
Dr. Rewalt (in closing) : I just want to state the
object of this paper. I did not mean to offer this
treatment as a specific, for it is far from being that.
I simply wanted to bring out the discussion that has
taken place, of the experience that various men have
had with the vaccine. If somebody can tell me where
there is any better treatment, I will be only too glad
to use it. I have seen failures from this form of
treatment, and do not mean to be overly enthusiastic
about it, but in my experience it is the best treatment
that we possess at the present time. I do believe that
the use of fresh vaccine is going to help us tre-
mendously. I am glad to know that we can get the
fresh vaccines, as Dr. Cartin suggested. At the time
of Dr. Freeman's paper, Lederle had not been manu-
facturing any of the fresh vaccines for the market.
Of course, I recognize the fact that 130 cases I have
cited in private practice and the opportunity for col-
lecting scientific and accurate data is certainly not the
same as in institutional work. I cannot help but feel
from my own personal observation that the use of
the vaccine has proved of distinct benefit. It must be
used early, preferably during the first or second week,
to do the maximum amount of good.
DIABETES (PANCREATIC) CAUSED BY
INFECTION OF THE TONSILS
STEPHEN H. BLODGETT, M.D.
BOSTON, MASS.
During the past twenty-two years in which it
has been my good fortune to have under my ob-
servation a very large number of cases of so-
called diabetes, it has been forcibly borne in on
me that there is a distinct relation between the
occurrence of sugar in the urine (in the pancre-
atic form of diabetes) and infections of the ton-
sils.
In almost all of the cases of the pancreatic
form of so-called diabetes, where the sugar has
been eliminated from the urine by means of
diet, if the patient has an infection of the tonslis
the sugar will reappear in the urine even where
the carbohydrate intake has been more re-
stricted than it was before the tonsil infection
occurred.
This recurrence of the sugar is not found fol-
lowing other infections accompanied by a rise
in the temperature, such as pneumonia, malaria,
etc., but seems only to occur following infec-
tions showing in the tonsils.
I can go a step further than this, and say that
at least a considerable number of cases of the
acute pancreatic form of diabetes are due to an
infection of the pancreas following an infection
of the tonsil. I might add also that where the
cause of the sugar in the urine is from a func-
tional disturbance of the liver (let us call it
hepatic diabetes), tonsillar infection is not a
causative factor; and when tonsillar infection
occurs during the course of the disease (the he-
patic form of diabetes), it will not cause the
sugar to reappear in the urine.
For a clinical division of cases having sugar
in the urine (so-called diabetes), I would refer
anyone interested to an article in the Boston
Medical and Surgical Journal of October 2,
1919.1
I should like also in this connection to call
attention to another fact that infection of the
tonsil is many times accompanied by large
amounts of acetone in the urine and a "sore
spot" over the pancreas.'
Without going into the theories involved, I
will very briefly report a few cases which will
illustrate my points as to the relation between
infection of the tonsils and pancreatic diabetes.
Case I. — A child aged ten years ; always well
except for an attack of measles when two years
old.
The family physician was visiting another
member of the family when it was casually
mentioned that this child had seemed somewhat
listless and had lost her appetite for twenty-
four hours. A hasty examination failed to re-
veal any particular trouble, but the physician
took a sample of the urine which that same
day he examined, with the following result:
Color, normal; specific gravity, 1019; no al-
bumen; no sugar.
The next day he was called and found the
child with a temperature of 103° and the tonsil
on the left side red and enlarged. The next
1. Diabetes: Stephen H. Blodgett, M.D.
2. Acetonuria in Relation to Contagious Diseases, N. Y.
Medical Record, April, 191 6. '
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408
THE PENNSYLVANIA MEDICAL JOURNAL
March, 1921
day a typical case of mumps was present on the
left side, and a couple of days afterward the
right side was also affected. Within two weeks
the parotid glands had return nearly to normal,
the temperature was normal, but there was con-
siderable thirst and frequent urination, which
had developed very suddenly. The urine was
examined, and a very large amount of sugar
(6.3%) found present. A diet was prescribed
very much restricted as to carbohydrates, but
the sugar was present in the urine constantly;
there was a great loss of flesh, and weakness,
which constantly increased until the patient died
about six weeks later, in coma. Permission
for an autopsy was secured, but it was found
that the pancreas, although preserving its shape
while in the body, had become so thoroughly
disorganized that it acted like so much jelly
when we attempted to remove it, and on account
of the unexpected condition and our clumsiness,
we were unable to secure any satisfactory speci-
men for a microscopical examination.
Here we have a case of acute pancreatic dia-
betes coming on suddenly within two weeks
after an attack of mumps, and we also have a
test showing sugar-free urine on the first day
of the tonsil infection, thus indicating that pre-
vious to the infection in the tonsils there had
been no sugar in the urine.
Case 2. — Man aged 35 years. He had vari-
ous children's diseases in infancy, but since
school age had been well and attended to his
duties. He said, however, that he was subject
to sore throat and some of the attacks were so
severe that he had been kept in the house for a
few days at a time. He was of rather spare
build, and had never been a "large eater." His
usual weight had been about 130 lbs; height,
5 ft. 6J4 in.
About six weeks previously he had consulted
a physician because suddenly he had developed
a gfreat thirst and very frequent urination.
Sugar was found in his urine and he was placed
on a diet. After continuing in this manner for
a few weeks, he gave up the diet, as he was
losing weight and strength, and passing from
two to three quarts of urine daily, which the
physician told him still contained sugar.
After continuing on the ordinary diet for
about a week, he consulted me. I found that he
had passed successfully a rigid life insurance
examination about six months previously, and
was a man of excellent habits. He weighed 117
lbs. His tongue was a dirty brown color, and
he had a bad taste in his mouth. He passed
large amounts of urine daily, suffered great
thirst, and cramps in the calves of his legs.
On careful questioning and reference to his
office record, I learned that he had been com-
pelled to remain at home for three days with a
very severe sore throat, just ten days before he
consulted a physician, because of great thirst
and frequent urination. He was instructed to
save the 24-hour amount of urine during the
next day, measure it, and bring a sample — ^this
on his usual diet. On the following day he was
to abstain from any food containing sugar or
flour, and to come to the hospital. The analysis
of his urine, and his weight in pajamas and
bathrobe follows:
Day.
Weight.
Amount. Sugar.
Gms.
Acetone.
Remarks.
ISt,.
. 104}i
. 104M
7,100
546
Trace
Ordinary diet.
2nd,.
Not saved
No sugar or flour.
3rd,.
. 101
1.493
52
Moderate
For diet, see Note
Sth,.
. 104J4
2,012
53
Moderate
I
4th,.
• I02!4
1,892
45
Moderate
6th,.
■ ios>4
1,892
35
Moderate
7th,.
. 106
1,420
26
Small
See Note 2.
8th,.
. 10s
1,242
22
Small
9th,.
. 106
1.537
28
Moderate
■oth,.
. 107
1,420
23
Small
nth,.
. io7>4
1,420
30
Small
See Note 3-
I3th,.
. jor}<
1,420
Trace
Moderate
13th,.
. 105
1.716
40
Small
14th,.
. 106
1,124
0
Small
See Note 4.
I Sth,.
. 107
1,892
0
Small
16th,.
. \o6V*
1,656
0
Trace
See Note 5-
17th,.
. 107
1,892
0
Trace
■8th,.
• lOS^
1.597
0
0
See Note 6.
I9tb,.
. 107
1.537
0
Trace
See Note 7-
20th,.
. J06«
. io6}4
1,587
0
0
2lSt, .
J.714
0
0
Note 1. — Diet of third day:
Breakfast. — 2 eg;gs, 2 Lister muffins and very small amount
of butter, coffee with top of bottle.
Dinner. — 8 oz. thin meat soup, one vegetable, 3 Lister muf-
fins.
Supper. — 8 oz. thin meat soup, one vegetable, 3 Lister muf-
fins, 6 olives, tea.
The vegetables were lettuce, celerpr, cucumber, spinach.
Nora 2. — The patient disliked Lister muffins, so substituted
those made from Hepco flour. Omitted all cream.
Nora 3. — Breakfast. — 1 egg, i biscuit (Hepco), no butter,
coffee.
Dinner. — 16 oz. thin meat soup, 1 biscuit (Hepco), small
amount lettuce or celery, tea.
Supper. — Same as dinner.
NoTB 4. — Breakfast. — 2 eggs, 2 biscuits, very small amount
of butter, coflfee.
Dinner. — 16 oz. soup, 1 biscuit, 1 vegetable.
Supper. — 16 oz. soup, 2 biscuits, i vegetable, tea.
Note 5. — Added a very small amount of meat or fish at
dinner.
Note 6. — Dessert sweetened with saccharin at noon.
Note 7. — Added another biscuit at supper.
He remained on this diet for a week at home,
and as he was feeling well and the urine was
free from acetone or sugar, he was allowed to
begin his work, which was clerical in character.
After two weeks of satisfactory progress, I
added one-half an orange to his breakfast menu,
and enlarged his vegetable list by adding peas,
string beans, and asparagus. On this diet, he
felt well, was able to do his work, and had no
sugar in his urine. His total solids averaged
about 70 grams daily, of which about 40 grams
were urea. He slowly increased in weight until
in three months he weighed 120 pounds with his
clothes on. (His extra clothes added 6% lbs. to
his hospital weights.)
In March, three months after resuming his
work, he developed a sore throat which kept
him in the house for two days.
Digitized by
Google
March, 1921
DIABETES— BLODGETT
409
^
ut
ITS.
c
3
■5
i
8.
etoiw
marli
0
u
3
0 u
<
H
t»
w
< ei
Mar.
I,..
• 1,124
71
31
0
0
Mar.
3...
. 1,716
120
45
37
Moderate Notei.
Mar.
4...
. 1,452
145
40
69 Moderate Note I.
Mar.
S,--
. 3.000
210
38
124
Trace Notei2.
Mar.
6...
. 2,480
161
37
90
Trace Note 2.
Mar.
8...
. 1,952
122
40
57
0 Note 2.
Mar.
12,.
. 1.390
77
31
Sl.tr.
0 Note 2.
Mar.
i8,.
. 1,420
72
31
0
0 Note 2.
Note i. — Sore throat and unable to eat as much as usual.
N0T8 2. — On same diet as on nth day at hospital.
On March 24 was placed on same diet as
when he left the hospital, and allowed to re-
turn to work.
Following this attack, at times he showed
traces of sugar in the urine, and his diet was
still more restricted in amount, so that his total
solids averaged about 60 grams daily. On this
amended diet, he continued at his work, feeling
well, and without any sugar showing in his
urine, until the next winter, when he had an-
other sore throat. I was out of town at the
time, but the sugar appeared at once in his
urine, and oji one day there were 128 g^ams.
Under the same procedure as to diet as before,
the sugar disappeared in about ten days, but fol-
lowing this attack his carbohydrate tolerance
was distinctly lowered, and to keep him sugar-
free it was necessary to so restrict his diet that
he felt unable to go to work daily. He re-
mained in this condition (going to work when
he felt like it, two or three times a week), with
his urine sugar-free, but containing from none
to a large trace of acetone for about six months.
Suddenly he had a severe sore throat, and al-
though he took nothing but a little water, large
amounts of sugar and acetone appeared in the
urine. Within forty-eight hours he becartie
comatose and died.
Here we have a case of acute pancreatic dia-
betes appearing about twelve days after a severe
infection of the tonsils, and a reappearance of
sugar and a lowered carbohydrate tolerance fol-
lowing each attack of sore throat (of which
there were three) until finally death occurred.
Case 5. — A boy, aged 17 years; always well.
During the last of October he had a rather se-
vere attack of tonsillitis which kept him in the
house for several days. He recovered and went
back to school. During the last of November
he noticed he had to get up from four to eight
times each night to ^urinate, had great thirst
and increased appetite. These symptoms came
on within a week. Sugar was found to be pres-
ent in the urine in considerable amount and he
was placed on a diet. After two months, as his
progress was not satisfactory, he was placed
under my care. He was fairly well-nourished,
and weighed 127 pounds (clothed). He was
placed on a diet as follows :
Breakfast. — Yt grape fruit, 4 Lister muffins with
butter, I egg, coffee.
Dinner. — 8 oz. thin meat soup, 4 Lister muffins, very
small amount of meat or fish; as a relish, 2 vege-
tables.
Supper. — 8 oz. soup, 4 Lister muffins, 2 vegetables
and 4 olives, or a baked apple.
Vegetable List. — String beans, peas, lettuce, celery,
spinach, cabbage, onions, asparagus.
1.
•a
^
s
1
1
(0
<
Remarks.
lbs.
cc. gms.
I St,
123
1,900
176
50
57
SI. tr.
and.
122^
J, 540
114
58
29
SI. tr.
3rd.
I22fi
1,240
72
39
14
0
Blood sugar 314.
4tb,
I22M
1,420
92
51
n
0
5th.
122^
2,000
no
56
28
0
Sore throat; took
only water. Blood
_ sugar 331.
6th,
> • •
>,i8o
82
35
20
Trace
Ate very little.
7th,
• < •
1,360
no
50
24
Trace
Ate very little.
8th,
1,420
nS
It
34
L. tr.
Ate very little.
9th,
iilK
1,660
n6
31. 5
L. tr.
Appetite better.
Took away egg
and gave only K
usual amount of
food.
nth.
119K
1,180
65
35
7.5
Sl.tr.
latb.
1.340
71
38
2
o
Added one egg.
13th,
1,420
72
38
2
, ,
14th,
...
1,420
85
49
4
0
Blood sugar 286.
iSth,
...
1,660
84
46
0
0
Kestored meat.
The analysis continued much the same, no
sugar appearing in the urine, and his weight re-
maining about 120 lbs. On the twenty-second
day his tonsils were removed, and for three days
he ate nothing, from his own choice, taking only
liquids.
His analysis showed :
a
2 1 St,
22nd,
23rd,
25tb,
26th,
}
3
<
CC.
8
1
120
1,661
92
980
51
710
n
n'754
1,180
1,660
92
Remarks.
&
a
CO
58
31
25
35
54
2 Trace Tonsils removed.
3 Trace
4.5 Trace Blood sugar 21 1.
o o
Here we have a case of sudden appearance
of sugar, polyuria, polydipsia and loss of flesh
in a boy previously healthy, within a month
after a severe tonsillitis. When placed on a
semi-rigid diet, the amount of sugar in the
urine was daily being reduced until an infec-
tion of the tonsils took place, and notwithstand-
ing that the patient took only water, the blood
sugar increased and the urine sugar also in-
creased, and would not decrease until a much
more rigid diet was prescribed than had pre-
viously been necessary to cause a constant daily
Digitized by
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410 THE PENNSYLVANIA MEDICAL JOURNAL Makch, 1921
reducticMi. A very interesting thing was the could be kept sugar-free on a diet that woirid
fact that following the operation for removal sustain Hfe, or in other words, where it seemed
of the tonsils, although only liquids, consisting probable that the process in the pancreas coaW
of thin meat soups and water, were taken for be held in check if no reinfection took place. In
forty-eight hours, a slight amount of sugar ap- nearly all of these cases the examinatiai by a
peared in the urine for two days ; also a trace specialist in throat diseases has shown that the
of acetone. tonsils have been diseased and a source of in-
I have just received a report from this boy's fection. When such has been the case, I iiave
physician, who says the boy has gained thirteen strongly advised removal {not cutting off). I
poimds in six months, and is apparently in ex- find that the tonsils have been removed in ten
cellent condition. cases, and in none of these cases has sugar ^ain
Case 4. — A girl, aged 16 years, but appeared appeared in the urine, except in one case, al-
20. Always well until about a month ago, when though of course the patients have remained 00
there was a sudden onset of thirst, frequent the restricted diet prescribed,
urination, and increased appetite. The urine A brief report of this one case may be inter-
was examined, and sugar foiuid. She was esting. A yoimg man aged 23 consulted me,
placed on a diet and the sugar disappeared in a giving the following history : Two years previ-
week. She lost 14 pounds in three weeks, and ously he was found to have sugar in his urine,
was then sent to the hospital and placed under and was placed under the care of a physician,
my care. He was placed on a "starvation diet," then
The exact diets and urinalyses are lost, but thrice boiled vegetables, etc. During, the fol-
the following figures are taken from my notes lowing year he remained on the prescribed diet,
made at the bedside. with regular periodic fast days. Sugar had ap-
D«te. Sugar. Remark*. peared in the urine four times during the year,
!,„ ,^ «^',- without any change in his diet. This glycosuria
g^- 'l' T|J^ would persist for several days, but after a
Dec- ao,' o couple of f ast days it would disappear. He had
Dec! 2I', '.'.'.'.'. I lost six pounds in the year, and. weighed 93
Dec! II', '.'.'.'.'. 76 Acknowledged that «he had eaten pOUnds. He also Said he WaS SUbject tO SOre
Dec. as 23 '*°'''^' throat, and had suffered several attacks during
Dm! tj'. '.'.'.'.'. Trace ***^ P***- X^^""' ^"* ^^^ "^ ^^7 ^f Connecting
S«<=- *8; o v. 1. J •■ , them with the appearance of sugar in the urine.
Dec. 29 43 Ate some white bread surreptitiously; . , , , . . °
was then placed under close watch. Alter a carcf ul examination, as the case
Dec! 3«! !!!!! 't seemed undoubtedly to be of the pancreatic
Jan. '"u, "■..?.' it Complained of sore throat; both ton- form, he was placed ou a diet and his tonsils
Jan. IS ,7 si?ih^r"JK'cres\*;*noa%p"eCe; was ^erc rcmoved, an examination having shown
m"t*Mi5^^tem ratSre^Vw 6*'"' ""'" ^^^^ ^^^^ diseased. Two mouths after the
{«n- «« •<)' ZM""'- ^» »pp«*'«e- operation, he had a "sore throat," much to his
Ian. 17 90 Thirsty. '^ . ' ; , t , , ^
Jan. 30 Slight coma; was given 1 cup cocoa surpnse, as his tonsiis had been removed. On
with^ 4 teaspoonfui, sugar every 4 jhe sccoud day, the urinc showed a tracc of
'""• " °"'' "■"■■ "«' '*'*^- sugar (10 gtt. urine to reduce drams Haynes
Here we have a typical case of the acute pan- solution). The next day sugar content was
creatic form of diabetes, where the urine could about the same, and the fourth day no st^r
be easily made free from sugar. vvas present.
Coincident with a follicular tonsillitis, the When sugar reappeared in the urine previous
sugar reappeared in the urine, although the pa- to the removal of his tonsils, it had taken only
tient took water and a thin meat soup which one drop to reduce two drams of the solution,
consisted only a flavored water, for a diet, and and it had persisted sometimes for several days,
in six days coma developed, followed by death. His urine has been sugar-free for a year, and
In addition to the above cases, I could report he is now taking a diet containing somewhat
a considerable number more, but I feel that the more carbohydrate than before his tonsils were
above are sufficient to illustrate my point. removed. He has not lost any more weight, in
In conclusion, I would say that for the past fact has gained about two pounds,
two years I have made it the rule to have the Of course I realize perfectly that this is no
tonsils examined in every case of pancreatic proof of the benefit from the removal of the
diabetes that has been placed under my care, tonsils, but I feel as time goes on and these
where there has been a sufficient carbohydrate cases remain sugar-free, that it indicates that
tolerance to make it probable that the patient we are on the right track.
Digitized by VjOOQIC
March, 1921
SELECTIONS
411
SELECTIONS
THE STATE TUBERCULOSIS WORK,
WHAT IS BEING DONE, AND
FUTURE PLANS*
A. P. FRANCINE. M.D.
HARRISBURG.
Director Division o( Tuberculosis, State Department of Health
(i.) The policy of the Department of
Health has been to enlarge the scope and use-
fulness of the state dispensaries ; to give these
the broader aspects of public health clinics in
which will center and from which will radiate,
particularly in the smaller towns and rural dis-
tricts, both the official and unofficial or volun-
tary work for community welfare. It involves
the idea of the local community meeting its
local and often peculiarly its own needs, with
the encouragement, sympathy, assistance, and
power of a centralized authority back of it, and
to back it up. The state does not want to, even
if it could, and it recognizes it could not, do all
the work; but it can work with and help the
voluntary efforts of a local community, just as
these voluntary efforts or agencies can help and
supplement the official work.
The function of the state clinics which has
heretofore been, strictly speaking, the preven-
tion and treatment of tuberculosis, has been
enlarged to include the prevention and treat-
ment of venereal disease, nutritional work
among children of school age; maternity and
child welfare work of pre-school age, etc.
In order to carry out this policy, it is essential
that the closest and most effective cooperation
should be fostered and maintained with volun-
tary organizations where such exist. This is
nowhere more apparent than as it affects the
Division of Tuberculosis in relation to the
tuberculosis work of the state clinics, and no-
where has a more auspicious beginning been
made in this relation than with the local or af-
filiated branches of the Pennsylvania Society
for the Prevention of Tuberculosis, the local
chapters of the Red Cross, the women's civic
bodies in different communities, the local cham-
bers of commerce, and local hospitals. While
the consciousness of this mutual need for a
great common cause has not had time to work
itself out in all parts of the state, it is spreading
rapidly and splendidly; and the necessity for
this united action is becoming increasingly ap-
parent and increasingly effective.
A concrete, but significant, example of this
is the ready acceptance by the Division of Tu-
*Read before the Conference on Pennsylvania's Tuberculosis
Problem, under the auspices of the Pennsylvania Tuberculosis
Society, Philadelphia, January 19, 1921.
berculosis of the generous offer of the White
Haven Sanatorium Staff to give a free resident
graduate course to the clinicians of the state
tuberculosis dispensaries. A very good response
has been received from our dispensary men
throughout the state, and this course cannot fail
to be of the greatest advantage clinically to
those who are able to avail themselves of it,
and will further result in a closer association
and respect for the men distinguished in tuber-
culosis work with whom our dispensary men
will thus come in personal contact.
(2.) The second effort of the Division of
Tuberculosis has been to increase the efficiency
of the individual tuberculosis dispensaries. This
is difficult and slow work, because it involves a
personal inspection of each dispensary and each
dispensaiy community, and the learning from
outside sources as to how the dispensary is serv-
ing that particular community. The men and
women identified with the local anti-tubercu-
losis society, the local charity organization, the
Red Cross, etc., have in each instance been con-
sulted, and proved most responsive and helpful.
These trips have been productive, in fostering
the spirit of cooperation already alluded to;
and have resulted in a change of clinic person-
nel, in a number of instances, and will result in
further changes for the good of the service. It
has been the recent policy of this Division to se-
cure, wherever possible, young, adaptable men,
of good training, to do this work. These
younger men will be expected to take the gradu-
ate course, and this must, sooner or later, result
in the raising of the whole standard of work of
the state clinics, especially as applied to the
smaller towns and rural districts.
(3.) By this effort at cooperation it has been
possible and will be still further possible to not
only increase efficiency but to reduce the ex-
penses of these clinics.
On account of the inadequacy of the budget
it was found necessary to close a number of
dispensaries. Perhaps it will give a better idea
of the extent of the state work in tuberculosis
dispensary service, to say that the curtailment
already found necessary resulted in the falling
off of 500 visits a month in our clinic service
throughout the state. The closing of these dis-
pensaries aroused a strong and gratifying pro-
test from the communities which were involved.
In a number of instances these communities
came forward through the local tuberculosis so-
ciety, the Red Cross, or civic body, or all three
(again showing a getting together of voluntary
agencies with the official work), with an offer
to supply suitable quarters rent free, heat, light
and janitor service, if the Department would
Digitized by
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412
THE PENNSYLVANIA MEDICAL JOURNAL
March, I92I
supply the doctor and the nurse, the necessary
supplies, and reopen the Dispensary. This has
been acquiesced in, in every instance ; and this
policy of asking local communities to bear, to
this extent, their share of the expense of these
clinics has been followed with remarkably suc-
cessful results, not only in relation to existing
clinics, but in establishing new ones. These
dispensaries- are run entirely for the benefit of
local communities, and it is only fair and proper
that the communities should bear a part of the
expense. These items for rent, heat, light and
janitor service, for a given community are
.small, the smaller the community the smaller
these expenses are, while in the aggregate, as
appearing heretofore in the Harrisburg office,
the expense was both relatively and absolutely
very great.
Wherever a hospital has been suitably located
for a tuberculosis dispensary, there has been,
without exception, a ready acquiescence under
the above conditions, to the offer of the Depart-
ment to establish a state clinic in the building.
It should be borne m mind, however, that not
all communities have hospitals, and that not all
hospitals are favorably located for a tubercu-
losis dispensary, or have facilities for out-pa-
tient departments. The very important prin-
ciple must be constantly kept in view of locat-
ing these clinics where they are easily accessible
to the section they are designed to serve. They
are meant to serve the indigent, and they must
be placed near at hand, in or very close to the
poorer sections of a community. The location
of a number of dispensaries has been changed,
and it is planned to open new ones for this
reason, or to move old ones, at an early date.
There is a growing feeling of the wisdom of
cooperating with the reUef or medical depart-
ments of great industrial plants. Here a large,
fixed, and supervised population become avail-
able for closer study, earlier diagnosis, and
earlier sanatorium care when tuberculosis exists.
(4.) A word must be said about the state
sanatoria. Mont Alto (1,000 beds) is limited
to adult camp cases and to children. Hamburg
(450 beds) takes advanced cases only from the
eastern part of the state. Cresson (700 beds)
takes both advanced and camp cases from the
western part of the state. So far as the ad-
vanced case goes, which is generally considered
the most dangerous to its surroundings, while
the state is doing everything it possibly can do
to handle these cases, it is impossible that they
should be handled at all adequately in this cen-
tralized way. Pennsylvania has an average
death rate of 10,000 cases a year, and the prin-
ciple is widely accepted that there should be
hospital facilities, beds, equaling the number of
deaths in a community. This official effort of
the state to combat tuberculosis has always been
and always will be handicapped by its inability
to care for many of the advanced cases. Nor
does it seem that this centralized way of ap-
proaching this problem is the correct way. For
obvious reasons these advanced cases are better
off in hospitals or sanatoria of a suitable char-
acter near their own homes, and until local com-
munities or groups of communities, can find
their way to supply this need there will always
be this failure to handle the advanced case and
this weakness in the anti-tuberculosis fight in
Permsylvania.
Local institutions, whatever else they should
be, should not be placed in any. relation with the
poor house or poor farm of a community. This
defeats the whole purpose of such effort. There
should be local institutions of a character to
which these cases would willingly go. Admis-
sion to the state sanatoria is necessarily de-
layed; nor can patients remain indefinitely at
these sanatoria. In many instances, even after
months of cure, and much improvement, they
leave still an open case. There should be suit-
able local institutions to which such a case could
return for a period of care and treatment. It
could then return to the state sanatorium again.
We must have sufficient accommodations for
the more or less permanent care of the advanced
case.
The health authorities have absolute quaran-
tine power over cases of tuberculosis ; they can
remove and confine the dangerous consumptive,
but there is such opposition to going to an alms-
house or poor farm that so far as I know, no
case, however intractable and careless, has yet
been forcibly sent there, and with good reason.
As I see this problem, the state's chain of
dispensaries can be run efficiently and with
great economy, and fulfill a very useful purpose
as outlined above, but their work and the work
of education carried on by the volunteer tuber-
culosis organizations is greatly handicapped and
vitiated by the absence of suitable facilities to
care for the advanced case and to care for him
in a more or less permanent way. So strongly
do I feel this, that subject to expert advice I
would almost be willing to recommend to the
Department that it close our state sanatoria to
all far advanced cases, thus putting the problem
definitely up to local communities for the care of
this very deserving and needful group of sick,
deserving of the best care on their own ac-
counts, and of segregation to prevent the spread
of the disease. With the local communities
properly caring for their own advanced cases,
Digitized by
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March, 1921
SELECTIONS
413
these splendid state sanatoria could be used for
children (whether tuberculous or only under
observation for tuberculosis, or contacts) and
for the treatment, isolation and education of
early favorable cases whose lives could be
saved.
Let me reiterate. Could we control and care
for the advanced cases in this way, and we can
under the law quarantine them if we had local
beds which we felt were suitable in the best in-
terest of the patient and where we would be
justified in committing them, it would increase
the efficiency of the whole campaign against tu-
berculosis to a degree hardly to be appreciated.
The problem of the advanced case is the prob-
lem of the local community.
MODERN THERAPEUTICS*
HORATIO C. WOOD. JR.
FHII,AI>EU>HIA, FA,
When a boy who has been brought up in an
atmosphere of superstitious religion arrives at
the age when he begins to think for himself and
perceives the irrational character of some of the
beliefs he has been taught, one of three results
may be the outcome, according to his surround-
ings and his temperament. He may be so im-
pressed with the errors of the past that he be-
comes hopeless of ever finding truth and turns
agnostic; he may be beguiled by the pleasing
sophistries of one or the other of the peculiar
cults of the day and join the followers of Mrs.
Eddy or some similar pseudophilosopher ; or he
may by a sensible application of logic to the
available evidence eventually arrive at a creed
satisfactory to his intellect.
Therapeutics is at present passing through an
analagous transition. Time was when medicine,
like religion, was based solely on legend. When
physicians began to reason and to see the ab-
surdity of some of their traditional doctrines
they were driven into one of three lines of con-
duct. The easiest is that of the therapeutic
nihilist, the man who having made the diagnosis
reasons thus within his heart: "This man has
pneumonia, 25% of pneumonias die. If the pa-
tient is one of the lucky 75% he will recover, if
not he is doomed. It is Kismet and not the doc-
tor that decides whether he live or die."
Fatalism, whatever the metaphysical attrac-
tions it may hold for the logical mind, is a spir-
itual opiate, dulling the sensibilities and paralyz-
ing progress.
The second path is followed by a group of
'Read before the Lycoming County Medical Society, Jan. 14,
1931.
men, who, repulsed by the horror of this supine-
ness yet lacking the perseverance to follow rea-
son unrelentingly as she leads them through
quagmire or over mountain, become infatuated
with some new-fangled panacea and join the
ranks of the faddists.
Finally we have those, constituting I am con-
vinced the great bulk of the profession who,
while realizing the imperfections of their knowl-
edge and attainments, nevertheless strive to
guide their treatment by reason.
Before I take up with you what seems to me
to be a rational system of therapeutics, harmoni-
ous with present day knowledge, let me empha-
size that therapeutics to be rational must be sys-
tematized. A religion which has no theology is
no religion at all and a therapeusis without a
creed is equally unreasonable. I know there are
those to-day who practice medicine in a sort of
hit or miss manner — ^here a powder, there a pill,
perchance to cure, perchance to kill — but I hold
that such random method of fighting disease,
however valiant it may be, is as wasteful as for
a general to hurl masses of troops now here, now
there, against the enemy's line with no clear idea
of what he hopes to accomplish.
A mode of practice based on no fundamental
hypothesis is not a system, it is therapeutic chaos.
Countless are the theories upon which physicians
have based their practice — from the ancient As-
syrians who exercised the demon of disease with
nauseous drugs and equally nauseous incanta-
tions, on down to the osteopath who makes
straight the crooked spine — but neither their va-
riety nor their absurdity disprove the necessity
of design. System there must be, else we are
like a rudderless ship sailing an uncharted sea.
If one be going to lay foundations for a
house, the ground must first be cleared. Simi-
larly before we can construct a rational system
of therapeutics, we must dear from the field of
medicine the rubbish which has accumulated
through the ages. Of this we can recognize two
sorts, ancient traditions and modern fads.
Why do we avoid the number 13? Because
we have been told from generation to generation
that it is unlucky, not because either logic or ex-
perience leads us to see danger in a numeral.
Why do men prescribe hypophosphites in tuber-
culosis? Or why do they imagine that an ice
bag on the outside of the chest can modify the
temperature of the lungs? Neither reason nor
experiment excuse these delusions. Some men
even to-day persist in wearing derby hats, not
because they are beautiful nor because they are
comlortable. In the same way there are phy-
sicians who insist on giving opium by supposi-
tory in diseases of the bladder, not that. ODiuni
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414
THE PENNSYLVANIA MEDICAL JOURNAL
March, 1921
can act any differently when given this way but
merely because it is an old custom. It would be
a wearisome task, wearisome both to you and to
me, to attempt to enumerate the superstitions
which still survive in medicine ; but when we see
remaining in the Pharmacopoeia such relics of
bygone days as hops, lettuce root, camomile,
mezereum, sarsaparilla, serpentaria and dande-
lion, one can realize how tremendous is the hold
that tradition has upon the medical profession.
As impatient, however, as I am at times with
the blind adherence to unreasonable therapeutic
archaisms, I am inclined to the belief that the
freaks, of the faddists are still more reprehen-
sible. Most of you can remember how, follow-
ing the announcement of Robert Koch some
years ago, almost every consumptive in the land
was being injected with tuberculin. I have little
doubt that many of these unfortunate victims
were hastened to their final release from all suf-
fering by the injudicious use of this toxin.
Blood brother to this hobby is the so-called vac-
cine therapy. To the worshippers of this cult,
the demonstration of pathogenic bacteria any-
where in the patient's body is an indication for
the injection of countless millions of the corpses
of similar microorganisms and when no bacteria
can be found, the patient is given a dose of a
polyvalent mixed vaccine containing every strain
of streptococcus and pneumococcus known to
science.
Nor has surgery escaped the blight of similar
extravagances. The day is scarcely past when
the zealous devotees of the knife maintained that
the diagnosis of peptic ulcer was as imperative
an indication for operation as that of appendi-
citis or when an internist who was rash enough
to attempt to treat a case of exophthalmic goitre
without the assistance of a surgeon was looked
at askance.
Do not misunderstand me to infer that there
is no element of worth in these measures. Tu-
berculin is of value in certain cases of phthisis;
vaccine therapy sometimes does produce results
and even the surgeon may occasionally be a use-
ful adjunct to the practice of medicine. It is
not that these things are useless but that the ex-
travagance of the claims made for them show
the mental imbalance of their protagonists.
The development of modern therapeutics is an
outgrowth of several movements started within
the last two centuries as protests against the per-
nicious doctrines of their day. Let me briefly
mention the most important of these in order
that we may better understand the developments
of our present theories.
In the Eighteenth Century there arose several
schools of physicians, represented in this country
by the so-called electics, that promulgated phi-
losophies of treatment in which the symptom was
given the place of paramount importance. Al-
though when compared with the practices then
prevalent, these movements might be regarded as
an advance, at least from the patient's standpoint,
yet knowing how diverse are the pathologic proc-
esses which may give rise to the same symptom,
it requires no great argument to demonstrate the
deficiency of a method which sees nothing but
symptoms.
The second foundation was laid about a cen-
tury ago when Magendie made his classical ex-
periments showing the stimulating action of nux
vomica on the spinal cord, from which he was
led to suggest its use in conditions of paralysis.
This. was the inception of a great principle which
for years dominated the thought of the leaders
in therapeutics and which still plays an important
role in the treatment of disease. This principle
may be briefly summed up as follows: Those
drugs which exalt the functions of certain or-
gans are useful to combat conditions in which
these functions are depressed and vice versa, sub-
stances which lessen functional activity are valu-
able to quiet over-action.
It is unnecessary to speak of the enormous im-
petus that was given to the study of the action
of drugs, and incidentally also of functional pa-
thology, by the thought that a rational system of
treatment must correlate pharmacology and pa-
thology. A great mass of our most cherished
remedies were the direct result of this intensive
study of what we may call the pharmacodynamic
principle. Strychnin, the nitrites, the salicylates,
acetanilid, chloral, ergot, pilocarpine and vera-
trum are a few examples of our heritage from
these investigators.
There was, however, a large group of drugs
whose usefulness had been abundantly demon-
strated but which could not be explained on the
grounds of their physiological actions. Many of
these were grouped together under the meaning-
less term of alternatives, on the supposition that
they possessed some mysterious power of alter-
ing the metabolic processes. The key with which
the mystery of these drugs might be unlocked
was found when it was shown that malaria was
due to infection by the plasmodia. The full sig-
nificance of this discovery, however, was not
comprehended until the monumental work of
Ehrlich, who introduced the organic arsenicals
for the treatment of protozoal infections. His
labors have led to the evolution of a new prin-
ciple which is yet in its infancy. The terms
chemotherapeutic or chemotactic have been ap-
plied to this group of remedies. These words,
however, are unfortunate, as overlooking the
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March, 1921
SELECTIONS
415
fundamental idea that the action is upon the etio-
logical factor. I prefer the word etiotropic,
turning toward the cause. Some of the most
striking developments along this line are the
feeding of endocrine glands, pulling teeth for
arthritis, the use of quinine in pneumonia and
of arsphenamine in syphilis. Although recog-
nizing the epochal importance of Ehrlich's idea,
when we recall the great mass of diseases whose
etiology is still obscure as well as those whose
causative agent we may know but are unable to
control, it is obvious that a therapeusis based
solely on etiology must fail in a large proportion
of cases.
My philosophy of therapeutics is this: that a
rational system of treatment must recognize three
fundamentals, the removal of the cause, the cor-
rection of dysfunction and the relief of symp-
toms.
We cannot have a chair stand firmly upon one
or two legs. Three points of support are the
fewest that will give firmness. In the same way
we cannot have a well balanced system of thera-
peutics unless we take into consideration the
three fundamental factors of disease, etiology,
pathology and symptomatology.
In some diseases after the removal of the cause
the patient will rapidly return to a normal con-
dition and no other treatment is required. This
is most strikingly illustrated by malarial fever.
But often the cause is either unknown, as in car-
cinoma, or is beyond the power of our art to
remedy, as in typhoid fever. In another group
of cases, while the etiological factor may be sus-
ceptible to treatment, its abatement fails to bring
about the hoped for amelioration ; for instance,
in certain types of hookworm infection the ane-
mia may persist after the sterilization of the in-
testinal tract unless some special treatment
towards the pathological consequence of the in-
fection be undertaken. In other conditions, ex-
emplified by certain types of nephritis, the etio-
logical agency may have led to structural altera-
tions of such a nature as to immediately threaten
life. In still another group of cases the original
cause, although perhaps no longer active, has
started a train of functional disturbances, which,
like an automobile running down hill, not only
tend to self-perpetuation but even to progressive
aggravation. In such instances while the eradi-
cation of the cause is of utmost importance from
the standpoint of preventing further pathological
damage, the greater part of our treatment is -di-
rected toward the correction of the functional
disturbance resultant upon the pathological le-
sions. You cannot cure cirrhosis of the liver by
prohibition laws.
While a system of therapeutics which takes
into account only symptomatic treatment can no
longer be regarded as rational, yet I am not one
of those who think that symptom treatment
should always be deprecated. Not only do our
patients demand as prompt relief from pain and
discomfort as is possible, but the mitigation of
symptoms may in some cases have a marked ef-
fect in assisting recovery. For example, in a
case of cardiac failure with dyspnea so severe
that the patient is unable to sleep, the> lack of
proper rest hinders reconstructive processes in
the heart ; here the administration of an anodyne,
by dulling perception may make rest possible and
thus indirectly exercise a beneficial effect upon
the cardiac muscle.
I am fearful that some of you may think that,
while the method of therapeutics here advocated
may be very beautiful in theory, it is too ideal-
istic for practical daily application at the bedside.
Any system, however fine it may appear on
paper, which is not applicable to our daily .needs,
is fundamentally unsound and I would not
knowingly advocate a method which I did not
believe to be clinically useful. I grant you that
a logical procedure of the nature that I have out-
lined requires a considerable knowledge, not
merely of pharmacology but also of pathology
and that it necessitates more mental effort than
a mere rule of thumb practice, but I maintain
that it will yield results more gratifying to both
the patient and the physician and that the in-
creased effort required will be more than repaid
by the satisfaction of a task well performed.
Permit me, therefore, to attempt to justify my
philosophy by a concrete application, using for
example a case of exophthalmic goitre.
We first ask ourselves whether there is any-
thing that we can do towards the removal of the
causative factor. While we are as yet uncertain
how the causes operate to produce disturbance
of the thyroid function, there is very strong evi-
dence that the hyperthyroidism is in some cases
the result of infective processes in the body and
that in others it is of nervous origin. In our
etiotropic treatment, therefore, we search the
body carefully for any source of infection, re-
membering especially the tonsils. If any local
infection can be found, it is eradicated if pos-
sible. Because of the nervous element in the
etiology, we will put the patient upon a rest cure.
This does not mean simply to confine her to bed,
although that is essential, but also to exclude all
sources of excitement and worry by shutting her
off from contact with her customary surround-
ings. "Out of sight, out of mind," is an old say-
ing which has much of truth in it, and when per-
sons are not reminded of their griefs or anx-
ieties by seeing or hearing those things which
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416
THE PENNSYLVANIA MEDICAL JOURNAL
March, 1921
are associated with the emotional disturbance,
after a period of time these emotions become less
acute and lose their dominating influence.
But, while the etiotropic treatment is of the
utmost importance, by itself it is not sufficient in
these crises, for the reason that there has been
started a train of functional disturbances which
tend towards self-perpetuation. The important
pathologic lesion is the excess of thyroid secre-
tion, which in turn leads to increased cataboHsm
and over-excitability of certain groups of nerves,
especially those governing the circulation and the
digestive organs.
We know of no drug which will check the se-
cretion of the thyroid gland but we may have re-
course to other measures of accomplishing this
purpose. Preeminent among these stand the sur-
gical removal of a portion of the gland or func-
tional destruction by the use of the x-ray. Where I
quarrel with the surgeons in their management of
these cases is that they seem to think that when
they operate upon the gland they are removing
the cause of the disease and that therefore the
patient will recover of herself. As a matter of
fact, they are doing nothing against the cause;
they are simply alleviating one of the pathological
results and tfiat often only temporarily.
The excessive metabolism which is the most
constant symptom of the disorder may manifest
itself either by a slight rise in temperature or a
loss in body weight. The most potent agent,
aside from physical rest, that we possess for the
purpose of restraining catabolism is quinine. .
Whether the universal preference for the hydro-
bromide is justified or not I am not prepared to
say, but at the same time it is at least as satisfac-
tory as any other salt and I believe in deference
to general opinion should be the salt of choice.
The next most striking symptom is the over-
action of the heart, the pulsations being not only
more rapid but often more violent than normal
and causing great discomfort, as well as exhaus-
tion of the myocardium. The most powerful
stimulator of cardiac inhibition is veratrum
viride, and I believe it more efficacious for these
case* than digitalis. In my own experience it
has almost invariably given at least temporary re-
lief from the cardiac symptoms. A third symp-
tom which requires attention is the general nerv-
ous excitement and insomnia. As one of the
causes of hyperthyroidism is nervous strain, it is
manifest that this hyperexcitability of the nerv-
ous system tends to the perpetuation of the dis-
ease and therefore demands symptomatic relief.
In some cases the quiet routine of the rest cure is
sufficient to calm the irritated nerve centers. If
it does not, the bromides should be tried. My
own preference, based, I must confess, rather
upon theoretic consideration than upon experi-
ential evidence, is for the calcium bromide ; this
for two reasons, first because lime of itself less-
ens the irritability of the nerve centers, and sec-
ondly because these patients generally show
marked loss of calcium from the body.
I have not attempted to tell you anythii^ new
about the management of Graves' Disease, but
only to show how a therapeutic problem can be
approached in an orderly manner. But I can
hear you asking, "All these measures are al-
ready familiar; what is the use of all this theo-
retical folderol if it ends merely in a recital of
well-known remedial methods ?" There are three
great practical reasons: First, it is always an
advantage to know why and how our remedies
do good. How are we to know when to stop the
rest treatment in Graves' Disease, for example,
if we have no concept of its modus operandi.
He would be a foolish man who would give
veratrum viride routinely and continuously in all
cases of this disease regardless of the pulse rate.
Second, if our treatment is based on sound
principles we are able to discard from our arma-
mentarium a host of useless or even harmful
measures which are of ancient if not honorable
lineage.
Third, we are in a position to select from the
continuous stream of new drugs and suggestions
flowing forth from the exuberant imaginations
of physicians and pharmaceutical manufacturers,
those which offer reasonable hopes of usefulness.
If a drug be recommended for a certain disease
but no explanation given as to how it can benefit,
or if the explanation be not in harmony with the
known properties of the drug, be very cautious
in expecting good results from its employment.
The type of testimonial, whether in an advertis-
ing leaflet or in a medical journal, which says "I
have used Exine in three desperate cases of
something or other with wonderful effects,"
brings no conviction to my mind. I grant you
that there are instances where empiricism has
outrun science and that there are drugs of un-
doubted value whose benefit we do not yet un-
derstand, but the proof of their virtue must be
confirmed by a mass of clinical evidence which is
stupendous.
THE DIAGNOSIS AND TREATMENT OF
PERFORATED ULCERS OF THE
STOMACH AND DUODENUM*
H. A. Mcknight, m.d.
PHII.ADEI.PHIA
There is no surgical condition in which the
sudden change from apparent perfect health and
'Read before tbe Northern Medical Association of Philadel-
phia, Jan, 28, 1931.
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Cnoogle
March, 1921
SELECTIONS
417
well-being, to marked distress and collapse, is so
marked as in ruptured ulcers of the stomach or
duodenum. Notwithstanding the marked ad-
vance made in the diagnosis of acute surgical ab-
dominal conditions, perforations still frequently
escape recognition, or are mistaken for other less
serious lesions, and the resulting delay in the ap-
plication of the proper surgical treatment leads
to the loss of many lives.
The importance of early recognition of the
rupture of an upper abdominal viscus by the
physician first called, cannot be too strongly em-
phasized. The fate of the patient lies in his
hands, and while it is most satisfying to diagnose
this condition correctly, still, no needless delay
is excusable in confirming such a diagnosis. It
is only necessary to know that an upper abdomi-
nal organ is perforated and that immediate oper-
ation is the only hope of a cure.
Perforations of the stomach and duodenum
are most frequently seen in early and middle
life, usually in the third and fourth decades.
We rarely see perforations in the very old or the
very young, except perhaps in the acute toxic
types following extensive burns of the integu-
ment. Duodenal perforations are more frequent
in males, gastric perforations in females, and in
both sexes the duodenal perforations predomi-
nate.
The most common site for the perforation of
an ulcer to occur is in the anterior wall of both
the stomach and duodenum, at a point within i
to 2 cm. of the pyloric ring. AUoncle found
that perforation occurred on the anterior wall in
6o per cent, of all cases examined, and Collin
found the same condition in 59.6 per cent, of his
cases of perforation.
Ulcers perforating in this region are usually
of the acute type ; occurring suddenly with mod-
erate escape of gastric or duodenal contents
which either floods the general peritoneal cav-
ity, or fills a definite part of the upper abdomen
depending on the site of the rupture.
The less acute types occur along the lesser cur-
vature and in the posterior wall of the stomach.
In these cases, which are relatively uncommon,
and perforate slowly, extensive abscesses with
many adhesions form in the lesser peritoneal
cavity, and the symptoms are atypical and
masked. There are no premonitory signs of the
impending disaster. The rupture usually occurs
while the patient is at work and is sudden and
overwhelming. Food in the stomach is not a de-
termining factor. A rupture is as likely to occur
in an empty stomach as in one filled with food.
There is usually a past history of long standing
indigestion, with pain after meals relieved by the
taking of food, with periods of freedom from
discomfort ; in other words the history of a long
standing chronic ulcer. The immediate history
preceding the rupture is usually negative. Duo-
denal ruptures in this respect appear more likely
to occur without any previous warning than gas-
tric ruptures.
The dij^osis of this condition is made from
the history. A patient stricken with a perfo-
rated ulcer says he felt perfectly well, when he
was suddenly seized with a terriffic, agonizing,
unendurable pain in the upper abdomen which
doubled him up. He describes this pain as the
most severe he has ever experienced. This is the
typical pain of a ruptured viscus, and is the most
constant and consistent subjective symptom
elicited. This pain is increased and augmented
by all bodily movements, by sitting up unassisted
by the elbows, by flexing the thighs and by ab-
dominal respiration. It is more severe than the
pain produced by a ruptured appendix or gall
bladder, as the acid contents of the stomach com-
ing in contact with the sensitive parietal perito-
neum are more irritating than either bile or pus.
As a result of this irritation and increased pain
on motion the attitude of the patient when first
seen is characteristic of his condition. He lies
perfectly still and motionless and wears a fixed
and anxious expression as if expecting at any
moment a return of his suffering. He holds his
upper abdominal muscles rigid in contraction to
still abdominal breathing, and uses his thoracic
muscles in light shallow respiration. He is re-
sentful to examination, manipulation, and pal-
pation of his abdomen.
Vomiting is by no means a constant symptom,
but is next to pain the most important subjective
symptom. It is more common in duodenal than
in gastric perforations. The reason for this is
an anatomical one. The gastric contents escape
more easily downward than upward and in per-
forations of the duodenum, the stomach wall be-
ing intact, the mechanism of vomiting in conse-
quence is undisturbed. In Petren's series of 92
cases it was present in 48 duodenal, and in 10
gastric perforations ; absent in 22 gastric and in 5
duodenal. Leroy, Minet and Dungery state that
in perforations near the cardia and lesser curva-
ture vomitftig is less frequent than when the per-
foration is near the pyloris or greater curvature.
Localized tenderness to pressure is a most valu-
able early diagnostic sign, it is found in the epi-
gastrium to the right of the mid-line in duodenal
perforations, and to the left in gastric perfo-
rations. It later becomes masked and is finally
lost as general peritonitis and distension ensue.
Muscular resistance is the most constant and
valuable early symptom, and in its point of maxi-
mum intensity, corresponding to the immediatftp
418
THE PENNSYLVANIA MEDICAL JOURNAL
March. 1921
area- of perforation, and primary peritoneal soil-
ing, the most reliable guide to the site of the
lesion. The resistance is unmistakable, it is
board-like in character, and in no other acute
lesion in the abdomen is it so intense as in a rup-
tured ulcer. It is the diagnostic sign, and once
felt and associated with the underlying cause is
never forgotten. Later in the course of the dis-
ease it, like tenderness, spreads and its diagnostic
value is lost. Dullness in the flanks and oblitera-
tion of liver dullness are late signs not wholly
diagnostic of the acute condition, but of the com-
plicating peritonitis and abdominal distension.
These signs are variable and in many cases alto-
gether absent.
Temperature changes are slight in the early
hours of a perforation. There is usually a short
period of subnormal temperature. following the
slight shock caused by the rupture, and, as the
peritonitis extends the temperature rises. Shock
so frequently stressed as a symptom is the excep-
tion in both gastric and duodenal perforations.
Such transitory shock as may be present, is usu-
ally over before the surgeon sees the case, and is
due to the contact of intestinal contents with the
peritoneum. It is of short duration, is quickly
overcome, and is no indication for delay in sur-
gical intervention.
The differential diagnosis between perforated
ulcer and the many other abdominal conditions
which stimulate it more closely is not easy, and
in the three following conditions — ruptured ap-
pendix, ruptured gall bladder, and acute pancre-
atitis, the diagnosis, at times, m-iy be made only
at operation. The differention between these
simulating lesions depends to a very great degree
upon the history of the onset, the site of the ini-
tial pain, and the course of the disease in the first
few hours.
The symptoms and physical signs of a rup-
tured ulcer and ruptured appendix more closely
resemble each other. Both are preceded by a
history of gastric disturbances ; the onset in both
is marked by severe pain, slight elevation of tem-
perature, increase in pulse rate and a leucocytosis.
In ulcer, pain is mpre pudden and severe than in
a ruptured appendix, the location is in the epi-
gastric region primarily, and from this point
radiates to the rest of the abdomen, and may lo-
calize late in the disease in the right iliac fossa.
In appendicitis, the pain is at first general and
about the umbilicus, and then localized in the
lower right quadrant. It is first general to the
whole abdomen and then localized ; while in
ulcer it is first localized to the epigastrium and
later becomes general. Rigidity of the abdominal
wall follows the same course as pain in ils locali-
zation. Vomiting is a late symptom in both con-
ditions but is more constant in lesions of the
appendix.
The differential diagnosis between ruptured
ulcer and ruptured appendix late in the course
of both conditions is further obscured by the ex-
travation of fluid from an ulcer. When a duo-
denal ulcer perforates, the fluids poured out flow
along the trough of the transverse mesocolon to
the right around the hepatic flexure, and down
the outer gutter of the ascending colon to the
right iliac fossa. The point of greatest tender-
ness at this stage is in the region of the appendix.
Many cases are opened for acute perforative ap-
pendicitis and at operation the diagnosis is diffi-
cult even with the abdomen opened.
When the belly is opened, in both conditions
fluid escapes. Gastric and duodenal fluid is yel-
low, free from odor, and is distributed uni-
formly, without change of color or odor about
the mesentary and cecum. The change in the
appendix in ruptured ulcer is limited to the se-
rous coat, which like the rest of the adjacent in-
testines may be reddened and injected. In acute
appendicitis, the fluid near the parietal perito-
neum is usually serous, small in quantity, and
free from odor, but as the appendix is ap-
proached the fluid becomes turbid and the appen-
dix is discolored, friable and surrounded by thick
offensive pus.
A perforated gall bladder presents s)rmptoms
similar to those found in a perforated ulcer. The
patient however is less dangerously ill. Both are
characterized by sudden onset, severe pain in the
epigastrium, vomiting and prostration, tender-
ness and rigidity of the right rectus.
Acute pancreatitis gives a history of long
standing gall bladder disease, with acute and sud-
den onset accompanied by intractable vomiting.
There is marked shock and collapse, more marked
in this disease than in any other acute condition
in the upper abdomen. When the head of the
organ is involved, the symptoms are referred to
the upper right quadrant of the abdomen, and
are similar to those of a ruptured duodenal ulcer.
When the tail of the pancreas is diseased, the
symptoms are referred to the upper left quad-
rant and loin, similar to those found in a rup-
tured gastric ulcer. In many cases the true con-
dition is only found at operation. In pancreatic
diseases the fluid in the abdominal cavity is of
dark color and blood-stained, fat necrosis of the
omentum is seen and on palpation the organ is
hard and markedly enlarged.
There is no disagreement among surgeons that
perforated ulcers should be operated at once, but
there is marked controversy as to the type of
operation to be done and the proper procedure
to be followed. We must first consider the
Digitized by VjOOQIC
March, 1921
SELECTIONS
419
course of the disease, because on it, and on con-
sideration of the time that has elapsed since the
rupture occurred, is based to some extent the
operative technique.
Mayo divides the course of the lesion into
three stages: (i) The stage of contamination;
manifested by slight shock, localized pain and
tenderness. (2) The stage of reaction ; in this
stage the patient improves and his subjective
symptoms diminish. This is the stage in which
the surgeon is in many cases led astray and by
waiting for more acute signs allows his patient to
enter (3) the third stage — that of general perito-
nitis, with acute pain, and tenderness subsiding
and sepsis rapidly intervening. This calamity
must be met promptly, for each hour's delay is
penalized by the loss of a definite per cent, to the
operative chances.
The patient should be operated upon in the
first stage if possible. The mortality for acute
perforated ulcers operated upon in the first 12
hours is less than 10 per cent.; after this time
has elapsed the mortality rapidly advances to
from 40 to 60 per cent, after 20 to 36 hours.
The operative technique should aim to do as
little as is necessary to send the patient from the
table with more than' a fighting chance. This
means that if a gastroenterostomy is thought
necessary, but the patient is in no condition for
further surgical work at the time of the primary
operation, inclusion of the ulcer with drainage
of the pelvis should suffice, and he should be put
to bed to recover from the effects of the immedi-
ately necessary operation and the further work
thought essential for permanent cure done at a
later date.
If seen early in the disease, when there is no
great soiling of the peritoneum and a small per-
foration readily accessible, the opening should be
closed, the surrounding indurated and diseased
'tissue about the point of perforation should be
invaginated by a purse-string suture, a gastro-
jejunostomy done and the pelvis drained. A pos-
terior gastrojejunostomy will not prolong the
operation to any great extent and will give a
greater sense of security against secondary per-
forations and subsequent pyloric obstruction.
If the perforation is large and the area of in-
duration marked, the suture line may be rein-
forced by sewing the great omentum to the
gastrohepatic omentum or tacking an omental
graft to the suture line.
The question of whether to do an gastroenter-
ostomy or not is a much debated one and both
sides are championed by operators of large expe-
rience. For the slow and occasional operator
simple closure and drainage is probably the best
technique. A gastroenterostomy safeguards a sec-
ondary rupture from coexisting ulcers, drains the
stomach, neutralizes the hyperacidity, is an added
safeguard against weak suturing of the opening
and a method whereby the patient may be nour-
ished within 24 to 48 hours following operation.
In late cases with peritonitis, the less surgery
done the better is the prognosis. In these cases
closure of the opening with upper and lower ab-
dominal drainage is the method of choice. The
upper abdomen should be dry sponged but under
no consideration should the peritoneal cavity be
douched. Food particles are not found in the
peritonenum even with large openings and the
fluid is usually steril and is easily evacuated by
pelvic drainage. In general the operation is de-
termined by the condition of the patient at the
time of operation and the degree and extent of
the associated peritonitis. The operative mor-
tality of duodenal perforations is lower than that
of gastric. This is due to the more accurate
localization of duodenal perforations. They are
found more quickly and with less manipulation.
The pyloric sphincter lessens the flow of fluid
contents, and the dissemination in duodenal rup-
tures is more localized.
Mayo has aptly said that a perforated ulcer is
a healed ulcer, and it is patholc^cally but not
symptomatically. Therefore after operation a
patient should not be discharged with the advice
to eat everything with impunity. His diet should
be carefully selected for at least a year and a
modified Sippy treatment instituted.
241 S. Thirteenth Street.
INSPECTION OF MILK PRODUCTION
I. P. P. HOLLINGSWORTH, M.D.
PHILADELPHIA
Former Director of Public Health, Sioux Falls, South Dakota
Milk is generally conceded to be one of the
most important articles of food, and in spite of
this fact is still handled in many places with less
respect than the water supply. An enormous
amount of money has been spent in the construc-
tion of elaborate equipment to deliver it to the
consumer in a sanitary condition, but there is
still great room for improvement.
Within recent years a question has been raised
as to the nutritive value of pasteurized milk.
While it is probably true that the vitamines are
disturbed, pasteurization must necessarily con-
stitute the only safe procedure for the great bulk
of the milk in large centres of population and far
outweighs the disturbance of the vitamines in im-
portance. Until the day has arrived of the mu-
nicipal dairy producing milk from tuberculin
tested, healthy cows, under strict sanitary corj-^
♦20
THE PENNSYLVANIA MEDICAL JOURNAL
March, 1921
ditions, the state of the raw milk previous to
pasteurization as now sold would be much im-
proved by more attention to inspection of dairy
conditions. Many state boards of health have
begun to realize the great importance of field in-
spections, and the latter are beginning to be car-
ried out in conjunction with laboratory exami-
nations. Minnesota has been particularly active
along these lines and in a paper read before the
South Dakota State Medical Society in May,
1920, Mr. H. A. Whittaker, of Minneapolis, Di-
rector of the Division of Sanitation, Minnesota
State Board of Health, emphasized the important
relation between field inspections and the labo-
ratory.
Writing as one who has been in intimate con-
tact for the past year with milk supplies in a rich
milk shed in the southeastern part of South Da-
kota at all stages, from the dairy to the consumer
and the laboratory, I have been particularly im-
pressed with the importance of the correction of
insanitary conditions at the point of production.
When the milk starts clean it is a comparatively
easy matter to keep it clean provided the haul is
not too gfreat and the temperature is kept low.
Here is where the importance of the dairy in-
spector develops, just as the milk inspector in the
city is so importailt in the handling of the milk.
They are the two most important liaison officers
along the line from the cow to the consumer.
There is a big field in many states for improved
legislation on djiiry sanitary requirements, and
for the enforcement of such. It is not necessary
that the dairy should have equipment similar to
that of the dairy where certified miilk is pro-
duced, as a very clean milk with a bacterial count
of fifty thousand or less per cubic centimetre can
be produced with ordinary cleanliness of the cow
bam, the cows, the hands of the milker, and the
pails.
A producer under my observation during the
past year produced an excellent milk of low bac-
terial content in a barn which was almost ready
to tumble down, but where the dairyman knew
how to observe the rules of cleanliness. His
cows were clean and not covered with dung, he
used plenty of bedding straw, and he kept his
bam cleaned out. His pails were scalded clean,
his hands were scrubbed before milking, and at-
tention was paid to the udder of the cows.
On the other hand another man produced very
dirty milk in an up-to-date, "expensive barn sim-
ply because he continually broke the technique
of clean milking. Milking machines, when kept
clean, are probably better than hand milking;
otherwise they are very much worse.
The greatest obstacles to clean milking condi-
tions at the dairies will be found to be either ig-
norant indifference or obstructive ignorance or
both. Agricultural education is proverbially slow
and this will be found to be particularly true of
dairy conditions. The educated young dairy-
man from an agricultural college will be found
only too willing and glad to use sanitary methods
in the production of milk. The so-called practi-
cal farmer or the old-timer will often be resistant
and hard to convince, but even he, when once
shown how much better and more profitable a
clean product is than a dirty one, will often
quickly reform. Sedimentation discs are a par-
ticularly powerful argument for such an indi-
vidual as he cares nothing about the bacterial
content. The Department of Agriculture is do-
ing an immensely valuable work in the distribu-
tion of bulletins on the subject, but the most im-
portant work will always remain with the local
state and county inspector. The ideal milk is
that from your own cow which has been tuber-
cuKn tested and is otherwise healthy, milked by a
healthy milker, with clean hands into a clean pail
in a clean barn and brought within a short time
to the table. Unfortunately there are not many
of us who can obtain such milk and we must de-
pend upon the pasteurized product, unpalatable
as it may be at times.
Pasteurized milk has an immense value but it
should be borne constantly in mind that the clean-
liness of this milk is relative only and that a dirty
milk previous to pasteurization will retain some-
what more of its bacterial dirt afterwards than
a cleaner milk.
With all the attention which dietitians and nu-
trition experts have drawn to the value of milk
as a food, surely more care should be paid to the
enforcement of sanitary conditions at the dairy.
In many states the dairy inspector is not very
thoroughly trained for the work and does not
make sufficiently frequent inspections. He
should be a man who, in addition to the neces-«
sary veterinary knowledge, should be informed
to some extent on the epidemology of infectious
milkers and in addition to a field training for
proper sanitary conditions at the farm, should
possess some laboratory information. He should
above all understand how to deal with the farm-
ers and be tactful enough to always bear in mind
that much more is accomplished as a rule by edu-
cational methods than by police work.
Pasteurization is by no means the last word in
a clean milk supply and it will appeal to the rea-
son of most consumers to have more attention
paid to the cleanliness at the source of supply
where experience has shown most of the con-
tamination occurs. It would seem more rational
to start with a clean product than with a com-
paratively dirty one, which from Jhe ]^^ 9Qf^^
Digitized by
March, 1921
PITTSBURGH ACADEMY OF MEDICINE
421
bination of bacteria and milk grows progres-
sively dirtier, and then attempt to dean it up by
partial sterilization.
All the child welfare agencies, which have
been so active in recent years, could do no one
thing of more value to the health of children,
than give powerful backing to all attempts to
produce clean milk. The value of such attempts
has certainly been demonstrated in New York
during the past few years.
Many consimiers, if they could inspect the
sedimentation discs of our raw milk as it is
brought to distributing plants in many communi-
ties, would rise up in their might and demand
revision of legislation for sanitary milk produc-
tion as well as trained dairy inspectors and suffi-
cient of them to make frequent inspections.
7008 Greene Street
PITTSBURGH ACADEMY OF
MEDICINE
ANGIOMATA OF THE SMALL
INTESTINES
DR. NICHOLAS SHILLITO
Nine cases are collected from the literature and
one reported by the author.
The first one was reported by Marsch in 1898,
the angioma being located in the rectum of a girl
ten years old. The second was reported by
Barker in 1898, the tumor occurring in a man
aged 43, who died from anaemia. The third was
reported by Pierre Delbet in 1899, the angioma
being located in the small intestines of a woman
aged 21 years. At operation a partial obstruc-
tion was found. The patient died subsequently.
Laboulbene reported an angioma in a man aged
64 years who had suffered for years with slight
constipation. He passed blood by the bowel for
several years, after which the stools became nor-
mal. This incident was repeated a month later
and was accompanied by the vomiting of coagu-
lated blood. A diagnosis of duodenal ulcer was
made at this time. A few days later there was
an extensive hemorrhage from the bowels, re-
sulting in the patient's death. At autopsy the in-
testines were found to be full of blood and in
the duodenum above the papilla of Vater there
was an ulcerated angioma.
Boyer reported a case of multiple angiomata
in the jejunum and ileum in a man aged 62 years
who had died from pneumonia.
Pad reported an angioma which had been
passed by the rectum by a woman who had suf-
fered from intestinal obstruction. Apparently
hemorrhage had occurred in the substance of the
tumor, enlarging it to such an extent as to cause
an obstruction, after which it had been torn from
its pedicle and passed on along with the rest of
the intestinal contents.
Hektoen described one case of angioma found
at autopsy.
MacCallum reported multiple angiomata in
the small intestines found at autopsy in a man
who had been '"an excessive whiskey drinker and
had given a history of vomiting before breakfast
and once had vomited blood. The immediate
cause of death in this case was acute alcoholism
and bronchopneumonia.
Bennecke reported multiple angiomata not
only of the intestines, Jbut also of the stomach
and the oesophagus.
The author reports the following case: A
man aged 27, molder by occupation, consulted
him for pains localized in the appendix region.
Ever since he was seven years of age he had had
attacks of colicky pains at two- to six-month in-
tervals which would always become localized in
the region of the appendix. The attacks were
always accompanied by vomiting and at times a
mass could be made out in the appendix region.
At one time this mass seemed as large as a lemon.
The attacks always terminated with free bowel
movement and on two occasions blood was pres-
ent in the stools. A diagnosis of recurrent ap-
pendicitis was made and an operation was per-
formed January 18, 1912. The appendix was
found to be normal, but in the ileum four inches
from the ileocaecal valve a mass was found. The
gut was resected and an end to end anastomosis
was made. The tumor showed it to be a cavern-
ous angioma.
It would seem that a reasonable explanation
for the obstruction is to be found in the erectile
nature of the tumor which becomes engorged
with blood and hence mechanically obstructs the
lumen of the intestines, the obstruction persist-
ing until the engorgement is relieved.
A SIMPLE CLINICAL METHOD OF CAL-
CULATING THE GENERAL NUTRI-
TIVE VALUE OF ANY GIVEN
DIET BASED UPON A FEW
WELL-KNOWN, WELL-AT-
TESTED AND WELL-ES-
TABLISHED PHYSIO-
LOGICAL FACTS
A paper, with the above title, was read by Dr.
William H. Mercur. In his introduction, he em-
phasized the fact that more is known about the
well-attested and well-established physiologic
facts concerning nutrition than is actually car-i
Digitized by VjOOQIC
422
THE PENNSYLVANIA MEDICAL JOURNAL
March, 1921
ried out in practice, the cause of this being that
probably many physicians who know these facts
are unaware how easily such knowledge can now
be made available. In support of this, he quoted
two recent cases which had come to his personal
attention where such knowledge had not been ap-
plied. He gave certain psychological reasons
why he was presenting his subject to physicians
in such a simple and elementary manner, and
said if their patients are to carry out a diet suc-
cessfully they must have an intelligent idea of
what the doctor is trying to do for them. In
order to secure this necessary cooperation, such
knowledge must be conveyed to the patient in a
simple and convincing manner in order to secure
his confidence. The average patient of to-day
either will not or cannot grasp any long drawn-
out, scientific explanations, especially if ex-
pressed to him in strange or unfamiliar terms.
He stressed the point that to-day it is not nec-
essary to know all about any subject in order to
get a working knowledge of it. "No one knows
all the details about any subject or ever will."
Another great advantage of dealing with a sub-
ject in a broad and general manner is that one
can easily find out what has really been accom-
plished by others, and thus save much time, in
that he does not then try to do what others have
already done for him.
The dic^am he showed on the blackboard was
a simple one. In it, he drew an analogy between
a man building a brick wall which called for 75
bricks and the time and work taken to build it,
and the himian nutritive problem. The bricks
represent our tissue food and the time and work,
our fuel foods (the fats and carbohydrates).
The diagram took up the further steps of what
we really know concerning the digestion of tis-
sue and fuel foods and how they are assimilated.
The main idea of putting the matter in this form
was that a physician might thus quickly and con-
cisely explain to his patient all he wants him to
understand concerning the dietetic problem. He
summed up by stating that a man whose weight
was 150 pounds would need approximately 75
grams daily of protein and 2,500 calories in do-
ing light work. In order to quickly calculate the
amount of protein in grams and fuel foods in
calories which any given patient was taking, all
one had to do was to put down, in domestic
measures, exactly what is eaten for breakfast,
dinner and supper, and then use Locke's book of
"Food Values," where the exact amount of pro-
tein and calories in any given cooked or raw food
is given. With little practice, after these amounts
are written down, the necessary calculations can
be made in ten minutes. Any intelligent patient
or nurse can easily be taught to do this.
Knowing then, these primal or foundation
facts, it is a comparative easy matter to outline
a simple dietary based upon them.
Dr. Mercur's conclusions were : ( i ) That too
little protein is more dangerous than too much.
(2) That the correct proportion of tissue foods
to fuel foods was important. (3) That nature
has made ample provision for storing fuel foods
in our body but none for tissue foods. (4) That
in many cases a properly balanced diet of pro-
tein, fats, carbohydrates and inorganic salts is
not all that is necessary but that there is, in addi-
tion, some unknown quality which must be pres-
ent in all diets which, as yet, has not been care-
fully worked out and for the present this is
roughly called the vitamins of diet.
SOME COMPLICATIONS OF DIABETES
MELLITUS
DR. LAWRENCE LITCHFIELD
The standardizing and popularizing of a sim-
ple and efficient treatment of diabetes mellitus
by Allen has prolonged the life of the diabetic
and will prolong it still further as the medical
profession gradually wakes up to this innovation.
This prolongation of the life of the diabetic
makes the study of complications of diabetes
mellitus particularly necessary. The point on
which the greatest stress should be laid is that, in
all complications, the patient must be treated first
and foremost and unceasingly as a diabetic, and
any relaxation of the regimen necessary to keep
the patient free from sugar and diacetic acid will
be attended with disaster; that the water con-
tent of the body should be carefully watched,
that the antipathy between general anasarca and
acidosis should be recognized ; that the salt ra-
tion should be carefully watched and not sud-
denly changed under any circumstances; that
radical change in the diet should only be brought
about gradually and under careful supervision;
that in all acute infections there is a marked ten-
dency to acidosis which should be guarded
against by promptly cutting down or entirely
eliminating fat from the diet on the first signs of
an infection; that if this were done in cases of
middle ear infection they would not be followed
by acidosis and coma, as has been frequently re-
ported ; that the keynote in the modem treat-
ment of diabetes is that the patient, or some
member of the family, must make the tests for
sugar and diacetic acid and regulate the diet,
rather than relying on the physician to do so;
in the average case the physician does not treat
the patient but teaches the patient to treat him-
self.
Digitized by
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March, 1921
COMMUNICATIONS
423
Attention is called to the increased number of
deaths of diabetes from tuberculosis, and warning
against insidiousness of this complication. The
moderately severe diabetic may be carried safely
through a pregnancy on these lines, but if dia-
betes is discovered during the pregnancy there is
great danger of serious acidosis unless the diet
is changed with the greatest caution. In all sur-
gical conditions the anesthetic of choice is nitrous
oxide combined with oxygen unless local anes-
.thesia can be used; the latter never in cases of
gangrene. In all infections the carbohydrate tol-
erance will be diminished and after convalescence
it may or may not be possible to reestablish the
former tolerance ; the reduction of the patient's
weight to the lowest point consistent with com-
fort and efficiency, which is a part of the mod-
ern treatment of diabetes, is highly beneficial to
a large number of patients, such as cardiorenal,
arteriosclerosis, and adipose.
Frederick B. Utley, M.D., Reporter.
COMMUNICATIONS
Executive Secretary :
Dear Doctor. — A number of physicians again at-
tended the public meeting of the Health Insurance
Commission on the 4th inst. in Philadelphia. Looking
over the personnel, the doctors anticipated what was
coming, inasmuch as no Pennsylvariia citizen appeared
to address the gathering. The occasion was the ap-
pearance of Messrs. John A. Lapp, Chicago; John B.
Andrews and Miles M. Dawson, of New York, telling
the citizens of this great state what was best for them
along health insurance lines and described the fallacy
of the medical profession for antagonizing their eflforts
and not readily agreeing with their plans and helping
along, as Mr. Dawson later stated "that health insur-
ance was coming anyway." Since no Pennsylvania
citizen advocated health insurance before the commis-
sion that day, the men from distant cities assumed that
privilege. It was plainly evident that an artificial de-
mand was being fostered for the scheme by outside
agitators. Later the conclusions of the doctors became
obvious.
The Davenport Bill of New York State was fre-
quently referred to as a sample in the discussion. Mr.
Lapp, of Chicago, acknowledged that he was an active
instigator of that bill and assisted in drafting parts of
the measure — a, serious reflection upon the ability of
the New Yorkers to frame their own legislation. It
likewise showed the activity of "outside agitators" in
going into another state and helping to promote inim-
ical legislation. Such conduct likewise reflects upon
the Commission of this State which is paid out of the
State's funds to spend its time and effort to listen to
outside propagandists who are trying to foist legisla-
tion upon this state which most of its citizens do not
want. The Commission's time and expense is unwar-
rantably consumed to promulgate idealistic schemes.
The matter of lay or political interference with the
profession and adequate compensation was the bone
of contention. The provision suggested by Messrs.
Lapp and Dawson that the several county medical so-
cieties should formulate a complete schedule of fees
and that the adopted scale should be the guide in the
application of the compensation in that particular lo-
cality, was a very slick way of sliding over the very
gist of the entire insurance .scheme ; when pinned •
down to facts, they were as far away from the real
is5ue as anybody and pleaded ignorance. They fur-
ther stated that the plans were that everybody should
have free choice of doctors and that panel doctors
should not exist. If the doctors disagreed, the laity
would have to decide.
The shrewdness of those propagandists is surely
astounding in what they try to pull off in this state
and likewise how they try to pull the wool smoothly
over the profession's eyes. Their actions are bold and
disgusting to the profession. Their procedure com-
pels the noble profession of this state to spend a lot
of good money to combat the sinister eflforts of the
nefarious outside influence.
Fellow physicians, the word picture is fairly drawn ;
contemplate the aspect of the outsiders' influence in
this State and the unfair, wasteful procedure which is
open to serious criticism. This extrastate menace to
the munificent profession brought before bodies of
this State by paid theorists, is becoming offensive to
the better class of citizens. If a large body of citi-
zens of this State really wanted health insurance, the
problem would assume a different aspect and would
then be a just concern to the profession; but as the
matter really exists to-day, men of the type as those
who appeared at the recent commission meeting, it
was plainly shown that they were trying to manufac-
ture a demand for it; it was the effort of the idealist,
the theorist and foreign propagandist who is likely
paid for his effort by some hidden foreign influence.
The conclusions are plain and true.
Another thought. If physicians from this State
should go to New York or Illinois and work against
the interests of those states, they would be called down
very quickly by the very men who come from this
State and presume to tell the citizens and the generous
medical profession what is the best for them to do.
The arrogance of the extrastate agitator is becoming
unbearable; this State has had enough of it. Smite
the outside menace with a vengeance and do it NOW.
.Anthony F. Myers, M.D.
Blooming Glen, Pa.
THE DI.AGNOSIS OF ATYPICAL MALARIA
By Fr.\ncis B. Johnson, M.D.
Laboratory of Clinical Pathology Medical College of the State
of South Carolina
Charleston, S. C.
One cannot emphasize too strongly the careful search
of the blood for the malarial parasites that is required
in every case that offers the slightest suspicion of being
malarial in origin. '
The thick film methods and the concentration
methods offer the only way of simplifying the tedious
search. Proficiency in its use can be readily acquired
and be of the greatest aid in defining for us what is
really malaria and what is not, for it certainly is true
we lay too many things to malaria that are not malaria
and sometimes miss our diagnosis on those rarer atyp-
ical forms which may occasionally happen in the prac-
tice of any one. — From the Journal of the South
Carolina Medical Association.
Digitized by
Uoogle
424 THE PENNSYLVANIA MEDICAL JOURNAL March, 1921
THE PENNSYLVANIA laboratories, demonstrates that we have been
using in America, x-rays of approximately the
1^ trriTPAf fOITRMAT ^^^^ penetrative value as those used in Ger-
I^'IEjU l\^t\Lt jyj U MXl^rki^ jj^^^y ^g ^ routine, and that now the exceptional
==^=^==^====^==^==^= were only lo per cent, to 25 per cent, greater in-
c^^Sl^for?S^^ru'^^:/ofh,r'^r^^s^i.t\^t^^S. stead of loo per cent, as we were led to believe
o{ Pennsylvania. This Same laboratory has, however, developed
— ~~ purely as a laboratory experiment, rays of more
PREDEEicK L. VAN siS,' M.D HarrUburg than ICO per Cent, greater penetration than those
Aiatstant Editor "o^ used. Dr. Coohdge, the mventor of the
FRANK F. D. RBCKORD HarriBburg CooHdge X-Ray Tube, is making investigations^
Aisooute EditoM along this line. Professor Duane is also mak-
&E E.' p^LEi, Vd.. •::::::::::::::::::: : iPhuadllgSu ing similar investigations in higher voltage, but
hioKotC. joh»"o'n,°'m*d^'. :::::::::::::::::::: ipuubSlS as reported at a recent meeting had not shown
J. stswa«t Rodman,' m.d.,' Philadelphia jgo per cent, increase.
John B. McAlister, M.D Hamsburg r
bebnabd J. mtbbs, Esq Lancaster Even after these more penetrating rays have
PnbUcaUon CommittM heen developed, it will remain to be proved that
r^^?iofrB:'A"ll.\°D\.'^!'^::r"^:::::::::^ they have a more curative power in cancer.
Frank C. Hammomd. M.D Philadelphia gj^jjj jj^ ^^^^ ^g^ ^f gyj,j^ ^^yg ^jjj ^jgQ ^aVC tO be
All communications relative to exchanges, books for review, developed. This wiU require investigation by
manuscripts, news, advertising and subscription are to be ad- , u- i- r i u _u _:~:„« ...U- U^^
dressed to Frederick L. Van Sickle, M.D., Editor, aia N. the Combination Of WOrk by a phySlCian WhO haS
Third St., Harrisburg, Pa. knowledge of caucer and its clinical manif esta-
The Society does not hold itself responsible for opinions ex- tions, and alsO a knowledge of radiology, tO-
S«««mints°."'^"' ""'"'' ""''"»''''"'■ """"""i""""' »' "d- g^^j^g^ ^j^,^ ^,jg ^Qj.jj q{ ^ physicist, a biologist
— and a pathologist.
Subscription Price-$3.oo per year, in advance. ^^^^ ^^^^^^ .^ j^^^,^^^ -^ ^^^^^ investiga-
March, 1921 tions, and some of these men must be paid sal-
=^===^^===^=^====^=^= aries for it would require much, or all, of their
EDITORIAL t**"^- Therefore, it would be a great blessing if
some philanthropist would give a sum of money
THV "\i\^\\r V T? A v<;" TtJ THT? TPTfAT sufficient for such purpose, or endowments from
THE '^^!:i^:^^^p^^p™ '■ ^^^ ^ ' insurance companies which are interested in the
prolongation of life, or even state appropriations
The wild newspaper announcements which for such a purpose could profitably be made,
have developed lately with regard to the discov- G. E. P.
cry of a new form of x-rays, may lead some
people astray. Therefore, I feel the facts n^r, a T-wTmrr^xT r^z-^n^rn^r^xT owxtoc
should be presented, or rather restated. TRADITION vs. COMMON SENSE
The x-rays have been used in the treatment of When the human body is out of order why
cancer for at least twenty years, with more or does it not get the same rational consideration
less success. At first one of the superficial can- that an automobile receives? It is because man
cers yielded to the treatment, but as skill, ap- has an innate conviction that every ill must have
paratus and the knowledge of the disease ad- a remedy and he has been born with a strong
vanced, some of the deeper cancers responded tendency to look for that remedy outside of the
to treatment. There is hope for more and more body. This reliance upon the unnatural, if not
progress in this direction but false newspaper supernatural, undoubtedly goes back to the
reports only lead to false hopes, with a corre- dawn of human intelligence and since that time,
spending reaction and retardation of progress, throughout the ages, progress towards a logical
No really new discovery has been made. Ad- adjustment to our environment has been a very
vancement along well known lines, and with slow evolution. How strong the barbarous con-
well known principles, is being made in a num- victions and superstitions of our ancestors must
ber of laboratories, but no advancement, or dis- have been may be judged by the residues that
covery has been made such as will in anyway have come down to us, — our superstitions re-
compare with that made in the development of garding sitting down at a table of thirteen, pass-
the Coolidge tube about ten years ago. ing under a ladder, spilling salt, seeing the new
Experiments made in one of our research moon at the proper angle, are a few examples,
laboratories by those who have visited Germany, The faith of our forbears in drugs and herbs,
and even by a scientist from one of the German though becoming rudimentary, is still responsi-
Digitized by VjOOQIC
March, 1921
EDITORIALS
425
ble for shelves full of drugs, — traditional "ma-
teria medica," in the pharmacies and in the doc-
tors' offices and for the childlike confidence with
which we snap at any new "phylacogen." It is
because the doctor looks wise and seems to be-
tray a confidence (which he often feels) in his
own expeditious efficiency that the ingenuous
patient allows himself to be placated visit after
visit with a new tablet or a changed prescription,
instead of demanding an examination such as
the automobile would have received promptly.
It is the same instinct that leads the layman to
exhaust all the patent medicines that he can find
before he consults a doctor, — apparently the
same influence which leads many of the profes-
sion to exhaust the unpatented or "ethical"
proprietaries instead of stripping and examining
the patient. The doctor often says that the pa-
tients will not pay for a proper examination, but
does the doctor ask the patient ? What would
be the response of the patient if the doctor were
to say, — "I will look at your tongue, feel your
pulse, listen to the sounds made by your various
articles of clothing over your heart and lungs,
hear a part of your story, and give you a pre-
scription for one dollar, or I will examine you
thoroughly, carefully listen to and weigh your
entire storj', .send your blood, urine, or anything
else that should be examined to a competent
laboratory technician, possibly refer you to spe-
cialists for the examination of your eyes, ears,
throat, teeth, etc., and when all are finished I
will take the various reports into consideration
and try to determine what is wrong and what
had best be done. For this the charge will be in
proportion to the time consumed — from ten dol-
lars to twenty-five dollars."
A knee which has been treated for months for
"rheumatism" is cured by a specially prescribed
and carefully fitted shoe. A stomach harassed
for years with tonics, digestives, "alteratives,"
etc., is cured by removing a chronically infected
appendix. A child that has had semi-annual at-
tacks of rheumatic fever and finally endocarditis
is suddenly cured by an operation on a chronic
mastoid or the removal of infected tonsils.
These are daily occurances and the masses are
becoming familiar with such things and learning
to compare the final cost between the superficial
and the thorough.
The doctors say, on the other hand, that they
cannot possibly get through their work if they
give to each patient sufficient time for a proper
examination. Their waiting rooms are crowded
every day, they cannot get time to eat and sleep,
and the sociologists say there is a real shortage
of doctors! Why not diminish the congestion
in Ihe waiting room by referring some of the
patients to competent specialists, or to young
doctors in the neighborhood who are known, to
have an up-to-date equipment and education?
Why not make time to treat the real patients
fairly by teaching the others that they do not
need treatment? Why not try in every way to
show the laity the absurdity of their faith in
drugs instead of encouraging it by passing out
prescriptions and tablets "because th,e patients
are not satisfied if they do not get something"?
Why not preach to them at every opportunity
that they should ignore trivial discomfort unless
definitely localized and persistent, and that for
the rest they should give their bodies the same
logical consideration that they give to their au-
tomobiles? Here there are no befogging tradi-
tions. We do not rub it with St. Jacob's Oil
when the shaft is bent, or pour foreign chem-
icals into radiator, crank-case, or carburetor
when they do not function .smoothly. We strip
the thing and study each part to find out what is
wrong. We should look upon the human body
in the same way. It is not a question of what
drug may help or what operation does she need
now. The question is, what is the real trouble
and how did it occur. First : Is there an infec-
tion and if so of what nature and from what
source? Second: If no infection can be found
that will account for the symptoms, then does
the patient get enough food, or does he take too
much, or does he do something wrongly, too
much or too little. Has he a mechanical handi-
cap, curvature, ptosis, varicose veins, broken
arches, or badly fitted shoes ?
We hear a man who is eighty pounds over-
weight report that "doc" says he has a weak
heart and has given him a good heart tonic, or a
poor little undernourished woman with every
organ in her body crying out for food or support
who exclaims "the dear man says I am on the
verge of a nervous breakdown and that I must
go to Atlantic City and take my valerian and
iron regularly." 'The pathos robs the situation
of its humor.' L,. L.
ARSPHENAMIN
This preparation first came to the notice of
the profession through the name of "606" dis-
covered by Ehrlich-Hata and recommended in
the treatment of Syphilis, Yaws, Pernicious
Malaria, Pernicious Anemia and other proto-
zoan infections. Soon thereafter, the profession
were given the trade name for "606," namely,
Salvarsan.
This chemical was a yellowish powder which
rapidly oxidized, on exposure to the air and was
therefore put up in vacuum tubes. Ii
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426
THE PENNSYLVANIA MEDICAL JOURNAL
March. 1921
of the preparation for use it was found that the
acid sokition was very painful following injec-
tion and the substance was converted immedi-
ately before injection into an unstable sodium
salt by the addition of sodium hydroxide solu-
tion. The administration was first recom-
mended to be made deeply into the thick muscles
and subsequently used interveneously.
The second preparation to appear on the
market was known as Neosalvarsan, a much less
irritating salt and which became very popular
previous to the war.
During the war the German patents for the
product, under which salvarsan was first intro-
duced, were taken over by the United States
Government and, at the present time in this
country, it is necessary for a firm desiring to
manufacture arsphenamin to obtain a govern-
ment license before being permitted to sell their
product.
In view of the fact that during, and since the
war, many of the chemical compounds imder
trade names have been introduced and many
firms are now entering the field of manufacture,
the profession has a right to possess full in-
formation as to the reliability of all these prepa-
rations used in the treatment of syphilis.
One brand of arsphenamin is known as Arsa-
minol; another Arsenobenzol ; another Diar-
senol and the name of Salvarsan is still used as
well as Xeoarsphenamin.
Recently two other firms have entered the
market and are now manufacturing arsphenamin
using the firm name to designate their product.
The fact of the comparative toxicity of these
products and the possibility that, with the con-
tinued introduction of new preparations, there
may come a time when great danger will accom-
pany the administration of some of these prepa-
rations, especially if they are not pure, led to
this discussion.
There is at present a rather wide difference in
toxicity as noted by Shemberg and others in ex-
perimentation upon rats.
"By subcutaneous injection in mice, neo-
arsphenamin was found to be half as toxic as
arsphenamin, but when administered subcuta-
neously in rats, neoarsphenamin was found
twice as toxic as arsphenamin.
In so far as the intoxicity in arsphenamin and
neoarsphenamin may be determined by inta-
venous injection of solution in rats, the single
dose of arsphenamin commonly administered
(0.6 gni.) may be said to be about twelve times
less than the highest total dose, and the highest
sinjjle dose of neoarsphenamin commonly in-
jected (0.9 gm.) is about nineteen times less.
From the standpoint of margin of safety, larger
amounts of neoarsphenamin may be given and
maintain the same ratio by the dosis theraputica
and the dosis tolerata, as apparently exists with
arsphenamin.
Experimentations on the lower animals have
been reported by Jackson and Raap "showing
that first class preparations of arsphenamin have
almost no direct action on the bronchial mus-
cleature of the dog."
"Toxic doses tend to lower pulminary pres-
sure."
The following is a review published in the
Journal of the American Medical Association,
September 18, 1920:
"Report of the Colc^ne Arsphenamin Com-
mission"— Meirowsky states that "The commis-
sion appointed to investigate arsphenamin ac-
cidents finds that the dosage plays a decided part
in the occurrence of fatalities following its ad-
ministration. As regards neoarsphenamin, it
was found that if a dosage of 0.6 gm. was never
exceeded, the danger of a fatality was only
I in 168,800, whereas in the case of hospitals and
physicians that were in the habit of going be-
yond this does (0.6 gm.) the danger was fifty-
four times as great, namely : i in 13,000. Over-
dosage is one of the main causes also of cases of
encephalitis and dermatitis. In all cases of
dermatitis and in six out of ten cases of en-
cephalitis overdosage could be shown to have
been responsible. There seemed to be no special
sex incidence. Almo.st half of the deaths oc-
curred following either the second or third in-
jection. However, the commission confirmed
the frequently noted observation that a timid
administration of the remedy or courses of treat-
ment extending over too short a time favored
the reappearance of nerve symptoms."
We can well appreciate the danger of impure
products of a chemical such as arsphenamin. It
would be more dangerous and more toxic the
less accurate the formula and carefulness in
preparation.
Recently several other preparations have ap-
peared on the market : Silver Sodium Salvarsan,
also Copper-Arsphenamin, neither of which
have yet been as largely used as the former
preparations.
In view of the great number of the profession
who are treating .syphilis and also in view of the
increasing number of cases diagnosed needing
treatment, a very careful inspection of the prod-
uct to be used should be made by the profession
and only those of recognized standard and re-
liability should be accepted. ,
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March, 1921
EDITORIALS
427
DOCTORS DUTY IN COMPENSATION
CASES
Compensation laws have made the general
practitioner and family doctor occupy more fre-
quently than formerly what may be called the
medico-legal relation to society. Experience in
courts of law as witnesses in suits for damages
has not been obtained by many medical men.
These are therefore put in an unusual position
when their patients become applicants for com-
pensation, under Workmen's Compensation
Acts.
It would seem as if emphasis should be put on
two facts: ist, that an injudicious, careless or
inexperienced doctor may be the real cause of
prolongation in treatment, unnecessary absence
from work and the production of traumatic
neurosis; and 2d, that prompt settlement of
compensation awards and damage suits in court
IS often a great aid in curing symptoms from ac-
cidental injuries, associated with contentions or
litigation.
Cases requiring discriminating attention of
the family physician under the circumstances
lieing considered, may be divided into three
classes :
1. Cases in which there is obvious physical
lesion of a serious character such as fracture,
dislocation or wounds. Here the doctor's
medico-legal' responsibility centres to a great ex-
tent in the prognosis, for the diagnosis and
treatment are sufficiently clear.
2. Cases in which a physical lesion is obvious,
but is evidently of little importance. Here the
professional responsibility is largely concerned
with diagnosis, and the doctor must be on the
alert to detect, by carefiil and repeated exami-
nations, symptoms of obscure injury to the nerv-
ous system or other deep structures.
3. Cases of mental shock without obvious
physical lesion, in which there is a possibility of
the development at a later time of the so-called
functional disturbances, to which the term trau-
matic neurosis has been applied. Here his
prime responsibility is the prevention, by judi-
cious treatment, of the development of a nerv-
ous derangement. Many of the nervous wrecks
seen in the courts, demanding, and often receiv-
ing because of injuries from accidents, large
sums of money are the creation of injudicious,
thoughtless or dishonest doctors.
The laity should be taught by doctors, that
mental discipline or hygiene, is as essential to
proper living and happiness as physical hygiene.
Hygiene of the body creates a spirit of religious
toleration and calms and fits a man for the next
world as well as this. Hygiene of the mind
gives a healthy digestion and a good income and
fits a man for this world as well as the next.
Many physical and mental derelicts in our
homes, who indeed may be said to be "possessed
of a devil" have drifted into that condition be-
cause of an absence of proper mental poise and
nervous control in their earlier years. Such
hygienic development of mind, is as much a par-
ent's duty to his offspring as is the procuring of
food, fresh air and exercise. What might be
vailed psychic gymnastics is as essential to a
happy life as the use of muscles, hearing and
eyesight. Nervous children (so-called) are
usually begot of "nervous" households. To call
a child nervous to his face should be as grievous
an error as to term him an "ugly duckling."
It is the doctor's duty to teach the state's in-
habitants this fact, and not encourage hysteria,
.neurasthenia, and general "cantankerousness"
by foolish sympathy, unwise talk or ignorant
diagnoses of "railway spine." Many wrecked
lives and useless citizens are made by unwise
advice given by doctors, into whose hands per-
sons with slight injuries first fall for treatment.
Many damage suits could be avoided with jus-
tice to the injured and to the agents responsible
for the injury, if all doctors realized the impor-
tance of mental control. Many "railway spines"
and traumatic neuroses are caused by the doc-
tor's unscientific and unreasoning sympathy.
The doctor's duty includes instruction to his pa-
tients in mental hygiene, and the prevention of
unnecessary litigation. It is easy to develop a
neurasthenic crank out of a patient, who has re-
ceived an insignificant injury, and it is easy to
make a hysterical valetudinarian out of a useful
citizen by magnifying his dangers and feeding
his imagination with depressing possibilities. It
is the doctor's public duty to see that such sad
occurrences do not result from his maladroit-
ness. The professional duty of the family phy-
sician and the corporation's medical examiner
are the same. The object of both should be to
obtain as quickly as possible the return of the
alleged injured man to health and secure prompt
settlement of any pecuniary responsibility.
Truth and justice are to be sought by them
equally. Both physicians' sole motive should be
to investigate honestly, to be reasonable and
neither to lay undue stress on symptoms nor to
impertinently exhibit suspicion of the motive of
the patient nor of the medical man on the op-
posite side.
Immediate and careful examination, accurate
record of the patient's statements at the time of
injury and of the symptoms then apparent, the
avoidance of injurious suggestions and the
])rompt institution of scientific treatment are the '
428
THE PENNSYLVANIA MEDICAL JOURNAL
March, 1921
family doctor's primary duty. He should make
several examinations lest oversights or errors
occur. He should remember that disease may
have existed before the accident, that disease
may follow injury and not be caused by it, that
the patient may be mistaken and not dishonest
and that hysteria, neurasthenia, or psychasthenia
are common conditions, which may exist with
organic lesions, but also without any perceptible
damage to bodily organs. He should try to
value subjective symptoms and discriminate be-*
tween them and objective symptoms.
Firms and corporations liable to be held re-
sponsible for injury to employees or others
would save money by always employing experi-
enced and honorable doctors to examine acci-
dent patients early. The examination in every
instance should take place in association with
the medical attendant of the hurt person. This
would be of value, if both sides to the probable
suit were desirous of getting at the truth.
Contingent fees to doctors and lawyers often
have been the cause of much injustice to cor-
porations and to patients. It is difficult to re-
spect either a member of the bar or a member
of the medical profession, who bases his own
fee on a percentage of the award to an acciden-
tally injured person, whether the suit be settled
out of court or by a jury. The contingency of
the amount to be gained tends to blight the hon-
esty of judgment, and the truthfulness of action
of the lawyer, the doctor and the patient. Its
frequency has debased both professions.
J. B. R.
MEDICAL SOCIETY BUILDING
The primitive hope of man is to own and con-
trol some form of a building which he can call
home. The aboriginal Indian in his primitive
state carried his home about with him in the
form of a tepee which was his habitation, or
dwelling place, when and where, as he pleased.
The evolution of man has created a desire for
something permanent. The more thoroughly
organized is he, as a unit of society, the better
home is his desire. It is only those who have
the wanderlust that do not, at sometime or other,
crave a permanent fireside and abiding place
called home.
The inspiration for this article was found in
an editorial of the Rhode Island Medical Jour-
nal under date of February, iQ2i, which says:
"Few of the State Medical Societies are for-
tunate in the possession of buildings of their
own, dedicated to their meetings and for the
housing of their libraries, and none of these are
better equipped than the Rhode Island Medical
Society, considering its size, etc."
True the membership of the Rhode Island
State Medical Society is not large, only in pro-
portion to the size of its state. However, the
principle involved is as pertinent to Pennsyl-
vania as it is to any other State in that the per-
manency of the organization would be benefited
largely by having a central headquarters, or per-
manent home, for the organization.
We assume that this is a step, forward in the
scheme of Medical Society growth that may be
some time in maturing but it is, nevertheless, a
subject for serious discussion on the part of
the membership; whether it is better to pay
rent than to sufficiently endow the State Society
with funds with which to purchase a permanent
home for the organization.
There are many advantages to be put forward
as the reason why this plan should be con-
summated. A greater interest in the aflFairs of
the State Society must be inculcated in the mind
of the individual member of the organization in
that the work done by the officers of the State
Society may be appreciated. If each individual
member realizes that he is a part owner in what-
ever property is owned by the State Society,
and that this property is as much his to see that
it is used for the welfare of the entire organiza-
tion, then, and then only, will the State organi-
zation assume its proper prospective in the
minds of our members.
This is a subject which might properly be dis-
cussed not only in Executive Session in the
State organization, but in County Societies and
by the individual members.
"SOCRATES REDUX'
MEDICAL ETHICS
The last copy for the "make-up" of the next
number of the Journal having gone to press,
our correspondence being all answered, and our
desk cleaned up preparatory to the next piece of
work to be undertaken, we were relaxing, so to
speak, when our old friend came in and sat
down in the armchair that he always takes with-
out asking.
We knew that we were "in for something,"
but with the sense of satisfaction that comes
from work done, we felt our fighting blood
begin to course through our vessels with ac-
celerated speed and we waited to hear what was
in the old man's system. As it gradually oozed
out, we had no opportunity to get a word in
edgeways, and sat listening with interest i
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March, 1921
EDITORIALS
429
"Here is a part of a letter I received the other
•day : 'I would be interested to hear whether you
have had any experience with the "Holy Roller"
in Medicine — the self-satisfied, complacent phy-
sician who thinks it is not necessary for him to
be interested in his brother practitioners, so long
as he himself is at the top of the heap.'
"Now I have had a good deal of experience
with men of this type, and I could give you the
addresses of a good many of them. Before I
made my pile and stopped practicing they used
to annoy me a good deal, and now my young
friends come to me with accounts of them that
arouse my feelings and give me a good deal of
food for reflection. They constitute a peculiar
sect loosely bound together, not recognizing one
another, having no definite organization, but the
single fundamental principle, — an extreme devo-
tion to "Medical Ethics." Whenever you meet
a man whose long suit is medical ethics, you
want to look out, for you will in all probability
soon find that he belongs to the sect.
"Medical ethics is a good thing just like pur-
gatives are good things; just like religion is a
good thing; just like reformers are good things.
They all help to keep us clean — purge and purify
us. But anybody with worldly experience
knows that it is a bad thing to purge too much,
and has found out that the overzealous religion-
ist and reformer is a troublesome and sometimes
dangerous kind of fanatic, the basis of whose
seeming altruistic actions is too apt to be pride
or egotism, whose conduct is hypocritical, and
whose expressions are cant.
"The real hero doesn't know that he is a hero,
and sometimes can't be made to believe it; the
really religious man is so devoted to the service
of God and man that he has little time to talk
about religion ; the really good man forgets all
about being bad, and it never occurs to him that
he is good.
"Don't misunderstand me, I believe that the
Ten Commandments and the Golden Rule and
the Civil Code are good and necessary things
that people ought to learn, and I believe that the
profession ought to learn the Code of Ethics of
the American Medical Association, of which we
all approve and ought to practice. If we all did,
it would greatly simplify our relationships and
obligations. But the Holy Roller does not do
this ; he is intent upon making the other fellow
do it, and in his hands the Code of Ethics be-
comes a source of revenue to him and a source
of impoverishment to his associates.
"Let me give a concrete example — I am sure
that it can be duplicated in any city in the state
— without mentioning other than fictitious
names :
"Dr. Brown, of Pleasant, — I think you know
him— is one of the best educated young men in
the profession. I have followed his whole med-
ical education and it is one of the best. He is
getting himself established, but he has been
greatly retarded through the actions of a Holy
Roller in Worthing. Now Brown's father is a
farmer and raises turkeys, and Dr. White of
Worthing is a good friend of Brown's and
wanted two turkeys for his Christmas dinner,
so he wrote to Brown to order them sent to him.
As Brown was indebted to White, the father
had the fowls dressed and shipped, but sent a
card with 'Merry Christmas' on it instead of a
bill. In January Brown had a patient who
asked him to see Dr. White in consultation about
his case, and together they went to Worthing.
At the close of the consultation White asked for
the bill for the turkeys, and was told that they
were a Christmas present. He was pleased, and
said so, but added that business is business, and
that he was not willing to accept for a present
turkeys that he had ordered. Against the young
man's protestations he therefore sat down and
wrote a check for five dollars, and forced it upon
Brown.
"Now it happened that Brown, when leaving
the hospital in which he had been an interne
sometime before, in order to equip himself with
the necessary instruments with which to start
practice, had borrowed some money from Dr.
Black of the same city. Black was very willing
to lend him the money at six per cent., the re-
turn to be made on installments at Brown's con-
venience. Having some money in hand, Brown
went to Black's office to make a payment, taking
the patient, who, by the way, had early cx-
pohthalrnic goitre, with him.
"Leaving the patient in the waiting room,
Brown went in to see the doctor, had a chat with
him, and paid the money, including with it the
small check that he had just received from
White, thinking it better to owe the money to
his father at no interest than to continue to owe
it to Black at six per cent. Black asked a great
many questions, and in the course of the con-
versation found out that Brown had been to see
White with the patient, and that White had just
given him the check. Brown had some errands
to do, and as Black's office is quite close to the
railroad station, asked permission to let the pa-
tient sit in his office until train time when he
would return.
"Now Black is a great stickler for medical
ethics, and is a typical Holy Roller. As soon as
Brown had gone, he sat down and began to put
two and two together, until he had made out a
clear case of fee-splitting against Dr. White.
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430
THE TENNSYLVANIA MEDICAL JOURNAL
March, 1921
What better evidence covild he possibly have?
Here was young Brown with a patient, just
from White's office, and with a check on which
llie ink was hardly dry. It was a terrible case,
and there was no doubt but that White ought to
be run out of the County Medical Society and
Brown warned against such conduct. After a
while he went into the waiting room, and began
to talk to the patient, from whom he found out
what was the matter, and all that Dr. White had
said. In the course of the conversation he made
it plain to the patient that he was now very for-
tunate as in addition to the advice of Dr. White
for which he had come to town, he was also
gratuitously securing his own. Brown and
White had agreed that the case was one that did
not require operation, and in which rest, care
and careful diatetic treatment might effect a
cure. Black, who soon had the patient under
his influence, gave him to understand that the
only result of the treatment about to be insti-
tuted would be that he would be kept in bed for
a long time to no purpose and in the end would
require operation after all, but that he could at
once effect a cure by operation. To all this the
patient listened, and he and Black came to un-
derstand one another so well that when Brown
came back, and they started home together, he
told Brown that he had concluded to undergo
operation. Brown was not very averse to the
proposal, and said he would notify White, and
have a room in the hospital secured for him.
He was, as you may imagine, much surprised
when the patient told him that as Dr. Black was
the one who gave him this advice, he intended
to have him do the operation. The whole story
of the voluntary consultation then came out,
much to Brown's disgust, and he gave up the
case. The operation was done, and before a
year was out Black had not only operated upon
the goitre, but also had removed the appendix
of the patient's wife, and had taken to himself
the conduct of his father's case of diabetes, thus
actually taking the whole family from Brown.
In addition to this Brown received a very severe
letter warning him against the pernicious habit
of fee-splitting, and White had to defend him-
self against charges of fee-splitting, and has
pretty nearly lost his reputation because of the
persistent statements of Black that he does split
fees, as he has with his own eyes seen the check
given by White to a physician who had brought
him a case.
"Now you see, Black is a typical Holy Roller.
He is steeped in Medical Ethics. In every so-
ciety to which he belongs, he has himself ap-
]>ointed on whatever committees have to do with
ethics or discipline. Very slick? I should say
so. He never splits fees — it isn't necessary.
There are other ways if you only look for them.
He makes a lot of money, and not a little of it
comes out of Medical Ethics. Oh, yes, 'Medical
Ethics' are great. Black wouldn't for a minute
be without them."
R.\BIES VACCINE
A. M. Stimson, Washington, D. C. {Jounuil A. M.
A., Jan. 22, 1921), calls attention to the fact that rabies
vaccine, prepared by various procedures, is now availa-
ble throughout all portions of the United States to the
extent that it may fairly be said that no exposed person
ni-ed die of rabies for lack of injunctions. Many state
boards of health are prepared to furnish it free of cost
to the indigent, and the cost of the commercial prepa-
rations is not prohibitive except to the destitute, for
whom other provisions could probably be made in
almost every instance.
PERTUSSIS VACCINE
In summing up the prolific and somewhat contradic-
tory literature on this subject, W. C. Davison, Balti-
more (Journal A. M. A., Jan. 22, 1921), says it may be
concluded that injections of Bordet-Gengou bacillus
vaccines may have a slight though unreliable prophy-
lactic effect, and that therapeutic inoculations are of
practically no value. Further experiments are neces-
sary to raise this procedure from the limbo of non-
specific therapy.
NOTICE
Call for Volunteer Papers — Philadel-
phia Session
The Committee on Scientific \^'ork at its
first meeting at Harrisburg, February 2,
192 1, decided to call for a total of eleven
volunteer papers for the Philadelphia Ses-
sion of the State Society, October 3 to 6,
1921.
(i) The subject and a brief outline of
all papers must be furnished the committee
before May i, 1921.
(2) The time limit for the reading of
each paper is ten minutes.
(3) An author wishing stereopticon or
projectoscope for the illustration of his
paper must ask for same when submitting
title and outline of paper.
(4) Titles of papers are to be sent di-
rect to section officers or the Chairman on
Scientific Work.
(5) The Committee reserves the right
to decline any paper not deemed of suffi-
cient merit for the sessions.
Tno.M.\s G. SiMONTON, M.D.,
Chairman.
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The Medical Society of the State of Pennsylvania
OFFICERS' DEPARTMENT
WALTER F. DONALDSON, M.D.
Secretary
8014 Jenkins Arcade Bldg., Pittsburgh
MARCH 31ST
In a fortnight from the time that you receive
your March Journal your 1921 county medical
society dues should be paid and your per capita
of $5.00 forwarded by the secretary or treas-
urer of your county society to the office of the
Secretary of the State Society, otherwise you
may for a time be entitled to all the privileges
of the State Society, except that you shall not be
entitled to any benefit from the Medical De-
fense Fund from January i, 1921, to the date of
the receipt by the Secretary of the State So-
ciety of your name and assessment. Possibly
two years from now you may be sued for al-
leged malpractice occurring between January i
and March 31, 192 1. If your 1921 dues are not
paid until April, May or June, 1921, you will
not be entitled to medical defense under the
last-mentioned circumstances.
Inclusive of February 14, the 1921 dues of
two thousand forty-seven members had been re-
ceived. This is an advance of forty-five per
cent, over February 14, 1920.
But one component society at this writing is
one hundred per cent, paid for the current year.
On January 27 we received from Secretary
Bradford, of the Sullivan County Medical So-
ciety, payment in full of the per capita tax for
each and every member of his society.
Avoid being placed in the 1921 aHbi class
by paying to-day.
MID-YEAR MEETING OF THE BOARD OF
TRUSTEES
The Board of Trustees met in the office of
the Executive Secretary, 212 North Third
Street, Harrisburg, on the first Wednesday in
February. After the routine transactions,
Chairman Knowles, of the Committee on Pub-
lic Health Legislation, and of the Medical Leg-
islative Conference of the State of Pennsylva-
nia, gave a comprehensive report of the activities
of the Committee and Conference. His reports
indicated satisfactory financial condition and
most efficient plans for the protection of medical
service to the people of the Commonwealth. In
concluding Dr. Knowles emphasized the neces-
sity for personal pressure upon legislative rep-
resentatives by individual members of the State
Society when called upon by health legislative
committees to express their views on pending
health legislation. Efficient machinery is at
hand to promptly notify our 7,196 members
when and where their individual action is
sought. The next meeting of the Board of
Trustees is scheduled for Harrisburg, May 2,
1921.
PROGRESS
In compliance with the request of the Board
of Trustees, the Committee on Scientific Work
through a subcommittee is planning to hold sev-
eral all-day scientific sessions during July, Au-
gust and September, at central points of certain
districts more or less remote from the larger
cities of the State.
The State Society will pay the traveling ex-
penses of competent instructors, and it is the
hope of the committee that the morning and
afternoon didactic and clinical sessions, with a
social dinner hour between, will bring together
many members for the day's work and exchange
of views and experiences. The committee will
be delighted to hear from enterprising members
located in districts that are strategically situated
for reaching the physicians of rural communi-
ties.
Communicate your desire for such a meeting
in your county to Dr. William L. Estes, Jr.,
South Bethlehem, or Dr. Harry J. Cartin, 100
Main Street, Johnstown, or Dr. Walter F. Don-
aldson, Chairman, 8014 Jenkins Arcade, Pitts-
burgh.
NEW COMMITTEES
The 1920 House of Delegates authorized the
creation of "a committee of five to study the
needs of various localities in the State for hos-
pitals for diagnosis and treatment, and to rec-
ommend methods for the establishment and
management of such by groups of physicians in
this society." The following committeemen ap-
pointed by President Jump are actively at work :
Dr. Collin Foulkrod, Chairman, 4005 Chestnut
St., Philadelphia; Dr. H. L. Foss, Danville;
Dr. William J. Wilkinson, Sellersville; Dr.
Melville Locke, Belief onte ; Dr. A. C. Morgan,
2028 Chestnut St., Philadelphia. ^ • j
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432
THE PENNSYLVANIA MEDICAL JOURNAL
March, 1921
The problems confronting this committee
arise from (i) the necessity for better physi-
cians in every community; (2) the need of
stimulation to advances in diagnosis and treat-
ment among physicians who are without compe-
tition; (3) the crying need for a return to
thoroughness of diagnosis by the use of the
physician's own hands, brains and special senses,
and the substitution of rational therapy for the
present-day craze for semi-proprietaries and
pseudo-specific anti-serums; (4) the obvious
necessity for practical constructive answers to
the criticisms and suggestions of those who
would substitute Health Insurance or State
Medicine for private practice. Improved health
and longer life for the people of a nation are
dependent upon the service of members of the
medical profession and cannot be delegated to
the centralized administration of either federal
or state bureaus. The above-mentioned com-
mittee will make its report to the Board of
Trustees.
Other committees recently appointed at the
behest of the 1920 House of Delegates include
a committee to "take up with certain hospitals
that were taken over by the state for the specific
purpose of caring for injured industrial em-
ployees and that have since extended the scope
of their operations and now take care of all
classes of cases accepting free patients, or upon
payment of a small fee, patients abundantly able
to pay, thus wasting the taxpayers' money, fos-
tering a spirit of dependency, and directly com-
peting with private and semiprivate institutions,
depriving them of revenue largely depended on
to care for the latters' charity cases." The reso-
lution creating this committee also requested the
Medical Legislative Conference of Pennsylvania
to take the necessary steps to correct by legisla-
tive action the above-mentioned abuses. This
committee is composed as follows : Dr. Herbert
B. Gibby, Chairman, 96 S. Franklin St., Wilkes-
Barre; Dr. J. W. Bruner, Bloomsburg; Dr.
Walter F. Enfield, Bedford; Dr. J. Newton
Hunsberger, Norristown ; Dr. Lenus E. Carl,
Newport.
A committee was also appointed to "attend
the next meeting of the State Teachers' Asso-
ciation, to cooperate with the subcommittee on
Health Problems of the American Medical As-
sociation in providing better health conditions
in our Public Schools." This committee is com-
posed as follows: Dr. V. P. Chaapel, Chair-
man, 2017 W. Fourth St., Williamsport (New-
berry Station); Dr. Harry Spangler, Carlisle;
Dr. Calvin Rush, 342 Main St., Johnstown ; Dr.
W. H. Banks, Mifflintown; Dr. W. Horace
Means, Lebanon.
ADVERTISING
The Pennsylvania Medical Journal is
your property and mine, and the financial outlay
requisite to its publication each month comes di-
rectly from your pocket and mine in amounts
varying with the advertising income accruing
each number. If the actual cost of publishing,
printing and mailing the Journal to each mem-
ber is twenty-five cents per month, and the only
means of reducing this cost to each member is
by increasing the income from advertising in
the Journal, it is obvious that all members
should be interested in increasing the value of
our Journal to advertisers. We don't want
business concerns to sign advertising contracts
with us solely as a good will offering. We must
make advertising in the PE!^nsvlvania Med-
ical Journal so attractive to legitimate adver-
tisers that none such can afford to omit us from
their annual advertising budget. Your share
and mine of the advertising income from the
Journal this month is about five cents. It
should be at least fifteen cents, and if it were,
tlie entire amount (aggregating over $1,000.00
for the month) would be available for our Be-
nevolence, Endowment and Medical Defense
Funds.
The present income from advertising will be
doubled only after our members confine their
patronage to our advertisers, or begin to insist
that other dealers advertise with us. Try the
following plan for the year 1921 : Order as far
as possible from our advertisers, and at the same
time mention your knowledge of the fact that
they are contributors to the success of our Jour-
nal; or if occasion demands that you buy from
houses that do not advertise in our columns, let
them know that you are cognizant of the fact
and that you believe in reciprocity.
CH.^XGES IN MEMBERSHIP OF COUNTY
SOCIETIES
The following changes have been reported to Feb-
ruary 14th :
Allegheny : New Members — Omar Hugo Mehl,
114 W. Swissvale Ave., Edgewood Park; Ross D.
Brant, 1 1 N. Emily St., Craf ton ; William O. Marlcell,
41,^ Whitney Ave., Wilkinsburg; A. Elmer Mullen,
Cambridge Springs; Harold A. Kipp, Mercy Hospital;
James I. Plyler, 7217 Bennett St.; John H. Wagner,
I^Iiland Court, No. 7. Reinstated Members — Lester H.
Botkin, Second and Kennedy Sts., Duquesne; Edward
Graver, 5537 Fifth Ave., Pittsburgh.
Bf.aver : New Member — Lewis W. Glatzau, Midland.
Reinstated Member — Emmett S. Burns, Beaver Falls.
Berks : Transfer — William B. Jameson of Hamburg
from Franklin County.
Blair: New Member — Harry W. West, Jr., 1125
Eighth Ave., Altoona.
Bucks: Transfer — James W. Harper, 186 Prome-
nade St., Crafton. to Allegheny County.
Butler: AV«' Member— Wionso M. Padilla, Butl<4w
Digitized by V l^
March, 1921
OFFICERS' DEPARTMENT
433
Dauphin: Xew Member — C. M. Dailey, 1727 N.
Sixth St., Harrisburg. Reinstated Member — H. J.
Kirby, Harrisburg.
Delaware: New Members — Hersey E. Orndoflf,
<;ien Riddle;- Thomas O. McCutcheon, Upper Darby.
Erie : Sew Member— P. A. Trippe, 220 W. i6th St.,
Erie.
Lawrence: Reinstated Member— F. W. Guy, New
Castle.
Lehicr : Xew Members — W. W. Eshbach, 520
Union St. ; Warren J. Peters, 214 N. 13th St. ; T. W.
Cook, 815 S. 6th St.; Elmer H. Bausch, 252 N. 7th
St., Allentown; H. P. Mickley, Neffs; Harry L.
Baker, Catasauqua ; C. J. Newhaid, Hokendauqua.
Lack.\wanna: New Members — William Lynch,
Fairview (Wayne County) ; Joseph A. Carr, Oly-
pliant; A. E. Simpson, Peckville; John Loftus, Old
Forge ; Frank Ginley, Dunmore ; Vladimir A. Shlanta,
■Olyphant.
Mo.vtgomery : New Members— Kdythe A. Bacon,
State Hospital ; Francis T. Krusen, Boyer Arcade ;
Edward A. Krusen, Boyer Arcade, Norristown.
Transfer — Clifford H. Arnold, Ardmore, from Dela-
ware County; Thomas B. Christian, of Columbus
-Academy of Medicine, to Franklin County Society,
Ohio.
XoRTnAMPTON : New Member — Clair G. Harmon, 62
N. Third St., Faston. D^a<A— Bertrand McAvoy
(Med. Chirurg. Coll., Phila., '07) in South Bethleh'em,
Jan. 25, aged 36.
Washington: New Members — Stanley L. Scott,
Roscoe; H. Hugh Hill, 517 Fallowfield Ave., Charle-
roie. Reinstated Members — ^J. A. Gormley, Canons-
burg: A. J. B. Peaiice, Wilmerding; James H. Shan-
non, Washington.
Westmoreland: Death — ^Jacob T. Ambrose (Long
Island Med. Coll. '70) of Ligonier, Jan. 15, aged 84.
York : Snv Members — William J. Shenberger,
Windsor : Horace W. Kohler, Red Lion ; John S.
Ziegler, Hanover; Maurice C. Wentz, Weiser Bldg.,
"York.
Feb. 2
PAYMENT OF PER CAPITA ASSESSMENT
The following payment of per capita assessment has
been received since January 24th. Figures in the first
column indicate county society numbers; second col-
umn, state society numbers :
Jan. 24
25
27
28
29
31
Teb.
Mercer
26-32
1156-1157
$10.00
Beaver
15-29
1158-1172
75.00
Lackawanna
1-21
1173-1193
105.00
Montour
I-IO
1 194-1203
50.00
Dauphin
4-63
I 204-1 263
300.00
Luzerne
54-77
1264-1287
120.00
Mercer
33
1288
5.00
Montgomery
40-75
1289-1324
180.00
Allegheny
96, 144. 145,
186,:
232,253,358-
377,;
579-413
1325-1384
300.00
Mercer
34-35
1385-1386
10.00
Washington
28-60
1387-1419
165.00
Union
II
1420
5.00
Sullivan
1-8
1421-1428
40.00
Cumberland
17-18
1429-1430
10.00
Snyder
1-2
1431-1432
10.00
Franklin
14-16
1433-1435
1500
Mercer
36-37
1436-1437
10.00
Armstrong
17-25
1438-1446
4500
Montgomerv
76-91
1447-1462
80.00
Erie
27-45
1463-1481
95.00
Venango
3«-32
1482-1483
10.00
Mercer
38-40
1484-1486
1500
Somerset
16
1487
500
Clinton
3-6
1488-1411
20.00
Mifflin
17-18
i492-l4-'3
10.00
Northampton
33-55
1494-1516
115.00
Blair
9-28
1517-1536
100.00
Mercer 41-43
Armstrong 26-31
Daufthin 64-75
Northampton 56-70
Mercer 44
Center 1-15
Westmoreland 40-65
Delaware 1-62
Allegheny 418-426, 428-476
Washington 61
Northumberland 28-41
10
12
14
Erie
Bucks
Lackawanna
Mercer
Montour
MifRin
Venango
Berks
Luzerne
York
Armstrong
Snyder
Somerset
Butler
Clinton
Clearfield
Mercer
Union
Washington
Delaware
Armstrong
Wyoming
Lehigh
Dauphin
Snyder
Cumberland
Clarion
Lawrence
McKean
Lebanon
Delaware
McKean
Mercer
Adams
46-56
35-50
22-32
45
11-12
19-20
33-35
62-81
78-103
7-51
32-38
3-6
17
1-5
7-1 1
1-23
46-48
12
62-67
64-65
3^40
10
18-65
75-80
7-8
19
21-26
20
1-12
1-14
65
13-14
49-53
15-18
1537-1539
1540-1545
1546-1556
1557-1571
1572
1573-1587
1588-1613
1614-1675
1676-1733
1734
1735-1748
1749-1759
1760-1775
1776-1786
1787
1788-1789
I 790-1 791
1792-1794
1795-1814
1815-1840
1841-1885
1886-1892
1893-1896
1897
1898-1902
1903-1507
1908-1930
1931-1933
1934
1935-1940
1941-1942
1943-1944
1945
1946-1993
I994-1C99
2000-2001
2002
2003-2008
2009
2010-1921
2022-2035
2036
2037-2038
2039-2043
2044-2047
15.00
30.00
5500
75.00
500
75.00
130.00
310.00
290.00
5.00
70.00
55.00
80.00
55.00
500
10.00
10.00
15.00
100.00
.130.00
225.00
35.00
20.00
5.00
25.00
25.00
115.00
15.00
5.00
30.00
10.00
10.00
5.00
240.00
30.00
10.00
5.00
30.00
5.00
60.00
70.00
5.00
10.00
25.00
20.00
FREDERICK L. VAN SICKLE, M.D.
Executive Secretary
Harrisburg, Pa.
MEDICAL AND PUBLIC HEALTH LEGISLA-
TION
Under date of February 18, 1921, there was
submitted to the Committees on Public Policy
and Legislation of the Cqunty Societies, the first
issue of the Medical Legislative Conference Bul-
letin which reviewed the bills introduced in the
Legislature up to that time. This bulletin re-
viewed four bills :
Senate Bill No. 36— in relation to the State
Department of Health and rooms in hospitals
for the purpose of establishing clinics under the
direction of the Department of Health
House Bill No. 23 — creating a Board of Chi-
ropractic Examiners
House Bill No. 400— prohibiting advertise-
ments of cures, or medicines, relating to vene-
real diseases
House Bill No. 449— amending the drug con-
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434
THE PENNSYLVANIA MEDICAL JOURNAL
March, 1921
trol act of the state in regard to administering
narcotics to children
This bulletin is the first of several which will
be furnished to the members of the profession
by the Medical Legislative Conference for the
purpose of keeping the profession informed as
to bills that appear before the House and Senate
during the session.
On March 2, 1921, a hearing on the chiro-
practic bill was held by the Committee ou Pub-
lic Health and Sanitation of the House of
Representatives, when a thorough discussion of
the merits of this bill and reasons why this bill
should not be accepted, were presented to the
committee. These discussions are too extensive
to present at this time but a rather comprehen-
sive discussion of this same problem in the na-
ture of chiropractic bills has appeared in the
Journals of every state where the chiropractor
has asked for recognition.
The summary of the reasons why an individ-
ual board of control is unwise is based, by all,
upon the fact that the chiropractor teaching, up
to the present time, is not preceded by sufficient
preliminary education and training to furnish
them a standard which would be worthy of rec-
ognition.
"If it is necessary for a person who wants to
practice osteopathy or surgery or to treat the
eye, to pass an examination showing that he has
enough general and special education to diag-
nose the conditions he proposes to treat, it would
be absurd to allow chiropractors, who assume
the same responsibility, to set up their own
standards of education and to define the prac-
tice of medicine to suit themselves. I cannot
see how you expect the law to discriminate in
favor of the chiropractors, by allowing them to
pass upon their own qualifications, simply be-
cause they have some special scheme for treat-
ing diseases."
"The law is not designed to protect the pub-
lic against certain plans of treatment. It is
designed to protect the public against ignorance
of those things upon which any plan of treat-
ment must be based. If the law should give
every ^roup representing peculiar ideas as to
treatment a right to license themselves, then
there would be no sense in having any law at
all."
In view of the fact that at the present time
something more tangible seems to be needed in
the way of a better way out as to the examina-
tion and licensure of occupations of all who
must comply with the law, not only physicians.
pharmacists and dentists, but all others who arc
amenable to the state law, there is a need of
something more in the State of Pennsylvania
than that which exists at the present time.
In this discussion we find a very pertinent
statement by Henry L. Winter, M.D., of Corn-
wall, N. Y., which was published in the A^ew
York State Journal of Medicine in January,
1921. In closing the article on "Impending Pub-
lic Health Legislation," he says :
"I want to refer briefly to the Chiropractic
P>ill. I am only using that as a means to get in
a suggestion which I have to make. I took this
up with Mr. Whiteside briefly, asking him his
opinion. It is my opinion that if we amend the
Medical Practice Act so that no matter wliat a
man wants to practice, whether it is chiropractic
or any other thing, he can do so provided he
passes the same examination in other things as
we do. It will be a good thing for the profes-
sion. You know we eliminated the osteopaths
when we made the General Medical Examining
Board and put an osteopath on it, and it made it
necessary for the osteopaths to pass the same
examinations that we were compelled to pass,
and to have the same educati'onal requirements
for entrance to practice.
Now, then, if you make this a specific act
against the chiropractor it will probably make it
necessary — because bills cannot be retroactive,
notwithstanding the fact that the chiropractors
are illegally practicing — to license every chiro-
practor who now has his sign out ; but if you
put it through regardless of the chiropractor
and get it on the statute books before the chi-
ropractor is recognized as such, then you will
have a good Medical Practice Act, which will
protect us from practitioners of that character
for all time.
I think that this Society and the State Society
ought to make every effort to get behind a bill
of that character, and make it general — do not
make it against the chiropractor; and I do not
believe we would have very much trouble in
putting it through. Of course, the quacks would
all fight us, but still I believe it could be done."
We trust that Pennsylvania may be as suc-
cessful as some of our si.ster states in getting
nearer to the answer of this bi-annual row of
who shall, and who shall not, be recognized by
the state.
It is hoped that the medical profession will be
in sympathy with whatever advance can be made
in the light of improving conditions in regard
to education and licensure.
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County Medical Societies
REPORTERS OF COUNTY SOCIETIES:
Adams — Henry Stewart, M.D., Gettysburg.
AiiBOHlNY — Paul Titus, M.D., Pittsburgh.
Akustrong — ^Jay B. F. Wyant, M.D., Kittanning.
Beavb»— Fred B. Wilson, M.D., Beaver.
BEDroRO — N. A. Timmins, M.D., Bedford.
Berks — Clara Shetter-Keiser, M.D., Reading.
Blair — James S. Taylor, M.D., Altoona.
Bradford — C. L. Stevens, M.D., Athene
Bucks — Anthony P. Myers, M.D., Blooming Glen.
BuTUR — L. Leo Doane, M.D., Butler.
Cambria — Frank G. Scbarmann, H.D., Johnstown.
Carbon — Jacob A. Trexler, M.D., Lehighton.
Center — James h. Seibert, M.D., Bellefonte.
Chester — Henry Pleasants, Jr., M.D., West Chester.
Clarion — Sylvester J. Lackey, M.D., Clarion.
Clearfield — J. Hayes Woolridge, M.D., Clearfield.
Clinton — R. B. Watson, M.D., Lock Haven.
Columbia — Lutker B. Kline. M.D., Catawissa.
Crawford — Cornelius C. Laffer, M.D., Meadville.
Cumberland — Calvin R. Rickenbaugh, M.D., Carlisle.
Dauphin — Marion W. Emrich, M.D., Harrisburg.
Delaware — George B. Sickel, M.D., Chester.
Elk — Samuel G. Logan, M.D., Ridgway.
Erie— J. Burkett Howe, M.D., Erie.
Fayette — George H. Hess, M.D., Uniontown.
Franklin — John J. ColTman. M.D.. Scotland.
Greene — Thomas B. Hill, M.D., Waynesburg.
Huntingdon — John M. Beck, M.D., Alexandria.
Indiana — Alexander H. Stewart, M.D., Indiana.
Jefferson — John H. Murray, M.D., Punxsutawney.
Juniata — Isaac G. Headings, M.D., McAlisterville.
Lackawanna — Harry W. Albertson, M.D., Scranton.
Lancaster — Walter D. Blankensbip, M.D., Lancaster.
Lawrence — William A. Womcr, M.D., New Castle.
Lebanon — Saratiel P. Hcilman, M.D., Lebanon.
Lkhi(-11 — Martin S. Klcckner, M.D.. Allentown.
Luzerne — Peter P. Mayock, M.D., WilkesBarre.
LvcoMiNC — Wesley F. Kunkle. M.D.. Williamsport.
McKean — James Johnston, M.D.. Bradford.
Mercer — M. Edith MacBride, M.D., Sharon.
Mifflin — Frederick A. Rupp, M.D.. Lewistown.
Monroe — Charles S. Logan, M.D., Stroudsburg.
Montcomery — Benjamin F. Hubley, M.D., Norristown.
Montdub — Cameron Shiiltz. M.D., Danville.
Northampton — W. Gilbert Tillman, M.D., Easton.
Northumberland — Charles H. Swenk, M.D., Sunbury,
Perry — Maurice I. Stein, M.D., New Bloomfield.
Philadelphia — Samuel McClary, .3d, M.D., Philadelphia.
Potter — Robert B. Knight, M.D., Coiidersport.
Schuylkill — George O. O. Santec. M.D., Cressona.
Snyder — Percy E. WhifTen. M.D., McClure.
Somerset — H. Clav McKinley, M.D., Meyersdale.
Sullivan — Carl M. Bradford, M.D., Forksville.
Susquehanna — H.- D. Washburn, M.D., Susquehanna.
TioCA— Lloyd G. Cole. M.D., Blossburg.
Union — William E. Metzgar, M.D.. Allcnwood, R. D. 2.
Venango — John F. D.ivis. M.D., Oil City.
Warren— M. V. Ball. M.D., Warren.
Washington — Homer P. Prowitt, M.D., Washington.
Wayne — Sarah Allen Bang, M.D., South Canaan.
Westmoreland — Wilder J. Walker. M.D.. Grcensburg.
Wyoming — Herbert Iv. McKown, M.D., Tunkbannock.
York — .\athan C. Wallace, M.D., Dover.
March, 1921 '
COUNTY SOCIETY REPORTS
BERKS— JANUARY
At the January meeting of the Berks County Med-
ical Society, Dr. Arthur M. Shipley, Baltimore, Md.,
addressed the members on "The Contribution of War
Surgery to Civil Surgery."
In operations on the brain, the wound was washed
out with normal salt solution, and then sealed. No
drainages were supplied. If the washing out was
complete, the majority recovered without any motor
disability. The average time elapsing between occur-
rence of the wound and the patient's arrival at the
hospital, was sixteen hours.
Until recently, chest surgery has been a closed field,
but not since the war. Now they can be opened by
the resection of ribs, or between the ribs, as easily as
can the abdomen. Large chest wounds had a high
mortality. When air could be heard in a chest wound,
it was termed a sucking wound and the patient usually
appeared to be in extremis. If the opening was closed
by gauze, or if it was sealed by suturing the skin, the
patient would feel better in five minutes. In old
empyemas the exudate fixes and steadies the lung, so
when air enters through an opening it cannot push
the lung. In early empyema, there occurs a difference
in pressure which causes mediastinal flapping, distress
and danger. A catheter .should be inserted in the
nares, hooked to a dentist's pump, or to gas or oxygen
tank, the assistant should close the mouth and air can
be pushed through the nares into the lung. Thus the
lung can be delivered at the opening and can be oper-
ated upon.
There are two modes of operating: (-i) Incision
between ribs, (2) Resecting a rib. If the rib is re-
moved the wound must be sealed no matter how small
it is, but if the rib is retained it is much simpler. If
a space is left between pleura and chest wall you may
have hemorrhage into the thorax. Of 175 chest cases,
25 died imopened. Of those operated upon and su-
tured 60 per cent. died. Of those operated extensively
on chest wall and not having a sucking wound, 8 per
cent. died.
If patient is still bleeding from a large wound an
operation should be performed, but the lung should be
blown up first.
In knee joint wounds or other joints, gas gangrene
does not occur, due to the absence of muscles, as gas
gangrene involves only muscles. In operating on the
knee, make a radical incision, trim the edges with
scissors, remove the injured bone, also all diseased
tissue and clothing in contact. Incise the skin, aponeu-
rosis, ligament, bone and muscle. Wash with ether
and close without drainage. Close all but those that
are too large to close. We had good results in twenty-
six out of thirty cases. Have patient move leg two
or three times a day. Dakin's tubes can be inserted
into the synovial membranes but not into the joints.
PLASTIC SURGERY IN OPTHALMOLOGY
By George H. Cross, M.D.,
Chester, Pa.
Surgery is just as important a branch in the educa-
tion and life work of the opthalmologist as is the
correction of visual defects and the estimation of
refractive errors.
An illustration by lantern slides was given showing
various types of injury of the eyelids, nose and orbits,
received by our men in the late war, and their method
of correction.
These men were all assigned to the Army General
Hospital at Cape May where Dr. Cross was stationed
for eleven months who was assisted by Dr. William A.
Krieger, of Poughkeepsic, N. Y.
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THE PENNSYLVANIA MEDICAL JOURNAL
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A number of cases needed only the removal of bands
of tissue in the socket to permit the wearing of an
artificial eye; others with contracted sockets needed
Thiersch grafts, and still others required an Esser
inlay for the same purpose. In the absence of an eye-
lid it was necessary for us to form the eyelid, in its
entirety, from the surrounding tissue.
In some of the cases we were able to restore ao eye-
lid, by the use of a Thiersch graft, in which we used
the open method of dressing. For building up an eye-
lid the pedimculated flap was most successful, while
with the free graft or "Wolf graft" as it is known, we
did not have very much experience, nor did we have
the opportunity to use many Cartilage grafts.
In quite a number of cases we were delayed in
operating until the Oto-Laryngological staff was able
to complete their important" part of the work, as the
draining of the sinuses, principally the maxillary, the
removal of foci of infecion in the nasal cavities, in
these and many other ways did we have the most will-
ing cooperation.
At times we would be called upon to operate with
the brain surgeons, and at other times with the oral
plastic surgeons.
-An article by Esser of Holland, published in the
j4iinals of Surgery, March, 1917, was productive of the
greatest improvement in plastic surgery.
Major Gillies of the Queens Hospital, Sidecup, Eng-
land, modified this at the Outlay and was the origi-
nator of the tubed pedicle graft which permitted the
use of tissue remote from the injured area.
You will be wonderstruck by the remarkable results
as portrayed in Major Gillies new book on "Facial
Plastic Surgery." Of what use is this knowledge in
civil practice ?
No doubt many of you can recall to mind injuries
to the eyelids, nose and face, due either to firearms,
burns, explosives, railway and automobile accidents, or
injuries received in the large industrial plants, iron,
steel, etc.; or deformities following ulcers and epi-
theliomas, where the patient has been told nothing can
be done to improve his appearance. This handicap, in
many cases, necessitating a complete change of occu-
pation.
These cases will reap the benefit of this work. Do
not hurry to start plastic work, be sure to wait until all
shrinking and contracting of scars is over and the tis-
sues have recovered their vitality.
CwsA Shetter-Keiser, Reporter.
BLAIR— JANUARY
The annual meeting of the Blair County Medical So-
ciety was held January 25th, with thirty members, and
the Assemblymen, present.
The address by Dr. Jump (abstracted below) was
most thoroughly enjoyed by the members, and it
brought forth a discussion from our State Senator,
Mr. Snyder, and two of our legislative representatives,
Messrs. Bell and McCurdy.
Preceding Dr. Jump's talk officers for the year 1921
were elected. The secretary cast a unanimous ballot
for the following officers: President, A. S. O'Bum,
Altoona; first vice-president, A. S. Kech, Altoona;
second vice-president. D. F. Glasgow, Tyrone; secre-
tary and treasurer, C. F. McBumey, Altoona; cor-
responding secretary, James S. Taylor ; censors, J. E.
Smith, W. A. Nason, and S. L. McCarthy.
The meeting was fairly well attended, and was held
in Caum's Lincoln Room, and after the business ses-
sion a very palatable dinner was served. By the noise
and confusion at this time, I should say that the meet-
ing was a success.
ABSTRACT OF DR. JUMP'S TALK
"Medical Legislative Matters"
Dr. Jump opened his talk with a statement that the
medical profession in demanding some and fighting
certain other legislative measures, was doing it with no
selfish interest. He spoke about the physician's posi-
tion in his community, and among our duties to the
community he referred to our returning the sick to
their work, and our public health, and welfare inter-
ests; Dr. Jump brought out that by reason of these
services, medical opinion is respected and sought.
"Information should preceed legislation." In line
with this, our president asked us to interview our leg-
islators, informing them of the views of the medical
profession on subjects which are of vital interest to
the public.
Dr. Jump spoke of the Osteopathic privilege of med-
ical practice in this state, informing us of the bill
which this school will present to the State Legislature
this year. This school is struggling to obtain permis-
sion to use drugs. The president stated that he
thought all who practice the art of healing in Penn-
sylvania should demonstrate their qualifications by a
common examination. The public should be protected
against an ill-qualified man, lacking principally the re-
quired knowledge in making a correct diagnosis. In
this connection he referred to authentic cases in which
o.'teopaths were treating pneumonia, heart disease, and
even presuming to^cure cancer of the breast. Dr.
Jump plead for a square deal for all, admonishing our
legislators to treat the public correctly.
The next question considered was the Chiropractic
bill, which will permit the Chiropractor a certain
standing in the state. He brought to our attention the
fact that there are thirty separate cults throughout the
state, and that they each are after a separate board of
licensure. Dr. Jump clearly showed us what a mixup
these thirty boards could cause, whereas one Board of
Licensure has been so very satisfactory, and the ques-
tion of reciprocity further emphasizes the fact that
one separate board is the only practical way of grant-
ing medical licenses.
The next question Dr. Jump considered was that of
Antivaccination and Antivisection. The legislators
have already been thoroughly circularized regarding
this bill. If the bill is passed, all animal experimenta-
tion, all treatment by sera, all preventive treatment by
vaccination are completely eliminated. The people ad-
vocating these measures fail to appreciate the progress
of medicine by proper animal experimentation, such as
is carried out at the present time, in our research labo-
ratories. If this bill is passed, the progress of medi-
cine is at a standstill. Dr. Jump referred to the pres-
ent-day assertion in some localities, that vaccination
for smallpox is the same as horse syphilis.
The last question Dr. Jump considered was that of
Compulsory Health Insurance. He stated that the
profession as a unit is opposed to it, and not from a
selfish standpoint. He drew a comparison between
oir present practice of medicine and the "panel sys-
tem" of Great Britain. He brought out how the panel
doctors are overworked, and what poor medical atten-
tion the working man obtains by this system.
Dr. Jump further stated that the medical profession
is opposed to this bill, because, the righteous and the
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March, 1921
COUNTY MEDICAL SOCIETIES
437
unrighteous, the thrifty and the unthrifty, the moral
and the unmoral, are alt put on the same basis. We
are further opposed to it from economic reasons ; all
paying a flat rate for insurance, e.g. three per cent,
taxation as planned by the bill. We are further op-
posed to this measure because it is a product of So-
cialism and Communism. If the state should give free
medical attention and drugs as proposed in this bill,
why not then have the state supply coal, clothes, and
food, putting a proportionate tax on these articles.
James S. Tayloh, Reporter.
BUCKS— FEBRUARY
In spite of mucky weather and bad country roads,
the doctors were decidedly on the map in this county
on the 9th of February at Newtown. The program
was the president's choice and his friends made good.
Thirty-four rural doctors were there and for straight
three hours there was something worth while doing
every minute. President Lehman officiated and the
secretary was present.
Dr. J. Fred Wagner presented an exhaustive study
from practical experience on "Scarlet Fever." It was
a splendid lecture and elicited a very practical discus-
sion. Bucks County has considerable scarlet fever of
a mild type scattered about.
Dr. Harvey P. Feigley read a well prepared paper
on "The Medical Aspect of Exophthalmic Goitre."
Dr. William J. Wilkinson presented the surgical side
of the subject. The lively discussion on these timely
topics by home talent evidenced their value. The meet-
ing was full of good things and ended with a fine din-
ner where medical legislative affairs were discussed
with a "get there" spirit. This was the best medical
meeting ever held in this historical burg — William
Penn's "New Town."
Anthony F. Myers, Reporter.
CHESTER— JANUARY
The regular monthly meeting of the Chester County
Medical Society was held at the Chester County Hos-
pital on Tuesday, January i8th, with President W.
Wellington Woodward in the chair. As this was the
first meeting in the year the election of officers for
nineteen-twenty-one was held. Dr. Willis N. Smith, of
Phoenixville, was unanimously elected president, with
Dr. W. Wellington Woodward, of West Chester, and
Dr. Jackson Taylor, of Coatesville, respectively, first
and second vice-presidents. No other changes in the
officers of the society was made. Dr. Joseph Scatter-
good remaining secretary-treasurer.
Owing to the increase of duties of the secretary-
treasurer. Dr. Bremerman, of Downingtown, moved
that the salary of this officer be raised from twenty-
five to seventy-five dollars per year. This motion was
unanimously carried, with expressions of commenda-
tion from members of the society upon the excellent
work of Dr. Scattergood during the preceding years.
The retiring president then addressed the society,
thanking the members for the honor of having been
chosen their president, and expressing his apprecia-
tion of the hearty cooperation with him during his
term of office. He commended the efforts of the Pro-
gram Committee, and expressed himself as enthusiastic
over the tendency to have the programs of the meet-
ings include papers prepared by the members them-
selves, instead of relying upon invited speakers from
Philadelphia and elsewhere. He urged upon the so-
ciety a greater effort to increase the attendance at the
meetings, and enlarge the membership. In conclusion
he introduced the incoming president, Dr. Willis N.
Smith, who thanked the society for the honor of being
their president, and assured the members of his inten-
tion to make the ensuing year a memorable one in the
history of the society.
Dr. Charles P. Noble, of Philadelphia, was then in-
troduced as the speaker of the meeting. After a brief
expression of his pleasure at being with the members
of the Chester County Medical Society once more. Dr.
Noble gave a most comprehensive and interesting talk
on Visceroptosis, giving the pathology of the condition,
the historical data in reference to our knowledge of it,
and the various symptoms and complications met with
in general practice. Dr. Noble considers that much
can be done to relieve the distress of the condition if
the cases are studied thoroughly and are placed upon a
very carefully worked out regimen. The importance
of endeavoring to train disused and atrophied muscles
was emphasized. He claimed that many of these pa-
tients are suffering because they have never been
brought to realize that they are absolutely unable to do
the same things that normal individuals can do. They
go through life continually overtaxing themselves, and
suffering later from the effects of this overstrain.
After a vote of thanks to Dr. Noble for his interest-
ing paper, the meeting was adjourned.
Henry Pleasants, Jr., Reporter.
ELK— FEBRUARY
The regular meeting was held February loth, with
all the old guard on hand. Officers for the ensuing
year were elected as follows : President, Jas. G. Flynn ;
vice-president, James E. Rutherford ; treasurer, M.
M. Rankin ; secretary, Andrew L. Benson.
One of the consultations with the State Department
of Health was held. The idea in general was ap-
proved. Aside from that, routine matters were dis-
posed of.
Dr. M. M. Rankin is spending several weeks in the
South.
Dr. W. C. Shaw is in Philadelphia doing some post-
graduate work in surgery.
Dr. A. C. Luhr is in New York doing some post-
graduate work.
Dr. E. J. Russ, of St. Mary's, is apparently recov-
ering from his recent indisposition.
The Ridgway Medical Society met February 15th,
with all the physicians in town present. The reporter
read abstracts from Dr. Billings and Dr. Leonard on
The Future of Private Practice, and Group Practice.
(A. M. A.) The local society expects to meet twice a
month. At the next meeting Dr. Leary will explain
what he is prepared to do in the laboratory end, and
what he would like to be prepared to do.
Samuel G. Logan, Reporter.
FRANKLIN— JANUARY
The Medical Society of Franklin County held its
regular meeting in the Flemming Building, Greencas-
tle, January 18, 1921. At 6 : 00 p. m. we gathered
around the tables and had dinner, after which the
usual program was carried out. Our officers for the
ensuing year were elected. Following, Dr. J. P. Ma-
clay, the retiring president, read an exceptionally in-
teresting paper on "The Early Days of Medicine in
Chambersburg." Dr. John Gilland, of^ Greencastlei
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THE PENNSYLVANIA MEDICAL JOURNAL
March, 1921
told us of the early days of Greencastle. Those who
were not present I am sure missed a very enjoyable
and instructive evening. After the meeting we spent
a sociable hour and adjourned.
S. D. Shuix, Reporter.
pressed. Many patients think they are persecuted and
fear being poisoned or injured by those about them.
Here followed the presentation of some 20 cases
which illustrated, in a most interesting and instructive
manner, the various forms, phases and stages of this
disease. J- H. Sandel, Reporter.
MONTOUR— FEBRUARY
The regular monthly meeting of the society was held
at the State Hospital for the Insane, Danville, Feb-
ruary i8th. and was called to order by the president.
Dr. R. A. Keilty, at 2: 30 p. ni. There were nine mem-
bers and thirteen visitors present. Owing to the al-
most impassable condition of the roads, the number of
visitors was doubtless much reduced.
The scientific program was provided by the staff of
the State Hospital, and they gave a most interesting
and helpful presentation of the subject of Dementia
Praeco.x, its Etiology and Differential Diagnosis, with
case presentation.
Dr. J. .Allen Jackson, in opening the program, stated
what he regarded the function of a hospital for the
insane to be : (a) To disseminate through its staff,
knowledge regarding insanity and the care of such
cases; (b) to confine and treat cases which could best
be treated in this way; (c) to see that patients are
properly cared for after leaving the hospital.
Dr. H. V. Pike followed with an able and well-
prepared paper on the Etiology of Dementia Praecox.
He stated that this affection has been termed the
psychosis of the period of puberty and adolescence,
and that most of the cases begin between the ages of
fourteen and twenty-eight years; that it is an affection
which tends to progress, and constitutes 15 to 20 per
cent, of all cases of insanity. That its pathology is not
clear, yet it is known there are destructive changes
involving usually the cortical cells. Heredity and en-
vironment were stated to be important etiological fac-
tors, while infections, syphilis, alcohol, drugs, etc.,
especially in the parents, play an important part. Un-
due excitement, such as the shock and stress of the
late war, pregnancy, and the establishment of the
function of the testicles and ovaries, bear an intimate
relation to the disease.
Dr. George B. M. Free followed, giving a clear and
concise statement of the differential diagnosis of
Dementia Prsecox. He outlined four forms, the sim-
ple, hebephrenic, catatonic and the paranoid.
The simple, or hobo type, comes on insiduously; the
patients show lack of interest in their person or sur-
roundings ; are dull, tired, decline to work, dislike
water, resist the bath ; men let full beards grow and
go about with long hair; they want to imitate im-
portant personages.
The hebephrenic cases have headaches and are de-
pressed ; they have hallucinations ; again they may
show a loose train of thought, are silly and ramble
away in a senseless fashion.
In the catatonic form there is an alternation of ex-
citement and depression ; there is stereopypies, man-
nerisms ; the patients use the same phrases over and
over, has disordered wills, resist any attention given
them, and often are filthy to a degree. Some will re-
main for quite a time in any attitude in which they are
placed. These two forms tend to drift from one to
the other.
The paranoid form usually comes on later in life
and the symptoms are strong delusions and hallucina-
tions, sometimes grandiose, again dejected and de-
NORTHAMPTON— JANUARY
The annual meeting of the Medical Society of
Northampton County was held at Seip's Cafe, Easton,
on Friday, January 21st, with an attendance in excess
of sixty.
The society went on record as being willing to ac-
cept ten dollars as a minimum fee for all cases of
venereal diseases referred by the State G. U. Dis-
pensary.
The address of the retiring president dealt with
many timely subjects among them the importance of
Compulsory Health Insurance.
The following officers were elected for the year
1021 : President, M. W. Phillips, Chapman Quarries;
first vice-president, E. D. Schnabel, Bethlehem; sec-
ond vice-president, Paul Correll, Easton; secretary-
treasurer, Paul Walters, Bethlehem; Corresponding
secretary, G. L. de Schweinitz, Bethlehem ; reporter,
W. Gilbert Tillman, Easton; censors, W. P. Walker,
Bethlehem ; J. C. Keller, Wind Gap, and C. E. Royce,
P.ethlehem ; committee on public policy and legislation,
W. P. O. Thomason, Easton; T. C. Zulick, Easton,
and W. L. Estes. Sr., Bethlehem.
Luncheon at the expense of (he society followed the
meeting.
The next meeting will be held at Bethlehem on the
third Friday of February.
W. Gilbert Tillman, Reporter.
NORTHAMPTON— FEBRUARY
The Medical Society of Northampton County met in
monthly session at the Hotel Wyandotte, Bethlehem,
Pa., on Friday, February i8th, with a large representa-
tion of the profession present.
After the transaction of routine business, which in-
cluded the acceptance of the resignation of Dr. A. O.
Kisner, of Bethlehem, the meeting was turned over to
Dr. John Cook Hirst, of Philadelphia, who gave an
interesting and instructive talk on "The Palliative Of-
fice and Operative Treatment of Prolapse of the
Uterus," illustrating his talk with lantern slides. The
talk as presented by Dr. Hirst proved to be very in-
teresting and the ground was so thoroughly covered
that no room was left for doubt. The society ten-
dered a hearty vote of thanks.
Dinner was served in the dining room of the hotel
after the meeting.
The next meeting will be held on the third Friday
of March at a place to be chosen by the program com-
mittee. W. Gilbert Tillman, Reporter.
PHILADELPHIA— JANUARY
The president, Dr. Herman B. Allyn, in the Chair.
Symposium on Occultism Particularly with Refer-
ence to Spiritualism, Freudism and other Phases of
Mysticism.
Occultism with Reference to Some Phases of Spirit-
ualism and Freudism. Dr. Charles K. Mills, of Phila-
delphia, presented this paper in which he first made
some general remarks defining "occultism" and re-
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March, 1921
COUNTY MEDICAL SOCIETIES
439
ferring to some of its cults or schools, like Vedanta ■
and Theosophy. He made some remarks about
Madame Blavatsky. He next discussed some of the
alleged reasons for the revival of occultism, holding
that, while the sacrifice of life and the distress brought
upon families during the recent war might be regarded
as important exciting causes, the whole matter could
not be explained in that manner. Back of it was the
tendency of the world to be largely controlled by in-
stinct and emotion which had an immeasurable part.
Dr. Mills gave his explanation, which he said might be
only partial, of the reasons that not a few men of high
accomplishment in science and scholarship had given
their adhesion to modern spiritism, referring to Robert
Hare, Sir William Crookes, Sir Oliver Lodge, Alfred
Russell Wallace, Flammarion and others. He said
that these men, in spite of their success in materialistic
lines of research and writing, were, after all, gov-
erned largely by their inherited temperaments in which
instinct and emotion played an important part. He
placed in the same list with Sir Oliver Lodge, and
others referred to, various men distinguished in medi-
cine, law and biology who at the same time clung
tenaciously to the tenets of some of the more primitive
of the religious sects. Here the emotional tempera-
ments held sway equally with or above the dominion
of reasoning.
The subjects of ghosts or apparitions, and of medi-
ums and mediumistic communications were next con-
sidered. He expounded the view that stories o!
ghostly visitations, when these were not accounts ot
crude frauds or literary efforts, were best explained
on the theory of hallucination. He held that most
mediumistic exhibitions were fraudulent and gave ac-
counts of some personal experiences with attempts at
fable tipping. Sir Oliver Lodge's "Raymond" received
brief attention, the speaker pointing out the credulity
of the author of the book and the evident mistakes
made by him in ranking many mediumistic communi-
cations as evidential.
In concluding his paper Dr. Mills discussed some
phases of Freudism which he classed as a species of
phallic-mysticism. After defining Freudism, he dwelt
briefly upon what he regarded as unsuccessful attempts
to apply some of its principles to both organic and
functional nervous diseases. He did not attempt to
traverse the whole subject of psycho-analysis, his paper
simply being intended mostly as an introduction to the
symposium of the evening, leaving amplification and
elaboration of the topic to Drs. Dunlap, Burr and
others, who were to follow him. He dwelt especially
upon so-called transference neurosis and indicated
some of the dangers which he believed threatened the
community from the active pursuit and propaganda of
Freudism.
The Unconscious in Spirit Communications and
Symbolism. — Dr. Knight Dunlap, of Baltimore, read
this paper in which he said that the conviction, appar-
ently shared by many spiritualistic mediums, that their
communications camei from outside themselves was
based upon the common fact that in any fluent compo-
sition the verbal expressions tended to arrange them-
selves, that the formulated thought first appeared in
. the form of spoken or written discourse. This phe-
nomenon might be observed by anyone who could
compose fluently. The explanation that the formulat-
ing was done by the "unconscious mind" was mislead-
ing, since it was merely a reformulation of the
problem: What was the mechanism by which this
formulation was made? The true explanation was to
be found in the analysis of thought as essentially a re-
action process which, in these cases, was specifically
a process of vocal reaction. The operation of the mech-
anism was then understandable in terms of the ordi-
nary principles of habit formation by which reaction
tendencies were formed and modified by preceding re-
actions based on hereditary predispositions existing
within the nervous system. Experimental work on
symbol recognition now in progress tended to indicate
that this also might be explained completely by ordi-
nary principles of habit formation, not requiring any
assumption of an "unconscious mind" other than the
central nervous system. Training in symbolization
was received by most persons through religious or
literary channels as well as by practical experience.
Associations which had been formed in the past per-
sisted as associations, without necessitating the per-
sistence of any form of memory of the detailed
experiences which formed the association, just as the
ability to sign one's name persisted as a definite set of
reaction tendencies without involving a retention of
the detailed processes through which the child had
gone in learning to write. The "unconscious mind"
was a mystical concept quite comparable to the concept
of divine agency in the production of thunder storms
and tended to obstruct a scientific analysis of the ques-
tion : How were the phenomena produced ?
Dr. Charles W. Burr, of Philadelphia, said that
Freud claimed that there was both a conscious and an
' unconscious mind. That one of the great functions of
the unconscious mind was to keep out of our con-
sciousness the things we wish, our real desires and •
wishes which were principally, usually and most
strongly sexual. This was done by a thing called a
censor during waking life which kept out of conscious-
ness the things that we consciously wished to keep out
of consciousness, namely, our real desires. During
sleep the censor ceased to act and the unconscious
mind revealed itself in our dreams. A man then was
what he really was, not in his waking hours, but dur-
ing sleep. The dream was the unfulfilled wish, but
when one dreamed he did not frankly and openly
dream what he wished ; he did it symbolically. Every
dream had a manifest content which was the dream as
he knew it and the latent content, which was the real
dream, and which could be found out only by the
methods of symbolism a la Freud. Freud's book on
Dream Psychology was sold in every department book
shop in this country; it was bought by a tremendous
number of adolescents seeking either for truth or un-
healthy emotional excitement. This was doing them
no good and it was not science.
He wished to speak of something of much greater
importance, namely, so-called communication with the
dead. It was no new thing at all but was as old as the
time when everybody was an atavistic worshipper and
thought trees had souls. But now as time went on it
seemed to him that mankind was pretty well split off
into two great branches, the mystic and the rational.
The mystic who hungered for a god and hungered for
immortality. He had feelings and believed what he
craved. On the other side was the rationalist who was
content with things as they were. The best subject for
hypnotism was not the man of science whose mind was
trained to believe what his experiments seemed to
show. Because a man was great in one way did not
indicate that his opinion about other things was better
than that of any of the rest of us. No one was so
easily deceived as the man of science. , In jregard_
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THE PENNSYLVANIA MEDICAL JOURNAL
March. 1921
communication with the dead we believe what we de-
sire to believe.
Dr. J. Hendrie Lloyd, of Philadelphia, said that the
subject lent itself to the ridiculous, but Iqnt itself still
more completely to misunderstanding. It was the half
educated poor in this country who believed in spirit-
ualism, mysticism, occultism and every confounded
ism going on nowadays. It was the fault of our de-
fective public educational system, so much lauded to
the skies, which did not teach our children how to
think, which left them the prey of any crank, half-
baked religion, mysticism or whatever you chose to
call it. Now he had a theory that all of us were more
or less superstitious. He personally did not believe
in the superstition that if thirteen sat down to a table
one would die within a year, but the idea brought up
unpleasant associations and, therefore, he did not like
to sit down with thirteen at a table.
JANUARY 26, 1921
The President, Dr. George Morris Piersol, in the
Chair.
Auricular Fibrillation, the Most -Common and Im-
portant of Cardiac Arrh>'thmiae, by Dr. Ross V. Pat-
terson, of Philadelphia. This paper will be published
complete in the April number of the Pennsylvania
^f RniCAL Journal.
Dr. E. B. Krumbhaar, of Philadelphia, said that in
spite of the commonness and importance of auricular
fibrillation we knew little of its actual causation.
Though easily recognizable and known to be found in
several well defined clinical conditions, its actual
■ pathogenesis was still unknown. Similarly its finer
pathology was still obscure and he thought there was
an important field for more intensive study of the sub-
ject. As to prognosis he thought it was correct that
the auricular fibrillation of cardiosclerosis was a
graver condition and less responsive to digitalis than
was the fibrillation of rheumatic cardiac disease. Sta-
tistics of the duration of life of fibrillators usually
limited them to two or three years, but, of course, it
was well known that individual cases might live much
longer. For instance, in his own family one individual
was pursuing a comfortable existence with a fibrilla-
tion of more than twelve years duration and his
brother had had a fibrillating heart for probably more
than twenty-five years. The heart that was not en-
larged and beat slowly would probably last longer than
the quick heart with frequent rate.
As to digitalis, the assay of the leaves used should
be known. It was generally accepted that digitalis
helped the ventricle, not only by blocking some of the
forms of auricular impulses, but also by depressing
the irritality of the ventricular musculature. It had
been observed that transient attacks of even the graver
forms of arrhythmia were by no means uncommon;
in fact, transient fibrillation could be divided thus:
I. The single transient attack, occurring in the course
of an acute infection or intoxication ; 2. The parox-
ysmal type, often occurring at frequent intervals and
clinically bearing some resemblance to attacks of flut-
ter and paroxysmal attacks of tachycardia.
A General Description of Cardiac Arrhythmias. —
Dr. Louis Faugeres Bishop, of New York City, read
this paper in which he said that modern cardiology
dated back only fifteen years and that it was only
about ten years since the profession had become con-
scious of its existence. The details of it were quite
intricate and baffling, but of vital importance to the
intelligent care of those suffering from heart trouble.
Many physicians had not taken up the subject at all
but had passed it over as a laboratory matter. This
was very unfortunate as there was nothing more vital
in the problem of the prolongation of life. He said
that there were seven varieties of irr^ular heart and
a friend of his had suggested taking, as a way of re-
membering, the word ships leaving out the I and
putting three A'a after it thus having the letters
SHPSAAA. S stood for sinus arrhythmia; H, for
heart block; P, for premature contraction; S, for
simple paroxysmal tachycardia ; A, for auricular flut-
ter; A, for auricular fibrillation; A, for alternation
in pulse.
In sinus arrhythmia we. found the beats of the heart
all right in themselves but the intervals between them
were unequal, the spacing between the beats becoming
gradually broader, then gradually shorter. In heart
block we found either a lengthened distance between
the auricle and ventricle or no regular interval ^t all.
The former meant that the impulse of the heart was
delayed between the auricle and the ventricle; the
other that the auricle and ventricle were beating inde-
pendently of each other. In premature contractions
the ventricle contracted prematurely independently of
the rest of the heart In simple paroxysmal tachy-
cardia the beats were very numerous and crowded to-
gether. In auricular flutter the auricle was beating
very rapidly and producing small waves at regular in-
tervals, but the ventricle was responding to only a
certain proportion of the auricular beat. Often the
rate of the auricle was 300 and that of the ventricle
150. In auricular fibrillation the auricle was paralyzed
but trembling and, instead of one definite wave, we
had a lot of irregular small waves that could not be
counted. The result was to irritate the ventricle and
make it very rapid and irregular. Alternation of the
pulse was a condition in which the heart was failing
and every alternate beat was reduced in size.
Dr. George W. Norris, of Philadelphia, said he
thought that of the advantages of working with the
graphic methods, the most useful was that they taught
us to observe carefully. As a result of this most were
agreed that ninety per cent, of all the cardiac condi-
tions met with could be practically diagnosed without
graphic means. That left ten per cent, in which the
most expert would be left in doubt as to the exact
condition. These had to be deciphered principally by
the electrocardiograph. Auricular fibrillation was
probably the commonest serious arrhythmia. Next in
order came premature contractions. This subject was
very complex, but a good knowledge of it could be
picked up by concentrated work.
Cardiac Arrhythmias. — Dr. Joseph Sailer, of Phila-
delphia, read this paper, in which he said that he had
decided to give a brief clinical description of certain
cases which showed various forms of cardiac disturb-
ance.
G. C, 56 years of age, suffered with dyspnea and
dizziness. The heart was enlarged. There was slight
reduplication of the first sound at the apex and slight
roughness of the first sound at the base, a moderate
degree of renal insufficiency, and marked inequality of
the blood pressure in the two arms without any evi-
dence of aneurysm. The condition had slowly grown ■
worse because the patient had persisted in continuing
his work. Two electrocardiograms showed extreme
left preponderance and arrhythmia, and numerous
ventricular contractions.
J. H. M., 70 years of age, when first seen eight years
ago had an extremely irregular heart coupled with
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STATE NEWS ITEMS
441
great slowness. The heart and liver had been greatly
enlarged and there had been periods of cardiac decom-
pensation associated with dyspnea, cyanosis, edema
and hydrothorax. The electrocardiogram had shown
a typical slow flutter with very large auricular waves ;
the auricular beats had been fairly rhythmical, run-
ning over two hundred per minute. There had been
all the evidences of mitral disease and towards the
end of the patient's life there had been vigorous pulsa-
tion of the liver. This patient had been given digitalis
from time to time, usually with almost disastrous ef-
fect. As far as treatment was concerned, there had
been numerous occasions of marked decompensation,
always relieved by numerous baths and caffeine. The
latter had seemed to be almost specific.
H. F., 27 years of age, suffered from what she called
nervousness with violent palpitation and pain in the
cardiac region and dyspnea, occurring about three
times a day and lasting about five minutes. The pulse
was 144, the heart action fairly regular and there was
evidence of mitral stenosis. The first lead of the elec-
trocardiogram showed only tachycardia. While the
second lead was being taken the patient had some vio-
lent trembling but this subsided and the latter part of
this lead was normal. During the third lead only the
violent muscular tremors were manifest. Occasional
picmature contractions were present.
I. D. had sharp pains in the left chest, under the
scapula ; there was marked dyspnea and sense of pres-
sure upon the chest. The remarkable feature of this
tracing was the deep notching of the rising branch of
wave R in the third lead and there was evidence of
moderate right preponderance.
J. M. W. had a tachycardia and evidence of hyper-
thyroidism. She was extremely emaciated and had
suffered various nervous shocks. She was a case of
temporary auricular flutter. During the intervals there
was a tachycardia with perfectly normal complexes;
then occurred the flutter which was usually a two to
one rhythm.
W. S., 29 years of age, felt well, was athletic, had a
diastolic murmur and Corrigan pulse, also a right pre-
ponderance.' The heart was entirely rhvthmical. The
reason for the right preponderance in this case, which
would lead one to suspect a Flint murmur in spite of
the Corrigan pulse, was not clear.
Dr. James Talley, of Philadelphia, said that in re-
spect to auricular flutter he had one patient who had
had it for more than seven years. He also had at the
hospital a carpenter who had been fibrillating for eight
years. As long as the man had a pulse that was not
too rapid, and there were no premature beats showing
that his ventricle was not involved and his lungs were
clear he might get along for a long time.
Dr. E. B. Krumbhaar, of Philadelphia, said that it
should be emphasized that if digitalis was used in
auricular flutter in the attempt to transform this to
fibrillation and thence to normal rhythm, and if this
attempt failed, the digitalis should probably not be con-
tinued unless it quickly showed an ability to reduce the
ventricular rate. The U wave mentioned by Dr.
Sailer in one of his cases probably was due to an im-
pulse from the vena cava. He based this opinion on
some animal experience, in which, with both auricle
and ventricle at rest, a small contraction was observed
in the superior vena cava and recorded as a monophasic
wave by the galvanometer. The case with the disap-
pearing P wave might possibly be explained as due to
naroxysms of auricular fibrillation, such as he had
previously mentioned, and these would not be ruled
out even if the ventricular action at these times were
regular, if one further assumed that complete block
was also present. John J. Repp, Reporter.
SOMERSET— JANUARY
.\t the January meeting of the Somerset County
Medical Society it was decided to send the chairman
of the Public Health Committee to Harrisburg to go
before the House and Senate Committees when the
proposed medical legislation conies before them, pro-
viding he is notified of the time the legislative com-
mittees meet to consider such legislation.
The meeting was largely taken up with business and
discussion of the most effective way in which we might
assist in the proposed legislation beside the interview-
ing of Representatives and the Senator from this
county, all of whom have promised favorable action
when the opportunity arrives.
H. C. McKiNLEY, Secretary.
STATE NEWS ITEMS
DEATHS
We regret to announce the death of Hugh P. Mc-
.Aniff, M.D., of Philadelphia, on January 29, 1921..
Dr. M.\lcolm S. Woodbury, aged aboiit 45, chief
physician and superintendent of the Clifton Springs
Siinitarium. who was widely known throughout the
\\ yoming Valley, died Friday night, January 7th, of
pneumonia.
Dr. Walter S. Patterson, of Butler, died of pneu-
monia, Tuesday evening, January 18th, aged 42. Dr.
Patterson was formerly a member of the Butler Coun-
ty Medical Society. He was a graduate of Jefferson "
Medical College, 1901.
Dr. J. C. BiDDLE, a well-known physician and sur-
geon, is rounding out his thirty-eighth year as super-
intendent of the State Hospital at Fountain Springs,
the oldest miners' hospital in the country, and is as
active as ever at the age of (f] years.
Dir.ABiED MANY YEARS AOo in a runaway accident,
Dr. Tobias S. Gerhart, 85, of Reading, Pa., a graduate
of the University of Pennsylvania Medical School in
1864, died Feb. 21, 1921. at his home at Anglica, near
here, fifteen days after the death of his wife. He was
a native of Telford, Montgomery County.
Dr. Peter Swank, formerly of SaHsbury, but tem-
porarily practicing in Luthersburg, Clinton County,
was communicated with by some of the residents of
Salisbury and requested to return, which he did yes-
terday, to serve the people of Salisbury and vicinity.
He will remain permanently at Salisbury.
Dr. Isaac E. Roberts died February 15th at his
home in Philadelphia, from hardening of the arteries.
He was eighty years of age. Dr. Roberts was the son
of Anthony Ellmaker Roberts, who was sheriff of
Lancaster County and a member of Congress for two
terms. Dr. Roberts was bom in Lancaster, May 28,
1841. He served a ninety-day enlistment with the
"Emergency Men" at the time of the Battle of Gettys-
burg.
Dr. Albert Lichty, of Salisbury (Elklick Post Of-
fice), Pa., on the i8th instant was stricken with a
cerebral hemorrhage. There being no active physician
in the town. Dr. A. O. McKinley, not in active prac-
tice, was called and administered first aid. The case
was turned over to Dr. Bruce Lichty at the earliest
moment possible, but the patient has remained uncon-
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THE PENNSYLVANIA MEDICAL JOURNAL
March, 1921
scious up to this time with scarcely a hope of his re-
covery.
Dr. Evan J. Groom, Bucks County's oldest physi-
cian, a former coroner and for sixty-eight years a resi-
dent of Bristol, during the greater part of which time
he actively practiced his 'profession, died at his home
there, Feb. 24, 1921, following an illness dating more
than two years. Doctor Groom would have been 88
years old on July 9th. During an active career cover-
ing sixty-five years Doctor Groom, according to his
records, was the attending physician at more than
3.300 births.
On his way home after an early professional visit
to Fritztown, Dr. Thomas G. Binkley, of Sinking
Springs, 56 years old, was instantly killed shortly after
daybreak January 24th, when a Reading railway en-
gine, running light, struck the doctor's car at the grade
crossing at Sinking Springs. His neck was broken
and his skull fractured. Doctor Binkley practiced
medicine for thirty-two years and was a graduate of
Jefferson College. He leaves a widow and two daugh-
ters.
Capt. James W. McDonald, M.C.U.S.A., in charge
of Evacuation Hospital No. 6, near Verdun during
the war, since with the American Forces in Germany,
died at Coblanz, Oct. 7, 1920, of septicaemia, aged 59
years. Dr. McDonald was buried at Wellsburg, W.
Va., December 22, 1920. A large delegation was pres-
ent from Wheeling and Fairmont and all the local
Masonic lodges were represented; also a large num-
ber of the medical profession, in which he was well
known.
Dr. J. W. Dehopf, York's oldest physician, died
February i6th from general breakdown caused by over
work in attending to his practice. He was 73 years old
and a native of Carroll County, Md. He graduated
from Hahnemann College, Philadelphia, in 1876 and
had practiced in York since 1890. He was professor
of Obstetrics in the Southern Homeopathic Medical
College, Baltimore, for five years. He is survived by
his widow and several children, among whom is Dr. J.
E. Dehoff, of York.
Dr. James B. McAvoy, Bethlehem, died at his home
on January 25th from a complication of diseases con-
tracted during the world war. He was one of the
first local physicians to join the medical corps, serving
as head surgeon at the post hospital in Garden City,
L. J. Doctor McAvoy was a graduate of the Medico-
Chirurgical College, of Philadelphia. He was a mem-
ber of the Northampton County Medical Society and
a member of the American Medical Association. He
was 36 years of age, and leaves a widow and two chil-
dren.
Dr. William H. Welch died of heart disease Feb-
ruary Oth at his home in Philadelphia, after an illness
of a week. Dr. Welch, who was eighty-three years
old, was born in Bethlehem, N. J. He was graduated
from the University of Pennsylvania Medical School
in 1859. During the Civil War he cared for wounded
soldiers in the Chestnut Hill Hospital until after the
Battle of Gettysburg, when he was ordered to Gettys-
burg to treaty wounded there. Since 1870 he has been
chief consulting physician on contagious diseases in
the Municipal Hospital, and was active in his work
there until his death. Dr. Welch was also clinical
professor of contagious diseases in the graduate school
of medicine at the University of Pennsylvania. He
was formerly president of the Philadelphia County
Medical Society and of the Medical Society of Penn-
sylvania. He was a member of the state vaccination
commission in 191 1, and an ex-president of the Phila-
delphia Alumni Association of the University of Penn-
svlvania. Dr. Welch is survived by his wife, one son,
Robert Welch, and a daughter, Mrs. C. E. Schermer-
hom.
BIRTHS
Born to Dr. and Mrs. Edward H. Bedrossian, of
Philadelphia, a son.
Born to Dr. and Mrs. Joseph L. Connarton, of May-
field, a son, on January 4, i<;2i.
Born to Dr. and Mrs. Wagner, of Throop, a daugh-
ter, at the Mid- Valley Hospital, at Peckville.
Dr. and Mrs. Emory G. Alexander, 337 South
Eighteenth Street, Philadelphia, announce the birth of
a daughter. Mrs. Alexander was formerly Miss Har-
riet C. Deaver, daughter of Dr. and Mrs. John B.
Deaver.
ITEMS
Dr. John E. Scheifly, of Wilkes-Barre, Pa., spent
the past month in Florida.
Dr. John C. Kachline, formerly of Philadelphia,
has located in Quakertown.
Dr. F. a. Cross, of Scranton, spent the month of
January studying in New York.
Dr. Linford D. Roberts, of Quakertown, a recent
graduate, will open an office at Wycombe.
Dr. Samuel P. Glover, Altoona, left the middle of
February for a vacation in California, and will return
early in the spring.
Dr. Henry Stewart, of Gettysburg, succeeds him-
self as secretary of the Adams County Medical So-
ciety for the seventeenth consecutive year.
Dr. John P. Getter, of Belleville, was in Harris-
burg recently. Dr. Getter is recovering nicely from an
accident which resulted in a fractured rib.
The condition op Dr. Adolph KoEnig, Pittsburgh,
is reported as considerably improved, but it will be
quite some time before he will be able to resume his
work.
Dr. H. B. Davis, Lancaster, has accepted a position
as surgeon for the Conestoga Traction Company, fill-
ing a vacancy created by the resignation of Dr. G. A.
Sayres.
Dr. Evan O'Neill Kane, of Kane, is making a sat-
isfactory convalescence after having perfprmcd upon
himself an operation for appendicitis, about the middle
of February.
Dr. J. N. Richards, F-allsington, was knocked down
while crossing a street by an automobile recently. The
aged doctor had two ribs fractured and severely
bruised otherwise.
The Clearfield Hospital Endowment. Bitilding
and Equipment Fund has reached the sum of $180.-
000; $200,000 is required to go over the top, but the
last word has not been spoken.
Dr. John D. Butzner, Scranton, who suffered con-
siderable shock following a narrow escape from death
or serious injury in an automobile accident recently,
has recovered from the effects of the accident.
On January 31, Dr. Davis, of Berwick, a member
of the Columbia County Society, while returning from
a professional call, fell as he tried to jump over a mud
puddle, and sustained a fracture of his right ankle.
State Health Dep.«tment officials have recently
been engaged in arresting persons engaged in practic-
ing in various specialized branches without state li-
censes, including chiropractors, chiropodists and
others.
Dr. John W. Wrioht. Erie, was erroneously re-
ported deceased in a recent number of the Journal.
We are glad to note that although Dr. Wright had
been seriously ill, he has completely recovered and is
still a live member of the Society.
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The Lycoming County Society has appointed a
committee to cooperate with the Pennsylvania Med-
ical Journal in securing ads in that county. This is
good medicine, and much could be accomplished in this
line if all the counties were to do likewise.
Dr. John B. Carhell, of Hatboro, has a very well-
written article in the Doylestoivn Daily Telegraph, ad-
vocating the need of a hospital thoroughly equipped,
with emergency rooms, to be established in Doyles-
town. He points out the need in that particular sec-
tion of adequate hospital facilities.
Congratulations arc in order for Dr. C. D. Werley.
As grandfather, and to Dr. W. W. Werley, as father.
Dr. Louis J. Livingood. as father, announces a pros-
pective member for the society. It behooves the mem-
bership committee to get in immediate touch with Drs.
Werley and Livingood regarding these prospects.
Dr. Henry C. Bartleson, of Lansdowne, Delaware
Co., celebrated his seventy-seventh birthday at his
home January 29th. He has practiced medicine for
more than fifty years in Lansdowne and vicinity and
gave an informal reception. Many of his friends and
neighbors called at his home, at Baltimore and Wy-
combe Avenues, to extend their felicitations.
The Harrisburg Hospital is conducting a campaign
for from six to eight hundred thousand dollars, with
which to build a new, up-to-date, seven-story wing,
with a new nurses home. Up to the present time the
campaign has been quietly conducted, and with splen-
did results. During the spring the cause will be pre-
sented to the public, and it is hoped to go over the top
shortly.
Dr. W. E. Holland, of Fayetteville, was elected
president of the Medical Society of Franklin County
at the society's annual meeting, held January i8th at
Greencastle. Other officers elected were: Vice-presi-
dents, Drs. J. W. Croft, of Waynesboro; T. H. Gil-
land, of Greencastle; secretary. Dr. J. J. Coffman, of
Scotland; assistant. Dr. S. D. Shull, of Chambers-
burg ; treasurer. Dr. F. N. Emmert, of Chambersburg.
Two RADIUM NEEDLES valued at $24,000 were found
recently in rubbish at the medical arts building, Phila-
delphia. They had been missing several days, having
been inadvertently swept from a table in an operating
room. The office force joined the building's porters
in an all-day search of the basement before they were
found. The needles are three-quarters of an inch long
and one-sixteenth of an inch in diameter, and are the
property of Dr. William L. Clark.
The physicians of the state were recently called in
consultation to determine the best methods for han-
dling public health problems by Dr. Edward Martin,
commissioner of health. Ninety medical organizations
of the state cooperated. Communications on scientific
subjects will be prepared once a month by the depart-
ment and forwarded to every medical society, to be
read at its monthly meetings for criticism and sugges-
tions. Reports then will be made to the department.
Dr. F. a. Rupp and Miss Claire S. Schellenberg,
both of Lewistown, were married in the Reformed
church at Huntingdon on Monday at noon by the Rev.
D. E. Master, pastor of the church and a brother-in-
law of Dr. Rupp. The bride is a graduate of the Chil-
dren's Hospital, of Philadelphia. Dr. Rupp was a
member of the Medical Corps of the United State
Army in the World War, serving two years overseas
in France. For distinguished service he was promoted
from a captain to a major, which rank he held when
the war closed and he was honorably discharged.
At a meeting of the Chamber of Commerce in
Philipsburg December 11, 1920, where urgent com-
munity needs were under discussion, the inadequate
hospital facilities of the district was brought up. A
project to enlarge the Cottage State Hospital to meet
the growing demands upon it met with practically
unanimous approval. The first unit to be considered
will be a department devoted to the care of women
and children. At least twenty-five beds are to be pro-
vided for maternity cases. The money to cover the
cost of the first unit will be raised by subscription in
the district served by the hospital.
The Exbcutut; Secretary takes pleasure in sharing
the following with the Society :
"West Newton, Pa., Jan. 26, 1921.
"Dear Doctor:
"I do not belong to the Medical Society now; I
live too far from Greensburg, the county seat, since
the Society meets at night. I am too old to go so far,
and our country road is now impassable. But I am in-
terested in the fight against Compulsory Health Insur-
ance, so I enclose one dollar to help the fight. I-am
76 years old and am not doing much practice, but I
am deeply interested in the profession.
"Very truly yours,
(Signed) "E. K. Strawn."
Dr. F. D. Thomas, county coroner of Luzerne Coun-
ty, was host to his deputies at a dinner given in the
private dining room of Hotel Redington on Saturday
evening, Feb. 5, 1921. Several speeches and an in-
formal discussion designed to bring about a heartier
spirit of cooperation in the fulfillment of coroner's
duties marked the dinner. Those present: William
Brown. Dr. O. W. Dodson, Dr. A. M. Thomas, Dr. E.
S. Hay. Dr. H. H. Brown, Dr. Ben Cook, E. E. Sarge,
Dr.- Charles F. Dickinson, Dr. C. A. Long, Dr. N. J.
Hess, W. C. Taylor, John H. Thomas, Dr. F. D.
Thomas, R. B. Smith, Edward Balcomb, Dr. W. S.
Carter, William I. Williams, Daniel Mulligan, Dr. G.
L. Howell, Homer Graham, George T. Moss, Thomas
F. Barry, F'red Martin, Charles Howell, Hugh Hughes,
Dr. J. C. Fleming and H. G. Davis, Plymouth.
The Pennsylvania Conference on Social Welfare
was held at Erie, February loth to 12th. The program
included the following subjects : Coercive or Coopera-
tive Americanization, Unemployment, Prison Labor in
Pennsylvania, Prohibition: Has It Helped or Hurt?
Case Work in Small Towns Where There Are No
Social Resources, Social Welfare in the Legislature of
1921, Foreign Born People, Federation : Pro and Con,
Is Pennsylvania Caring for Its Dependent and Neg-
lected Children? The State's Program for Child
Health, Mimicipal Promotion of Child Health, What
Mother's Assistance is Doing for the Children of
Pennsylvania, First Steps in the Social Treatment of
Mentally Handicapped Children, Immediate Legisla-
tive Needs in the Field of Mental Health, Medical and
Social Treatment of Sex Offenders, Recreation as Bet-
ter Citizenship, Censorship of Motion Pictures.
The Pennsylvania Tuberculosis Society, which is
the representative of the National Tuberculosis .Asso-
ciation in Pennsylvania, has revised its constitution
and by-laws to make the organization thoroughly rep-
resentative of all sections of Pennsylvania. The board
of directors has been enlarged from fifteen to twenty-
seven members, one-third of whom must be physicians
and one-third laymen. Hereafter the board will meet
three times a year— in January, May and October, in-
stead of monthly.
While the Pennsylvania Tuberculosis Society was
organized in Philadelphia, has always had its head-
quarters in that city and has had its board of directors
composed almost entirely of Philadelphians through-
out its history, the society has not taken a sectional
view of its opportunities and responsibilities in the
fight against tuberculosis. It has gradually extended
its influence throughout the state until nearly all of the
sixty-seven counties have permanent citizen tubercu-
losis organizations affiliated with the state society. In
line with this extension of work and the naming of
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THE PENNSYLVANIA MEDICAL JOURNAL
March. 1921
directors from all parts of the state, it is likely that
meetings of the board will be held outside of Phila-
delphia.
The new constitution and by-laws were put into ef-
fect at the annual meeting in Philadelphia on January
igth and the following directors were elected :
For One Year: Dr. William Charles White, Pitts-
burgh ; Winfield Scott Lane, Greensburg ; Mrs. Alvan
Markle, Hazleton ; Dr. J. M. Wainwright, Scranton ;
.Marphall D. Brooke. Uniontown; Dr. Ward Brinton,
Dr. Henry K. Mohler. Dr. Thomas McCrae, Dr. Elmer
H. Furk. all of Philadelphia.
For Tx\.'o Years: Rollo S. Knapp, Easton; Mrs.
George J. Cook, Ambler; Mrs. William Henderson,
Harrishurg; John H. Scheide, Titusville; John Kudi-
sill, York: Dr. H. R. M. Landis, Dr. James M. .Anders,
Francis B. Reeves, Jr., Daniel M. Barringer. all of
Philadelphia.
For Three Years: George D. Jones, Reading; Dr.
Charles H. Miner, Wilkes-Barre ; George D. Sclden,
Erie: Giflford Pinchot, Milford; Edward D. Wet-
more. Warren ; J. William Hardt, Dr. William Duf-
field Robinson, Dr. Charles J. Hatfield, Dr. Frank A.
Craig, all of Philadelphia.
The new board organized by electing Dr. Anders as
president. Dr. White and Dr. Robinson as vice-presi-
dents. Dr. Brinton as secretary, Mr. Hardt as treas-
urer and IvOuis J. Palmer as solicitor.
The executive committee, which will conduct the af-
fairs of the society between meetings of the directors,
was named as follows : Drs. Anders, Hatfield, McCrae,
White, Robinson and Brinton and Messrs. Knapp,
Reeves and Scheide.
Dr. Thomas McCrae was named as the representa-
tive of the society on the board of directors of the
National Tuberculosis .Association.
GENERAL NEWS ITEMS
First Woman Doctor Penniless. — Paris, Jan. 12. —
Madeleine Bres, who is now 82 years old and who was
the first woman in the world to obtain a doctor's de-
gree, is blind and penniless. She has been offered by
the state charities a bed in the public ward in a home
for the aged.
One Doctor to 7,000 People in Poland. — Warsaw,
Jan. 5. — Poland lost 400 doctors from typhus fever
last year and now has only 4,000 for a population of
28,000,000, or one for every 7,000, according to an
oflTscial report made to the American Red Cross by the
Ministry of Public Health. The American Red Cross
is constantly reinforcing its medical men in Poland
for the purpose of helping the local health authorities
to offset their losses in native physicians.
On March 2d the Nexv York Medical Journal will
be converted into a semi-monthly publication. It will
be enlarged, greatly improved, and its high character
will be maintained.
The Pennsylvani.x Medical Journal wishes to
congratulate the New York Society on this accom-
plishment and extends its best wishes for continued
success.
The United States Civil Service Commission an-
nounces that on March 29, 1921, a competitive exami-
nation is to be held for associate in clinical psvchiatry
and psychotherapy. A vacancy at St. Elizabeth's Hos-
pital, Washington, D. C, at $2,500 a year and main-
tenance, and vacancies in positions requiring similar
qualifications, at this or higher or lower salaries, will
be filled from this examination, unless it is found in
the interest of the service to fill any vacancy by rein-
statement, transfer, or promotion.
The Annual Congress on Medical Education, Li-
censure, Hospitals and Public Health, was held March
7, 8, 9 and 10, 1921, in the Florentine Room of the
Congress Hotel, Michigan Avenue and Congress
Streets, Chicago, 111.
The program included the following subjects: Sym-
posium on Graduate Training in the Various Medical
Specialties ; Medical Curriculum, Clinical Subjects ;
Medical F^xaminations and Licensure; Conference on
Hospital Service ; Rural Health Centers ; The Organ-
ization of the Public Health work.
LiBR.\RiEs IN Public Health Service Hospitals. —
The fact that the sundry civil appropriation bill, re-
ported to the House of Representatives, appropriates
$100,000 for the purchase of library books, magazines,
and papers for beneficiaries of war risk insurance will
be welcome news to military patients in Public Health
Service hospitals. The American Library Association,
which still administers the libraries in the larger hos-
pitals, is embarrassed financially and has to be assisted
by other organizations. The Public Health Service
had no appropriation which it could use for the pur-
pose. The new appropriation saves the situation ;
but, unless it is made available immediately instead of
not until July l, as is customary, reading matter will
necessarily be at a premium in all hospitals caring for
soldier patients.
Youth and Lipe. — "Youth and Life." the new ex-
hibit of the U. S. Public Health Service, consists of 24
attractively illustrated cards, measuring 28x22 inches
each. The exhibit, which is especially addressed to
young women, is an appeal for physical fitness as the
best aid to fulfilling the duties and enjoying the pleas-
ures of life. The value of hygienic living and the need
for plenty of exercise, fresh air, sleep, and proper food
are emphasized. The function of the glands of the
body, including the sex glands, are shown. Human
reproduction is approached through a brief presenta-
tion of reproduction in plants and animals ; and atten-
tion is called to the probable effects of sex misconduct
(venereal diseases). Womanliness, motherhood, and
home-making are extolled. This exhibit may be bor-
rowed for special work from state boards of health
or be purchased through the American Social Hygiene
.Association, New York City.
Health Hazards in Lumbering Regions.— Health
problems in lumbering regions are being investigated
by the U. S. Public Health Service as part of a gen-
eral study into occupational diseases and industrial
h)'giene undertaken in Florida at the request of the
State Board of Health. The work has not yet gone
far enough to permit important deductions to be
drawn ; but jt seems to show that the problems are not
essentially different from those obtaining in other lum-
bering districts of the South and. indeed, in other parts
of the country, except in that they show a high inci-
dence of malaria and hookworm diseases. The re-
sults should be generally interesting.
Dr. J. A. Turner, of the Public Health Service, who
was sent to Florida with instructions to ascertain the
special needs of the workers and to make recommenda-
tions to the State Board of Health as to the best ways
of meeting them, has first taken up the lumbering in-
dustry and has found that this involves two sorts of
problems, the first pertaining to the actual working
conditions, and the second to the reactions of the more
or less transitory lumbering population and of the per-
manent residents on each other.
Study of working conditions involves investigations
of processes of production, medical and surgical care,
sanitation of camps, and food supply ; and study of
reactions includes investigations into the economic
condition of the residents, prevalence of transmissible
diseases, malaria, and venereal infection and possibili-
ties of soil pollution.
The object of the work is, of course, to reduce sick-
ness, accidents, absenteeism, and labor turnover; and
thereby to obtain increased efficiency and greater eco-
nomic prosperity for both workers and employers.
Digitized by
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March, 1921
BOOK REVIEW
445
BOOKS RECEIVED
A Textrook of Pathology, by William G. Mac-
Callum, M.D., Professor of Pathology and Bacteri-
ology, Johns Hopkins University, Second Edition,
thoroughly revised. Octavo volume of 1,155 pages
with 575 original illustrations. Philadelphia and Lon-
don: W. B. Saunders Company, ic2o. Cloth, $10.00
net
Embrvologv, a LAB0R.\T0Ry Manual and Text-
book OP Embryolosv, by Charles W. Prentiss, the
Professor of Microscopic Anatomy, Northwestern
University Medical School. Third Edition, Enlarged.
Octavo volume of 412 pages with 388 illustrations,
many in color. Philadelphia and London : W. B.
Saunders Co.. 1920. Cloth, $5.50 net.
A Textbook op the Practice op Medicine, by
James M. Anders, M.D., Ph.D., LL.D., Professor of
Medicine Graduate School of Medicine, University of
Pennsylvania, 14th Edition, thoroughly revised with
the assistance of John H. Musser, Jr., M.D., Associate
in Medicine, University of Pennsylvania. Octavo of
1,284 pages, fully illustrated. Philadelphia and Lon-
don: W. B. Saunders Company, 1920. Cloth, $10.00
net.
The Roentgen Diagnosis of Diseases of the Ali-
mentary Canal, by Russel D. Carman, M.D., Head of
Section of Roentgenology in the Division of Medicine,
Mayo Graduate School of Medicine, University of
Minnesota, Second Edition, thoroughly revised. Oc-
tavo of 676 pages with 626 original illustrations.
Philadelphia and London : W. B. Saunders Company,
irzo. Cloth, $8.50 net.
The Anatomy of the Nervous System, from the
standpoint of development and function. By Stephen
W. Ranson, M.D., Ph.D., Professor of Anatomy in
Northwestern University Medical School, Chicago.
Octavo volume of 395 pages with 260 illustrations,
some of them in color. Philadelphia and London : W.
B. Saunders Company, 1920. Cloth, $6.50 net.
Transactions op the Medical Association of the
State op Alabama, (The State Board of Health),
Organized 1847, Reorganized 1868. Meeting of 1920,
Anniston, April 20-22. Montgomery, Ala. : The
Brown Printing Co., 1920.
Dermatology, The Essentials of Cuta.veous
Medicine, by Walter James Highman, M.D., Chairman,
Section on Dermatology and Syphilology, American
Medical Association ; Member of the American Der-
matological Association, and New York Dermatologi-
cal Society; Associate Professor of Dermatology,
New York Post Graduate Medical School and Hos-
pital ; formerly Instructor in Dermatology, Cornell
University Medical School; Acting Associate Der-
matologist, Mt. Sinai Hospital, New York; Adjunct
Dermatologist, Lenox Hill Hospital, New York;
Pathologist, Department of Dermatology, Vanderbilt
Clinic, New York, etc. 482 pages, illustrated. New
York: The Macmillan Company, 1921.
BOOK REVIEW
THE SURGICAL CLINICS OF CHICAGO, October,
1920— Vol. 4, Number 5. with 46 illustrations. W.
B. Saunders Company, Philadelphia and London.
Among the various topics discussed, some deserve
special notice because they are examples of newer
things in surgery. For instance, Sevan's clinic on
bilateral recurrent dislocation of the patella treated by
shortening the vastus internus muscle may be cited;
also the discussion of the operative treatment needed
to close the opening of an unsatisfactory gastro-
jejunostomy by Andrews & Mix.
The lecture of R. J. Tivnen on congenital cataract in
an infant and a suggested early treatment, in order to
avert retinal deterioration seems pertinent and instruc-
tive. The association of a persistent enlarged thymus
gland, in a twenty months' old baby, and its treatment
with x-ray are also interesting chnical observations;
especially as it caused fear of death from anaesthesia.
Consequently the cataract operation was deferred by
Dr. Tivnen. J. B. R.
HELPING THE RICH, A PLAY IN FOUR ACTS,
By James Bay. Paper cover, 107 pages, price $1.50.
New York : Brentano's, 225 Fifth Ave., 1920.
This is an interesting and amusing playlet which,
although somewhat overdrawn, exposes to view the
methods of hospital management of a certain type of
medical politicians. Some of the ladies' societies
might find in it a refreshing form of entertainment as
it is son-.ething decidedly new. M. S. B.
PHYSIOLOGY AND BIOCHEMISTRY IN MOD-
ERN MEDICINE. Macleod. Third Edition. C.
V. Mosby Co. >
This unusual book requires more than a passing no-
tice. It is a good omen for the medical profession that
such a work has reached its third edition and has been
in part rewritten and greatly enlarged within three
years. It seems as though the preface to the first edi-
tion with its most excellent argument to the general
practitioner, that he should treat his cases from the
standpoint of physiology and chemistry, had reached
a large audience and been taken seriously to heart. Dr.
Macleod in this work takes up most thoroughly all the
fundamentals of chemistry as applied to physiology.
The conceptions are presented in a clear and logical
manner and the facts brought forward are strictly
true and conform in every way to the best teachings
of modern chemistry. The general principles on which
metabolic investigations are based are clearly and thor-
oughly outlined. The author has introduced many
tables which, while serving to illustrate and prove hi.';
points, will also be exceedingly useful to the practical
laboratory chemist who is carrying out metabolic
studies. The chapters on protein, carbohydrate, and
fats could be read with interest and profit by every
practicing physician.
This is particularly a work for the internist who
wishes to make his daily routine more interesting by
bringing himself up-to-date on the fundamentals of
medicine and putting himself in a position to make
new and possibly valuable deductions from his own
observations. Readers will find great satisfaction in
the simplicity and directness with which subjects are
handled such as, — vitamines, protein requirement,
acidosis, creatine and creatinine, the chemistry of
respiration, cardiac efficiency, and the endocrine sys-
tem. The most recent technical development in the
study of basal metabolism has not been incorporated
in the book, probably because the author realized that
it was undergoing constant modification and definite
.standards had not yet been attained. The demonstra-
tion of the great therapeutic value of oxygen properly
administered and the methods necessary for its most
efficient utilization may be cited as an example of the
practical value of this interesting book.
The nervous system has been entirely rewritten for
the third edition by A. C. Redfield, who gives many
new physiological facts which have not yet found
clinical application. It is most excellently done partic-
ularly as regards sensory phenomena and muscle
coordination. The work on the neuromuscular physi-
ology is especially interesting and valuable and also
the brief reference to Sherrington's work on reflex
action. It would be well if our textbooks on neu-
rology were to incorporate such up-to-date physiology
in their discussion of, and interpretation of symptoms.
Redfield has an unusual capacity for covering clearly,
and in a small space, an enormous amount of work.
It is refreshing to note his utilization of plates whiclL
are both new and practical. ^.^.^.^^^ ^^ GOOgle
446
THE PENNSYLVANIA MEDICAL JOURNAL
March, 1921
While Dr. Macleod is to be most hjghly commended
for his conception of this timely undertaking, for its
scope, and for the excellent manner in which its prac-
tical value has been clearly set forth, it seems to the
reviewer that he has failed to realize how far he has
gone beyond the comprehension of the medical prac-
titioners for whose benefit his work has been planned.
His most commonplace conceptions, in some cases, are
in a language which we -cannot understand ; many of
his more intelligent and educated readers took their
A.B.'s before Avogadro's law found its place in physi-
ology and before van't HofF, and other modern physi-
cists had furnished their contributions which have so
rapidly become fundamentals; for example the very
beginning of Macleod's book must be discouraging
even to the more highly educated practitioners of mid-
dle age or more, to say nothing of the rank and file
of the profession all of whom should read this book.
The younger and more advanced students of physi-
ology can read Bayliss. If Macleod were to treat such
fundamental conceptions as Avogadro's law in a man-
ner to make them intelligible to a person of average
intelligence but meagre scientific training, the useful-
ness of this book would be greatly enhanced and the
number of admiring readers would be increased many
fold. Such elementary but most necessary explana-
tions might be presented in different type so that they
could be skipped at will by more advanced readers.
FATHER PEXN AND JOHN BARLEYCORN. By
Harry Calcolm Chalfant, Editor, American Issue
— Pennsylvania Edition. 291 pages with five illus-
trations. Harrisburg, Pa. : The Evangelical Press.
Cloth, $1.50.
This book is not a series of temperance lectures but
a carefully written history of the obstacles, f.iilures
and successes incident to the efforts continued through
three centuries to lessen the evils resulting from the
use of alcoholic beverages and to overthrow the
.'\merican saloon, which has proved so antagonistic to
all that is best in family, social and civic life in Penn-
sylvania.
In 1665 the director appointed by the Dutch was in-
structed to observe "the published ordinances against
the sale of strong liquors to the Indians" and before
the close of that year Pennsylvania's first liquor reve-
nue law was promulgated. In 1726 the Yearly Meet-
iiiK of the Quakers adopted a resolution condemning
the giving of liquor at public sales. During that year
a law was put on the books forbidding a saloon within
two miles of any furnace, unless expressly permitted
by a majority of the owners. It is admitted by his-
torians that the darkest period in the annals of the
.•\merican Republic was during the winter of 1777-8
when Washington's army was starving at Valley
Forge. • A large part of the grain needed "to win the
war" was being turned into whiskey. To prevent an-
other such winter the Pennsylvania Legislature on
November 27, 1778, enacted a law effective December
10, 1778. to September I, 1779, prohibiting the use of
any grain, meal or flour in the making of whiskey or
other spirits.
Physicians more than any other class of people real-
ize the havoc wrought by alcohol and it is therefore
not surprising that they have taken a prominent part
in temperance work. In 1772 Dr. Benjamin Rush, of
Philadelphia, Surgeon-General of the Continental
.Army, and one of the most prominent of America's
pioneer physicians, published a book of three "Ser-
mons to Gentlemen Upon Temperance and Exercise."
In 1785 appeared Dr. Rush's celebrated essay "An In-
<iuiry Into the Effects of Spirituous Liquors on the
Human Body," which was republished in an English
magazine. When it is remembered that they had no
accurate instruments of observation and little knowl-
edge of blood pressure it is surprising how near the
following quotation from Dr. Rush approaches the
present-day accepted theory that alcohol is neither a
food nor a stimulant but a narcotic :
"Spirits in their first operation are stimulating upon
the system. They quicken the circulation of the blood
and produce some heat in the body. Soon afterward
they become what is called sedative; that is they
diminish the action of the vital powers and thereby
produce langour and weakness."
The Georges Creek Temperance Society was organ-
ized in Fayette County in 1829, the organizer being Dr.
Hugh Campbell, one of the county's leading physicians.
He related his experience of twelve years as a prac-
ticing physician being exposed to rain, snow, heat and
cold and to the loss of much sleep, and yet in all the
twelve years he used no liquor.
A committee of the Philadelphia Medical Society
appointed in 1829 spent six months in careful investi-
gation of alcohol in its relation to disease and death
and reported that of 4.292 deaths investigated with
consultation with the physician in charge, over 700
were due directly or indirectly to the use of liquor.
After the society had received this report the follow-
ing resolutions were adopted :
"Resolved, That this society earnestly advises its
members to employ their personal and private influ-
ence for the suppression of the moderate use of spirit-
uous liquors: and that for this purpose the members
are advised themselves to abstain from the use of
spirituous liquors under any circumstances except as
a medicine.
"Resolved. That the members are advised to dimin-
ish the employment of ardent spirits in their practice
as far as is compatible with a careful and prudent
consideration of the welfare of their patients."
Dr. Philip Syng Physic, possibly the most eminent
surgeon of that day, was the first president of the
Pennsylvania Temperance Society, organized in 1834.
Twenty-two physicians from Bucks County about this
time declared against the use of liquor.
The names of many other physicians might be given
as prominent in the temperance movements. No refer-
ence in this review having been made to the valuable
efforts of women physicians it will be in order to close
with the prophetic message given Frances E. Willard
by Dr. Harriet S. French, one of Philadelphia's pio-
neer women in the medical profession. Soon after
Miss Willard took up her work as the first correspond-
ing .secretary of the newly organized Woman's Chris-
tian Temperance Union, she visited Philadelphia, and
Dr. French accompanied her to Norristown for a
public meeting. Late in the afternoon they encoun-
tered a severe storm when the wind was a real gale
and the rain a downpour. There seemed small hope
for an audience that night, but as they reached Norris-
town the sky was clear and a beautiful rainbow
spanned the heavens. "Look, Miss Willard," said Dr.
French, "this dav is but a symbol of what your life is
to be — storms, disappointments, opposition, but in the
end, victory and a beautiful rainbow." C. L. S.
ADVERTISING THE HEALTH DEPARTMENT
How advertising .has been a big factor in the suc-
cessful work of the Chicago Health Department was
the principal theme of a discussion by Dr. John Dill
Robertson, health commissioner, before a recent meet-
ing of the Chicago Advertising Council. He said:
We have something to sell in the health department.
Every doctor has something to sell. A doctor spends
his time in medical school and in hospital perfecting
himself in internal medicine or in surgery or some
other specialty, and then he is prepared to sell that to
the people. Many of them never sell it because the
people never know about them. They never were able
to make the connections to get the advertisement in the
ethical way outlined by the medical profession.
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March, 1921
SELECTIONS
447
For instance, it is perfectly ethical to organize a
medical school, to issue a booklet and send it broadcast
throtiRhout the country in regard to that medical
school, to list therein the names of the faculty and the
particular chairs that they occupy, to spend money for
postage and for clerks and stenographers to write let-
ters and send them about the country to get as many
students to come to that school as possible It is then
perfectly ethical for that professor to go in the pit in
front of the students and lecture on surgery or some-
thing else and operate in front of those classes and
show that group of one hundred or two hundred stu-
dents sitting in front of him what a wonderful siu--
gcon he is so that they may go out and spread to their
friends that fact. That is ethical. That pays, because
the men who have done that in this or any other city
are the well known specialists. — Judicious Advertising,
December, 1920.
DO PROFESSIONAL MEN ADVERTISE?
There are certain prejudices in the professions
against advertising, but a survey of the field would
show that the doctor, lawyer or dentist is a pretty
clever advertiser after all. He may not pay for space
but certainly the ethical right to advertise is not de-
termined on that basis.
The doctor or dentiist is particular about letting his
patients see how thoroughly he sterilizes his instru-
ments, is advertising. The lawyer would not think of
letting his name appear in the advertising columns of
a newspaper, and yet he is glad enough to be mentioned
in the adjoining news column in connection with some
important case.
It all gets down to the fundamental principle for
which the Associated Advertising Club stands. Is the
advertising truthful? If so any business or profession
with a service to sell should, and has the right to.
— W. P. Green in a talk to the Akron (O.) Ad Club.
— Judicious Advertising, December, 1920.
ABDOMIN.^L SYPHILIS
By J. Q. Chambers, M.D.
Kansas City, Mo.
Disregarding for the present the protean characteris-
tics and variable symptomatology of syphilis of the
alimentary viscera the diagnosis rests on these sup-
ports :
1. A definite history of syphilis in former years.
2. Scars in bone, in skin, in scalp, in eye, in nose, in
throat, the relics of a former active phase.
3. Pupillary inequalities, Argyll Robertson phenome-
non, and other disturbances of spinal reflexes.
4. A marital history of spontaneous abortions and
stillbirths.
5. A family record suggesting syphilis.
6. The confirmatory tests of the blood and spinal
fluid.
7- The improvement under antisyphilitic treatment.
In reference to the fifth, or family history, suggest-
ing syphilis, the vast majority of our experiences have
dealt with adults. In children this information is all
important. Yet hereditary syphilis is not to be ig-
nored in grownups, for he has seen cases that were
probably hereditary showing up in adults, in one in-
stance as late as the forty-eighth year.
Not all of these diagnostic supports of course are
essential for every case. Any one of the first five may
be even vaguely present, with a positive Wassermann
and positive therapeutic test, and the diagnosis is war-
ranted. Per contra, even with forceful indications,
unless the therapeutic test is successful, the diagnosis
must often be held in abeyance. — From the Journal of
the Missouri State Medical Association, October, 1920.
PSYCHANALYSIS
Recently the minister of a prominent church in Chi-
cago was asked by the head of the social work depart-
ment to put his approval on the establishment of a
lecture course on psychanalysis. Being in doubt, he
conferred with several medical men of his congrega-
tion. Finally a neurologist settled the matter by say-
ing: "By all means have it. It should prove very
popular. Half the congregation is already crazy and
the other half is enroute to the asylum." The jest
was not wholly a jest. People are paying too much
attention nowadays to their minds. An abnormal in-
terest in the workings of one's own mind produces
either an introspective philosopher or a "common nut."
When the interest is related inore or less distinctly to
a concealed but nevertheless obvious fascination for
cogitation on things sexual, it has elements of danger.
Physicians are beginning to wonder where the normal
interest of the layman in these subjects ends and the
scope of the psychiatrist commences. We are flooded
with books on the subject by lay psychanalysts ; the
"movies" picture it; the theatres dramatize it; the
churches have lectures on it. In the not too distant
future this psychanalytic craze, if it continues, will
make the medical psychiatrist a very busy man. — Jour.
A. M. A., Jan. 29, 1921.
GALL BLADDER DISEASE
C. D. Brooks, M.D.
Detroit, Mich.
CHOLECYSTfiCTOMY VS. CH0i,ECYSTOST0MY
He advises cholectostectomy for the following con-
ditions :
1. Empyema with cystic duct obstruction.
2. For mucous fistulas following cholecytostomy.
first of all being sure that the cystic or common duct
is not obstructed.
3. Gangrene of the gall bladder in some cases the
patient is in such a serious condition that he has been
content to remove the mucosa, this we perform by
splitting the gall bladder to the cystic duct and shelling
out the mucus membrane.
4. The infected gall bladder often with subaccure
symptoms the so-called "strawberry" gall bladder. In
some of these cases we believe the gall bladder should
be opened and ducts carefully explored before pro-
ceeding with cholecystectomy.
5. Carcinoma of the gall bladder. Most of the cases
of cancer of the gall bladder follow gall stones and
not frequently follow cholecystotomy for such. We
have had five cases of cancer of the gall bladder in the
last ten years, all of which had gall stones and have
had an operation of cholecystotomy. We believe that
these cancers would not have occurred if the gall
bladder had been removed instead of having been
drained at the primary operation. He also behevcs
that there are many unreported cases of cancer of the
gall bladder until it would seem that it was a very
serious question regarding the leaving in of an organ
which has entirely lost its function which may finally
be the seat of a cancer. — From the Journal oj the
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THE PENNSYLVANIA MEDICAL JOURNAL
March, 1921
Michigan State Medical Society, Grand Rapids, Mich.,
November, 1920.
THE RESULT OF SPUTUM TYPING IN PNEU-
MONIA FOR THE SEASON OF 1919-1920
By J. E. Robinson, M.D.
Temple, Texas
The following data seems to be fairly well fixed by
clinical and experimental work :
(i) That the diflferent types of pneumonia can be
accurately identified in from eight to twelve hours.
(2) That Type I serum is a specific in the same
sense that diphtheria antitoxin is a specific.
(3) That there is no polyvalent serum or specific
serums for Types II, III or IV.
(4) That prophylactic immunization will reduce the
chances of infection, and will lower the death rate
among those who contract the disease subsequently.
(5) That Type I serum must be given early. Its
value diminishes the later in the disease its administra-
tion is started. While the death rate is lowered in
undertreated cases the percentage of complications is
higher. — From Texas State Journal of Medicine.
PROPAGANDA FOR REFORM
Echinacea. — Intelligent members of the medical
profession must be well aware that both the Pharma-
copeia of the United States and the National Formu-
lary include many products that can scarcely be justi-
fied as medicinal on the basis of scientific consideration.
Among the products included in the National Formu-
lary is the fluidextract of echinacea. In 1909 a report
of the Council on Pharmacy and Chemistry denied
echinacea a place in New and Nonoflicial Remedies
because there was no evidence to show that it pos-
sc.<.sed therapeutic value. Despite this, echinacea is
used extensively. The fluidextract and the tincture are
made in enormous quantities, and the root enters into
the composition of a large number of "patent," pro-
prietary and nonsecret mixtures. For this reason
Couch and Giltner of the U. S. Bureau of Animal
Industry made an extensive experimental study of
echinacea therapy. Animal experiments designed to
determine whether the drug possessed the properties
that are ascribed to it gave negative results in every
instance (Jour. A. M. A., Jan. i, 1921, p. 39).
Inhalation Therapy. — The possibility of effecting
absorption of many drugs, other than the anesthetics,
by inhalation is beyond question. Mercury, for exam-
ple, has been so administered. The difficulties that
attend such a procedure relate in particular to the un-
certainties of accurate dosage. It has already been
demonstrated that calcium chloride solutions can be
nebulized for inhalation so that the salt is absorbed
from the respiratory tract. Since absorption of cal-
cium from the alimentary tract is slow, indefinite and
undependable. while subcutaneous or intravenous ad-
ministration is objectionable or impracticable or both,
attention becomes directed to the inhalation method
of administering calcium. However, while small
quantities of calcium are of dubious value, recent in-
vestigations indicate that the administration of larger
amounts by inhalation methods is liable to exceed the
limits of advisable concentration in the blood without
any suitable mode of regulation. These findings may
be a timely warning at a period when therapeutic
novelties are likely to be proposed in increasing num-
bers (Jour. A. M. A., Jan. 8, 1921, p. 116).
1000 PRESCRIPTION BUNKS, $2.50
(lln«u llDlib Iwnd, 100 In pad
1000 Profaiiionat Cardi .... (4.10
1000 NoMbciili 4.U
1000 Drug Biivelop«a 3.00
1000 Btatementa 4..'iO
1000 "AcCaar'Typewrltten Lett«ri 6.50
Pricmt Inclndm Pareml Pott Chargmm
A yew samples free
A. H. KRAUS, 407-40e CboatBat St., MOwkokM, WU.
Wanted.^To purchase a general practice in Penn-
sylvania. Address Dept. 501, c|o Pennsylvania Med-
ical Journal.
TABLE OF CONTENTS— Concluded
COVNTT KEDICAI. SOCIETIES
County Society Seporta
Berks — January 435
RIaIr — January 436
Bucks — February 437
Chester — January 437
Elk — February 437
Franklin — January 437
Montour — February 438
Nortbampton — January — February 438
Philadelphia — January 438
Somerset — January 441
STATE NEWS ITEKS 441
Deaths
Births
ITEMS
OEHERAI. MEWS ITEVS 444
BOOKS RECEIVED 445
BOOK REVIEW 445
FROPAOAMSA FOE REFORM 418
INDEX OF ADVERTISERS 448
INDEX TO ADVERTISERS
Aloe, A. S., Comi>any viH
Armour & Company cover p. 4
B. B. Culture Lalmratory cover p. 4
Bauer & Black v
Brady, Geo. W., A Company xvll
Burn Brae xlv
Crest View xv
Deutseh, Max, The Oravid Shoe xvl
Dcvltt's Camp xv
Felck Brothers Company xl
Ooodell. J. E., Laboratory vl
Ilorlick's Malted Milk Co xtI
Hynson, Wcstcott and Dunning xvll
Jacobi, Edward, Prescription Blanlis xi)
Jeflferson Medical College xiil
Kenwood Sanitarium xlv
Kraus, Prescription Blanks 448
Langner Laboratory, The x
.Mcintosh Battery & Optical Co xl
Maltbie Chemical Co !t
Manhattan Eye Salve Co xl
Massoy Hospital, The xil
Mayo Foundation. The xil
Mead Johnson & Co Iv
Medical Protective Co II
Mercer Sanitarium xlv
Metz, H. A., Laboratories, Inc cover p. 4
Moore's Hospital xv
.Multord. H. K., Co vii
Mutual Pharmacal Company, Inc xl
Parke. Davis & Company ill
Physicians' & Surgeons' Adjusting Association vi
Pomeroy Company xvl
Radium Company of Colorado xi
Radium Laboratory rvl
Saunders. W. B., Csmpany front cover
Schering & Glati, Ind x
Storm, Katherine L., M.D., vUi
Sunnyrest Sanitarium xlv
Takamine Lalwratory, The vlii
Taylor Instrument Co xvil
University of Pennsylvania xiil
University of Pittsburgh ill
Victor X-Ray Corporation Ix
Woman's Medical Co'lege of Pennsylvania xUi
Zemmer Company, The vli
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ORIGINAL ARTICLES
LETHARGIC ENCEPHALITIS*
DANIEL J. McCarthy, m.d.
PHItADELPHIA
When the first cases of lethargic encephalitis
appeared in the American Expeditionary Forces,
we were at a loss to place the disease either
pathologically or clinically. The clinical pic-
ture of the disease was somewhat different
from that to which we have since been accus-
tomed, at least in consultation practice here, be-
cause, I take it, of the decided difference in the
intensity of the infection. This may have been
due to a difference in the virulence of the infect-
ing organism or more probably to the fact that
we were dealing with a class of selected men in
good organic physical condition with a high re-
sisting power. This latter theory is rather borne
out by the difference in the clinical picture
shown by the enlisted personnel and by the of-
ficers, more particularly those men advanced in
life.
It is well to bear in mind in this connection
that the epidemic of influenza did not reach the
same grade of severity in the American Expe-
ditionary Forces as it did in the United States.
There was to my mind a distinct relationship
between the epidemic of influenza and the epi-
demic of lethargic encephalitis.
Many classifications of the disease have al-
ready been offered. The most comprehensive
and inclusive is that presented by Roger (Pro-
gressive Med., 35 pp 247).
I . Motor Forms.
(a) Hyper-myoclonic, choreo-ataxic. con-
vulsive, tetanic.
(b) Hypo-motor, paraplegic type, poly-
neurotic type, Mullard-Grubler
type (a combination of these
two), the oculo-motor and op-
thalmoplegic forms.
(c) Para-motor (the Parkinson or mya-
tonic form).
'Read before the Section on Medicine of the Medical Society
of the State of Pennsylvania, Pittsburgh Session, October 7,
1920.
2. Sensory forms (the hypersensory or algic
form).
3. Psychic forms.
(a) Hyper-delirium, mental excitation.
(b) Hypo-psychic depression.
4. Sleeping Forms (depending on the func-
tion of the sleeping centre).
(a) Hyper-somnolent or lethargic.
(b) Hypo-insomnia form.
In addition to the forms presented here, which
would appear to be all inclusive, other classifica-
tions as follows have been suggested :
1. On age, (infantile, senile and gravid
forms).
2. On clinical course (acute, subacute, chron-
ic, circulatory relapsing forms).
3. On anatomical distribution (cortical, bul-
bar, peduncular, spinal, meningeal, polyneuritic
forms).
From such a variety of symptom groups, re-
lated to practically the entire central and peri-
pheral nervous system, it is not difficult to place
the pathologic basis of the disease. It is, as the
name indicates, an encephalitic or medullary in-
flammation affecting the brain and more rarely
the spinal cord. The lesions are focal; in the
vast majority of cases an accumulation of round
cells (small nuclear, large mononuclear, and
phagocytic cell types) scattered here, there and
everywhere throughout the nervous system.
The lesions may be so slight that they could
easily escape detection ; a few cells around the
blood vessels of the medulla may be all that one
may see, even in fatal cases. In other cases, the
lesions may be widespread and extensive. They
differ from post influenzal encephalitis pure and
simple, due to the lesions of poliomyelitis epi-
demica. The rapid recovery even of extensive
cases indicates the certain lack of a destructive
tendency as seen in poliomyelitis and post in-
fluenzal encephalitis. The meninges are, as a
rule, not involved in as marked a way as in polio-
myelitis. Occasionally pial round cell infiltra-
tion has been observed. The lesions predomi-
nate in the brain around the acqueduct of
Sylvius, the optic thalmus, the pons, the me-
dulla and the lateral ventricles. In poliomye-
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THE PENNSYLVANIA MEDICAL JOURNAL
April, 1921
litis the lesions are most frequent and intense in
the spinal cord. In poliomyelitis ganglion cell
destruction is a characteristic microscopic pic-
ture. In lethargic encephalitis, while the gal-
glion cells show marked alteration, at times they
show relatively little change.
We may sum up the pathological changes in
lethargic encephalitis as a multiple focal in-
flammation of the central nervous system with
marked vascular congestion, associated with
proliferation of the interstitial cells of the vessel
walls and an infiltration of these cells into the
surrounding tissue, an infiltration of small
mononuclear cells into the v. r. spaces, a toxic
degeneration of the ganglion cells, and a sec-
ondary gliosis. These foci may be found in any
part of the brain and may produce any single
group of symptoms, or any combination and
may, on account of their multiple disseminated
nature, produce the symptom groups found in
multiple disseminated syphilis, multiple dissemi-
nated sclerosis, and multiple disseminated tuber-
culosis.
TRANSMISSION
The causative organism has not yet been con-
clusively demonstrated. Strauss and Loewe
have described a coccus type of organism which
they have found in the brain tissue, in the naso-
pharyngeal washings, and which when injected
into monkeys and rabbits produces a disease
s)mdrome identical with that in the human
being. These findings have not been accepted
as conclusive by other observers, largely I take
it, because other organisms have been occasion-
ally described in isolated cases and similar re-
sults from transmission to rabbits have been
described.
Levaditi (Bull, de L'Acad. de Med., April 20,
1920) succeeded in inoculating a rabbit with an
emulsion of brain substance from a human case.
The autopsy of the rabbit showed characteristic
meningo-encephalitic lesions. He concluded
that the disease is due to a filtrable virus non-
pathogenic for the monkey until after it has been
passed a number of times through rabbits. The
virus survives in glycerin, and after dessicated
cultures. It would appear therefore that the
organism is ultramicroscopic, passing through a
Chamberlain filter and is pathogenic in the fil-
trates for rabbits and monkeys.
S Y M PTOMOTOLOGV
The disease is an infection. It is frequently
met with, fully developed, with a normal tem-
perature. This is particularly true of the mild
cases. It is assumed, however, that in this
group of cases, the febrile stage existed at the
onset and rapidly passed off. It is usual in the
severe cases to have a moderate rise of tempera-
ture that persists throughout the entire duration
of the illness. In fatal cases a terminal rise to
104 or 105 degrees, or higher, is noted. The
prodromal period for rabbits, according to
Levaditi is five days. Sabitini, irom a single
observation, concluded that the incubation period
in the himian is three weeks. Not infrequently,
the onset is that of an acute coryza with mild
fever. In some of our army cases, it followed
within one week of an attack of influenza.
Mental symptoms are the predominating
group. They are present in approximately 80
to 90 per cent, of the cases collected from the
literature. While this is unquestionably too
high for cases seen in the army, they are in the
severe group of cases the symptoms dominating
the clinical picture and are of great assistance
in the diagnosis of the ccmdition. Mental symp-
toms vary from slight somnolence, through the
category of listlessness, lethargy, stupor, mental
inertia, to complete unconsciousness with or
without a low type of delirium. Maniacal and
catatonic symptoms have been reported. In the
milder cases, and in the earlier stage of some of
the severe cases, mental symptoms may be en-
tirely absent.
The resemblance of the severe lethargic cases
to deep sleep in striking. The patient can with
some effort be aroused from what at first ap-
pears to be a deep coma into a fairly normal
mental state, responding to simple questions but
immediately dropping into a deep sleep as if
tired to death and too bored to continue the con-
versation. In the intense paralytic forms where
the extremities are involved, true coma is likely
to appear shortly after the paralytic symptoms
have developed. I have seen, however, severe
paralytic forms without even a trace of mental
symptoms, not even listlessness or diminution of
the usual energy or mental working power. On
the other hand, I have seen extreme somnolence
and lethargy with practically no focal symptoms
or irritation of the cortical motor centre. In the
listless, apathetic and somnolent groups, the
face, even without nuclear involvement of the
seventh nerve takes on a wooden, blank expres-
sion with, at times, a definite Parkinson expres-
sion. Where the superior oculo-motors are only
partially affected the myasthenic face is some-
times observed. Bilateral seventh nerve involve-
ment gives the typical facies of this syndrome.
Of the focal symptoms, ocular palsies are by
far the most frequent manifestations. In the
Alexander Allen group of cases they were pres-
ent in 57 per cent, of the cases. In our Ameri-
can Expeditionary Forces cases, when combined
with seventh and eighth nerve involvement, they
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April, 1921
LETHARGIC ENCEPHALITIS— McCARTHY
451
were present in even a higher percentage. Even
in cases that later developed severe paralytic
phenomena in the extremities, the primary
symptoms were referred to the superior nuclear
group of the bulb. Ptosis in one or both sides,
isolated, or combined muscular paralysis, com-
plete external ophthalmoplegia in one eye with
isolated muscle loss in the other eye, bilateral
terminal ophthalmoplegia, alone or combined
with other cranial nerve involvement, have been
present in my own cases. Pupillary phenomena
are relatively infrequent, as compared with the
muscular nuclear involvement, Argyl-Robertson
pupils, irregularity as to outline and reaction
and complete loss to light. In one of my cases
the eye symptoms were limited to the accommo-
dation mechanism. Later, this case presented
severe paralytic phenomena. Choked disc has
been reported in five cases. This has great sig-
nificance, as in cases of headaches, progressive
lethargy and paralytic phenomena, it could easily
be mistaken for tumor or abscess.
In one of my cases the symptoms developed
in complication with an old middle ear disease.
Eye grotuid symptoms were negative. In this
case, the mastoid cells were opened in order to
exclude the possibility of this being the causa-
tive factor. -The case was progressive and se-
vere and it seemed only fair to eliminate the old
ear condition as a possible factor. The opera-
tion gave entirely negative results clinically and
anatomically.
In the medullary group, dysphagia is a com-
mon symptom. It appears as the disease pro-
gresses in approximately 20 per cent, of the
severe type of case.
Paralysis of the extremities is not common.
It was present in only three of my army group.
The tendon reflexes vary greatly, depending
on the intensity of the disease and the distribu-
tion of the lesions. In the pure focal lethargic
group, the reflexes are normal or slightly exag-
gerated. In the widespread diffuse group, the
reflexes are, as a rule, exaggerated, with the
Babinski present when the motor tracts are in-
volved.
Sensation is rarely involved. In extensive
diffuse cerebral cases, it may be involved in a
hemipl^c or paraplegic distribution. In one of
my cases, the sensory involvement was marked.
This case is worthy of note as it presented a
problem for diagnosis. The early symptoms
were ocular — loss of accommodation with a very
transient diplopia. This lasted for two weeks
and was followed by marked asthenia. At an
interval of two weeks, marked ataxia with
pseudo loss of power developed in the four ex-
tremities. This was most marked in the legs.
There was complete loss of reflexes in all four
extremities. The sensory phenomena were
marked. There was loss to all forms of sensa-
tion in an irregular distribution to about the
knees; the subjective parastheniae were marked
and very disturbing to the patient. There was
no pain. The plantar reflexes gave normal
response, i. e., there was neither Babinski, Gor-
don nor Oppenheim. When the patient was ly-
ing on his back, the muscular power was normal,
and yet he was not able at first to stand. He
rapidly progressed to the stage where he was
able to stand but when he walked it was with
the ataxic gait of an advanced case of tabes.
There was no tenderness over the peripheral
nerves. There was, however, some slight ten-
derness over the muscles such as one sees in a
mild case of alcoholic multiple neuritis. The
case presented the symptomotology of a loss of
the sensory elements in the peripheral nerves,
complete of the lower extremities and partial of
the arms. It presented a sensory neuritis, mul-
tiple in type. Were it not for the ocular symp-
toms it would rest on this diagnosis. The ocular
symptoms place it in the general group of en-
cephalitic lethargia. I have seen, all said, three
such cases. Two of these followed the epi-
demic of 1898.
Tremors are presented in about 10 per cent,
of the cases. Muscular twitchings are common,
due to cortical or subcortical irritation. Mus-
cular twitchings of the abdominal and lower
chest muscles in the region of the diaphragm re-
ported by Reilly are considered diagnostic.
Any combination of pain, central motor nerve,
peripheral nerve, sensory or pain manifestation
with any of the various pathological mental
states are possible in this disease. Various syn-
dromes have been reported, the most common
being the so-called Parkinson syndrome. In this
the case presents some of the symptoms of
paralysis . agitans — the f acies, the f estinating
gait and tremor. Marie and Levy (Bull, de
I'Acad. Med., June 15, 1920), call attention to
the fact that the tremor of epidemic encephalitis .
could not be mistaken for the typical pill rolling
tremor of paralysis agitans which stops invol-
untary effort. The tremor of encephalitis epi-
demica is initiated and intensified by voluntary
effort, develops in cases usually before 40, is a
part of an infectious process, develops acutely,
does not involve the body progressively, and is
not associated with cranial nerve involvement or
abnormal movements of the tongue and jaws in
mastication and deglutition.
Sicard has attempted to establish a myoclonic
syndrome as follows : fever, lassitude and lanci-
nating pains for 7 to 10 days, followed by mv-i
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THE PENNSYLVANIA MEDICAL JOURNAL
April, 1921
oclonia, muscular jerkings, twitchings for 7 to
10 days and a third period of delirium lasting
from ID to 20 days or to a fatal termination of
the disease.
THE CERBBRO-SPINAI, FLUID
The fluid on tapping may be under increased
pressure, and is clear as a rule. The number of
cells varies greatly. It is usually over 100 and
may be under 10. The usual range is between
10 and 20 per cubic millimeter. The mononu-
clear type predominates with an occasional poly-
morphonuclear. The sugar content may be in-
creased. Dapter considers this suggestive of the
disease. According to Netter, there may be a
tendency of the lymphocytes to increase during
the first three weeks of the disease. In 19 days
in one case, his records show 14, 16, 84, 30 and
in another 56, 118, 16, 9. Loewe and Strauss
give a positive result to cultures of their organ-
ism in 75 per cent, of cases where it has been
inoculated into rabbits, thus by this method dif-
ferentiating the disease from epidemic poUo-
myelitis.
I have had three deaths in my cases, one in a
hemiplegic form, one in a meningetic form and
the third in an ocular-lethargic form.
The differential diagnosis is a matter of ex-
perience and exclusion. Given an afebrile case
with oculomotor symptoms and lethargy or
more pronounced mental symptoms, the first
thought should always be not that of encepha-
letic lethargia, but of syphilis of the nervous
system. A case was admitted to my service at
the Philadelphia General Hospital — a young
adult negro with these symptoms. The nervous
examination was at first negative and the case
looked as if we might be dealing with a leth-
argic encephalitis. On the day after admission,
symptoms of meningeal irritation developed.
Some rigidity of the neck, a positive Kemig,
excited tendon reflexes, all equal, with a normal
plantar reflex were present. The cerebro-spinal
fluid gave a cell count under twenty. The Was-
sermann reaction was not reported until the
fourth day and then came back positive for both.
The patient died on the fourth day. The au-
topsy showed a frank chronic productive me-
ningo-encephalitis of the base of the brain. In
this case, as a precaution, mercury was ordered
while waiting for the laboratory tests, but on ac-
count of some misunderstanding on the part of
the resident physician, it was not given.
A meningo-encephalitis syphilitica, can easily
be mistaken for tuberculous menengitis, or the
reverse. The symptomatology of the two condi-
tions, up to the stage of advanced internal hy-
drocephalus, could be identical with that of
lethargic encephalitis. The differential diagno-
sis in the earlier stage can be made by an
examination of the cerebro-spinal fluid, giving
the tubercle bacilli, the lymphomatosis, and the
escape of the fluid under pressure. It is impos-
sible to mistake this disease for cerebral hem-
orrhage, as happened in a case I saw in consul-
tation. The onset was slow, with a febrile
attack, the paralysis of arm and leg, was asso-
ciated with a third and sixth nerve paralysis,
typical lethargy was present, which passed into
coma only the day before the fatal termination
of the case. In this case the lethargic pseudo-
coma was entirely different from the progressive
coma of a fatal case of cerebral thrombosis.
The diagnosis of epidemic meningitis can
easily be made by the cerebrospinal fluid. A
detailed history should differentiate the diag-
nosis between brain tumor and encephalitis
lethargica. In the absence of a history of slow
development, with headache and vomiting, a
mistake in these cases where optic neuritis is
present, could easily be made. The differential
diagnosis from some types of cerebral abscess,
is much more difficult. The onset may be sud-
den, or at least as sudden as in some cases of
lethargic encephalitis; the cases run a febrile
course; relapses may occur. Abscess of the
frontal lobe will give the sleeping picture of
sleeping sickness. Coma supervenes much
earlier. The leucocyte count, the presence of a
marked pleiocytosis, at times a cloudy cerebro-
.spinal fluid, with the primary focus of infection
established, should eventually lead to an accurate
diagnosis. Where mastoid or middle ear, sinus
disease, or other infections have recently been
active, the patient should be given the benefit of
the doubt, and exploration guardedly carried
out. Loewe and Strauss (Jour. A. M. A., May
15, 1920) report not only the presence of the
causative organism in the nasopharyngeal wash-
ings, but that when this is injected into rabbits,
the disease is produced in 78 per cent, of cases
studied; that the filtrated organisms injected
intravenously into rabbits produce the disease
in 64 per cent, of cases ; that the cerebrospinal
fluid injected confirmed the diagnosis in 75 per
cent, of cases and that positive cultures were ob-
tained in 50 per cent, of cases.
Practically all observers have agreed on the
use of urotropin in doses of 10 grains, three
times a day, with the hope that it will have some
antiseptic action on the nervous tissues. There
is no evidence that it has much value.
Repeated lumbar punctures ( 10 to 20 c. c. of
fluid being withdrawn every three or four days)
are done with the idea of accentuating the effect
of the urotropin, and possibly having an altera-
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Aprh, 1921 MENTAL SYMPTOMS IN ENCEPHALITIS— WHOLEY
453
tive eflFect on the nutrition of the central nervous
tissues.
In the restless cases, the bromides, and in the
more severe cases, morphine and scopolamin or
atropin in small doses may be given.
The convalescence should be treated much in
the same way a case of epidemic meningitis is
treated. Careful attention to prevent exhaus-
tion should suggest a well considered, modified
type of rest treatment, carefully carried out.
The paralytic phenomena, as a rule, take care of
themselves.. The tremors, musctilar twitchings,
all may yield to the bromides or hyoscin.
AN ANALYSIS OF THE MENTAL SYMP-
TOMS ASSOCIATED WITH EPIDEMIC
(LETHARGIC) ENCEPHALITIS*
C. C. WHOLEY, M.D.
PITTSBUROH
A survey of the mental symptomatology ob-
served in epidemic encephalitis brings out the
fact that there are two opposing sets of mental
symptoms associated with this disease. On the
one hand we have a syndrome embracing leth-
argy, apathy and euphoria; on the other, we
find insomnia, anxiety, and discomfort. In cer-
tain cases one of these sets of .symptoms may
exist, to a greater or less degree, throughout the
course of the disease; again these opposing
syndromes may alternate as the encephalitis
prepresses. In certain other cases we see the
paradoxical picture of these opposing groups of
symptoms existing simultaneously; in other
words, we may have at one and the same time
evidences both of lethargy and of anxiety. It is
further observed that these characteristic mental
syndromes align themselves noticeably with cer-
tain correlated states of irritability, and of to-
nicity, of the muscular system.
Our observations are based upon a series of
20 cases. The mental condition most in evi-
dence was the lethargy. It was present to some
extent in 18 out of the twenty cases, varying
from a mild degree to such intensity at times that
it was impossible to arouse the patient to con-
sciousness. The nature of the lethargy was
such that many patients who appeared to be in a
stupor could be aroused sufficiently to answer
questions intelligently, and we found them ori-
ented. But they immediately lapsed back into
their somnolence, until again roused for food or
some bodily need. The somnolence in some
cases persisted for but a few days, in others it
continued for many weeks. It comes to mind
'Read before the Section on Medicine of the Medical Society
»f the Stat« of Pennsylvania, Pittsburgh Session, October 7,
1920.
that these lethargic cases do not generally pre-
sent the appearance of ordinary slumber. When
we look at them, particularly the Parkinsonian
types, prone on their backs, with hands charac-
teristically folded across the chest, and often
with waxen, expressionless faces, we observe a
very different picture from that of the restful
relaxation of normal sleep.
The depth and duration of the lethargy
seemed to bear no definite prognostic correlation
as to outcome. Four cases: 8, lo, ii, 15, in
spite of the fact that their lethargy was most
pronounced, made excellent physical recoveries.
These were all Parkinsonian types, with cranial
nerve, and other neurologic complications. And
their outlook during the course of the disease
had appeared grave. On the other hand case
20, in whom such neurologic pathology was so
slight as to justify a favorable prognosis, passed
into coma with the development of bulbar symp-
toms and terminated fatally.
The depth of the lethargy was at times indi-
cated by associated amnesic periods, distinct
gaps in memory being recorded in several cases.
Case 10 presented a period of complete amnesia,
covering three weeks' duration. Case 11 re-
membered only a few incidents during a period
of two weeks. On the other hand, many of our
patients who were lethargic, or even at times
delirious, showed, when questioned, a surprising
and unexpected knowledge of events which had
happened during their lethargic or confused
period.
The clouded mental condition, sometimes mis-
taken for delirium, which some of these leth-
argic patients show upon being roused, may be
compared to the confused state often seen in
senile individuals when awakening from sleep.
In senile patients this confusion results from the
crippled, sclerotic circulatory mechanism, and
can be correlated with the resulting inability of
the cortical cells to assume at once normal f unc- '
tioning, because the crippled and inelastic cif-
culation is unable to adjust itself to the sudden
change from sleep to consciousness. In other
words, the sen.sorium cannot, because of the cir-
culatory disturbance, put itself readily in con-
tact with the outside world. In the encephalitic
case, the confusion, or disorientation, upon wak-
ening is also, apparently, due to circulatory em-
barrassment, but here the interference is of a
very different nature from that which occurs in
the senile; for in the lethargic case there is a
local perivascular congestion about the basal
ganglia and brain stem which blocks and im-
pairs the physiologic functioning of the sensory
and interconnecting nerve paths, commissural
and associative, thus preventing the cortex from i
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THE PENNSYLVANIA MEDICAL JOURNAL
April, 1921
ready tabulation of peripheral and outside
stimuli, for purposes of orientation.
In marked contrast to the picture of lethargy
presented in these cases, are manifestations
characteristic of anxiety. These symptoms
seemed to be, in some form, as definitely asso-
ciated with the disease as were the symptoms of
lethargy, 15 of the series showed varying pic-
tures of restlessness, insomnia, delirium and ap-
prehension, alone or variously combined, at
some time during the course of the disease. I
am inclined to believe that indications of anxiety
could be elicited in the initial stages of every
case, though they may be so evanescent as to
escape observation. Case 5 presented an initial
anxiety state succeeded in a few hours by oc-
cupation delirium. This was a fulminating
type. The patient had been at his routine work
and had seemed well the day before delirium
developed. At the end of two days this had
passed into a stuporous amentia with muttering
delirium. A week from the onset death oc-
curred following coma, bulbar, paralysis, hyper-
pyrexia, and profuse sweating. In certain cases
the restlessness and lethargy alternated, though
the lethargy in the majority of instances domi-
nated the picture.
It is to be remembered, however, that the ap-
pearance of lethargy by no means excludes the
fact that there may exist coincident with the
drowsiness, or stupor, an underlying state of
anxiety. In some cases, even where the leth-
argy was extremely marked there was evidence
of mental distress. Case 9 expressed fear of
death whenever he could be aroused. Case 8,
presenting a cataleptic state for weeks, if
aroused, muttered anxiously about his work, and
those dependent upon him.
In many cases an occupation delirium mani-
fested itself, thus indicating, we believe, an
anxious mental state. A fact observed in con-
nection with the occupational delirium was that
it appeared early in the course of the disease
during the purely toxic, irritative stage. How-
ever, where the disease became severe with the
addition of exhaustion, the delirium developed
into a confused mixed type, suggesting a transi-
tion from a purely toxic, to that of a toxic ex-
haustion delirium.
Case I, an electrical wire worker, imagined
himself at his work during the early course of
his disease. He gave orders and spoke in terms
connected with his shop work, wound the bed
clothes about his legs, and twisted his ties and
socks about his arms and legs, indicating his
confused ideas of applying his occupation.
Case 8, a shoemjiker, imagined himself mak-
ing shoes. During convalescence, this patient
had a clear recollection of the content of his
early delirium.
Case 19, a minister, kept himself, during the
early period of the disease, busy conducting
marriage ceremonies and other affairs of his
parish.
Case 15, a telephcme operator kept busy call-
ing and receiving numbers, and operating an
imaginery keyboard.
One circumstance in determining the nature
of this delirium was no doubt the fact that many
of these patients anxiously struggled^ for a time
to carry on their occupation, even while the las-
situde to which they finally succumbed was in-
capacitating them.
As already stated, we found a striking rela-
tionship existing between the mental symp-
tomatology and the condition of the muscular
system. In the lethargic period, however, this
relationship between muscular tension and men-
tal anxiety, so far as appearances go, does not
always exist. But upon analysis of the condi-
tion we find that though the musculature is, as
it were, set for the accompanying mental state
of restless anxiety, such a mental state is either
in abeyance or temporarily abolished, due to the
peculiar pathology of this disease, the action of
which is later explained.
The accompaniment of apprehension, or anx-
iety, with muscular tension was pronouncedly
and continuously present in those cases in whom
there was no lethargy, or where the irritability
of the nervous system was so overwhelming
that the anxiety was never submerged by the
lethargy. Normally we expect manifestations
of anxiety with irritability and tension in the
muscular system. Yet, in certain of our cases
where the lethargy was pronounced, we found
in the mental field, indifference and lack of anx-
iety existing along with a tonic and irritable
state of the musculature. This picture is in con-
tradiction to that physiologically observed. But
it is significent that lethargic patients who pre-
sent this paradoxical condition have shown anx-
iety symptoms both previous and subsequent to
the lethargic period, indicating, it seems to me,
interruption to the physiologic relationship be-
tween musculature and the psychic state.
In certain cases (these were the paramy-
oclonic cases, and our most severe types), there
was added to the usual muscular rigidity, an ex-
treme degree of muscular irritability shown in
more or less violent muscular spasms, fibrillary
twitchings and tremors. It was here that the
lethargy seemed unable to overcome or neutral-
ize, the irritative, toxic, and exhaustive effects
of the disease, upon the nervous system. And
we had, as it were, the manifestation of a strug-
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April, 1921 MENTAL SYMPTOMS IN ENCEPHALITIS— WHOLEY
455
gle between conditicms making' for anxiety, fear
and anguish on the one hand, and somnolence
and comfort on the other.
Case 9 illustrates the extreme anxiety type.
The condition was ushered in with occipital
pains, and paroxysms of pain over the left side
of thorax. There was weakness and soreness
in left arm. From the onset there was marked
restlessness and insomnia, passing rapidly into
an occupation delirium. The fourth day leth-
argy intervened, but it never deepened to the
extent of submerging the anxiety. The patient
constantly expressed fear that he would die,
leaving his family unprovided for. A mutter-
ing anxious deliriimi with excessive tremors and
general fibrillary twitchings set in some days be-
fore' death, with difficulty in swallowing and
some retraction of head. This patient presented
the most distressing picture of pain, anguish
and apprehension the writer has ever witnessed.
Even in his confused drowsy state, he would beg
piteously for relief from his suffering, and ask
for assurance that he would live. For two days
before death, muscular rigidity reached an ex-
treme degree, and fibrillary twitchings and tre-
mors were general, including the face. There
w^as bulbar paralysis, profuse sweating and tem-
perature of io6° F.
In this tjrpe of case it is evident that the motor
areas of the cord, and finally the cortex itself,
are highly irritated. Here, also, the anxiety
reached a degree of severity not found in any
other type of case of lethargic encephalitis.
In another case we have the contrasting symp-
toms of apprehension and indifference alternat-
ing with each other during the course of the
disease. This is the condition commonly seen.
The onset, extending over two weeks, was
marked by pains in bones, restlessness, occupa-
tion delirium, insomnia, anxiety about work, and
involuntary jerking of arms and legs, diplopia,
and ptosis of eyelids. These symptoms became
more and more aggravated, with increased mus-
cular tension until in the fourth week, with the
development of lethargy, all indications of anx-
iety gave way to the contrasting symptoms of
indifference, somnolence, and euphoria. A typ-
ical Parkinsonian syndrome was presented, ex-
cept that the picture of anxiety and restlessness
so common in Parkinson's disease was replaced
by stupor and immobility; there was automatic
obedience to commands, and perseveration of
acts performed. The patient lay motionless like
a wax figure for six weeks, though she could be
aroused to take food. At the end of six weeks,
stupor began gradually to disappear, with re-
laxation and ability to use muscles. And sig-
nificantly, symptoms of anxiety reappeared.
replacing those of euphoria and sleepy content,
and insomnia took the place of the excessive
somnolence. The patient would say, "I can't
sleep until my brothers are in at night." "I'm
so worried about getting back to work."
This patient is a good illustration of the man-
ner in which, in my series, anxiety and restless-
ness typically alternated. Anxiety and restless-
ness were in evidence up to a certain time, when
lethargy intervened ; then, as lethargy subsided
evidences of anxiety again came into the fore-
ground.
The mental state which accompanies a condi-
tion of general muscular tension is one of rest-
lessness, an*iety or fear. This relation between
muscular "tension and mental agitation is seen
throughout- the animal world where danger
threatens. In certain psychopathological states
we find this physiological relationship main-
tained. Striking examples are to be seen among
the involution melancholias, particularly the
presenile type. In other pathological conditions
this relationship may be maintained, or may be
absent, or even the very opposite mental state
from what we might expect with muscular ten-
sion may be substituted. Thus in catatonic types
of dementia precox any of these conditions may
prevail ; in other words, we may find muscular
tension with anxiety, or with apathy and indif-
ference, or even with euphoria. In these, and in
other such psychopathological conditions, we
have not been able uniformly to correlate with
precision the mental symptomatology with a
definite and constant underlying pathology. In
encephalitis, however, we have, I believe, a dis-
ease in which we are able to correlate mental
manifestations with a characteristic pathological
process. The fact of this correlation gives ad-
ditional diagnostic significance to the mental
symptoms in epidemic encephalitis and places
them on a level as diagnostic signs, with the
neuropathology peculiar to the disease.
MacNalty's explanation of the most conspicu-
ous mental symptom, the lethargy, also with
equal authority could account for the other
mental symptoms peculiarly associated with this
lethargy ; it would further explain the circum-
stance of the blotting out during the lethargic
period of the symptoms of anxiety, restlessness
and irritability, in the face of the parodoxical
situation of excitation and tension of the muscu-
lar system.
MacNalty in his explanation of the lethargy,
points out that the usual method of inducing
sleep is by cutting off external stimuli. The in-
dividual lies relaxed and at rest, the blinds are
drawn and the room is darkened. Similarly
hypnotics mainly act by inhibiting afferent stim
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THE PENNSYLVANIA MEDICAL JOURNAL
April, 1921
uli to the sensorium. It is known, he says, that
all the afferent stimuli from the environment
stream into the optic thalamus, thence pass to
the neopallium or cerebral cortex, and to the es-
sential organ of the thalamus. In taking this
route, in the main they pass upward through the
crus cerebri in near proximity to the nucleus of
the third nerve. Fibers of the third nerve come
into close relation with the fibers conveying af-
ferent stimuli to the thalamic region. Hence it
follows that any illness affecting this anatomic
localization of afferent paths is associated with
stupor, for it involves a blockage of the afferent
stimuli.
MacNalty further substantiates his theory of
the pathology in and about the optic thalamus by
citing such local and proximal signs as the clin-
ical involvement of the third pair of cranial
nerves, post mortem findings, and the absence
of optic neuritis, and by correlation of such
pathology with drowsiness, lethargy, stupor or
coma.
Assuming the correctness of MacNalty's
theory, further application of the same reason-
ing gives anatomical explanation of the varying
degrees of muscular stimulation and rigidity
found in lethargic encephalitis. Interference
with the sensory, or afferent paths has been re-
ferred to in the above hypothesis. We can as-
sume that the efferent, or motor paths, are also
directly hampered in their furiction by the same
basilar pathology, thus removing the stabilizing
control of the upper neurons over the body mus-
culature. The great body reflex arc is thus
blocked on the motor side, as well as on that of
the sensory.
As we know, we have in lethargic encephalitis
a large group of cases which we designate as
Parkinsonian in type. In appearance the re-
semblance of these patients to cases of true paral-
ysis agitans is indeed striking, but upon analysis
of symptoms we find that this resemblance is
restricted to the physical manifestations. The
mental symptoms characteristic of true Parkin-
son's disease are replaced in encephalitis by a
mental symptomatology of an entirely opposite
character. It would seem that the specific pa-
thology underlying Parkinson's disease becomes
active in these lethargic cases, but by reason of
the sensory blocking, the encephalitic patients
are spared the mental distress common to true
paralysis agitans. The apparent exception to
this finding among my cases, was the few in-
stances of the myoclonic type where the lethargy
did not itisensitize the patient to the violent
nerve irritation.
While the sense of euphoria, or feeling of
well being, usually found in these patients along
with the lethargy, is probably in large measure
dependent upon the same pathology as that in-
ducing the lethargy, there is reason to believe
that it depends rather specifically at times upon
the degree to which the pain tract is obtunded by
the pathological process. This observation is
particularly true of the myoclonic cases. Case
I was subject from the beginning of his disease
to a violent contraction of his abdominal mus-
cles; during the first day it was present only
upon the right side, and occurred at intervals of
a few seconds. On the second day a similar
condition appeared on the left side, but the con-
tractions alternated with those on the right. The
patient's entire bpdy was visibly jerked from
side to side by these contractions which gradual-
ly lessened in frequency until death occurred,
one week from onset. His entire musculature
became rigid, his neck was retracted, and for
two days before death, he was unable to swallow,
apparently because of the spasmodic contraction
of the muscles about the throat. Consciousness
was clear up to last day of illness, though he
presented a picture of intense pain and anguish,
and the conditions were present which ordi-
narily produce excruciating pain; but though
questioned many times, he always replied that he
was not suffering and felt comfortable. Even
when articulation was impossible, he would nod
his head, indicating that he felt well. On the
other hand case 9, already cited, a similar my-
oclonic type, complained distressingly during
his entire illness, and until his death, of intense
pain and anxiety.
While both these cases were equally lethargic,
in one there was acute sensitiveness to pain, and
in the other there was no pain. It seems reason-
able to conclude from such cases that the pain
tract may be separately involved by the patho-
logic process.
The state of euphoria which exists in so many
of these lethargic patients often accounts for
the very noticeable lack of insight they exhibit
in appreciating the gravity of their illness. Un-
less very lethargic the euphoria at times occa-
sions some difficulty in handling such patients
for they insist upon being up, as they feel so
well, and think they ought to be at work, and can
see no necessity for the rest they so urgently
need. Another case of an ambulatory type kept
at work though he would fall asleep at his desk,
and while at lunch, and immediately upon reach-
ing home in the evening.
Four of my cases were of the severe myoclonic
type. Two of these terminated fatally. There
were ten cases of the protracted deeply lethargic
type, and there was but one death in this group.
It would seem reasonable to conclude, judging
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April, 1921 MENTAL SYMPTOMS IN ENCEPHALITIS— WHOLEY
457
from this series of cases, that the prc^osis for
life is more favorable in the deeply lethargic
patients, regardless of the prolongation of the
disease. It is not improbable that the favorable
outcome in the somnolent cases is in part due to
the fact that in these patients, by reason of the
sensory blockage, the cortex is spared the ex-
haustion due to insomnia, pain and other irritat-
ing stimuli which overwhelm the myoclonic case.
The mental symptoms in certain cases of brain
tumor may closely simulate those seen in leth-
argic encephalitis. A case in point was a young
man I saw, who after a few days of restless
activity fell into a state of somnolence precisely
like that characterizing lethargic encephalitis.
There was a left side spastic hemiparesis, with
facial palsy and eye symptoms. Post mortem
examination revealed a large glioma involving
the right hemisphere, and invading the mid-
brain and center of medalla in such a way as
probably to account for the mental symptoms of
somnolence and euphoria such as are produced
in lethargic encephalitis.
The mental symptomatology of encephalitis
may closely resemble that of dementia precox.
Particularly true is this where catatonic symp-
toms prevail, such as negativism, automatic obe-
dience to commands, waxy plasticity of the
muscles, etc. Case 12, a youth of 14, presented
mannerisms, silly behavior, and hallucinatory
experiences strikingly resembling those of hebe-
phrenic dementia precox, throughout the course
of his encephalitis. We must, of course, re-
member that encephalitis may occur in dementia
precox types of individuals, and may tempo-
rarily bring into the foreground the latent pre-
cox symptomatology. Encephalitis may also, on
the mental side, resemble cases of cerebro-spinal
lues of the euphoric, mildly clouded types, but
here the laboratory findings at once decide the
diagnosis.
As to the prc^osis for mental recovery, I be-
lieve that a long period of observation is neces-
sary in order to make any definite statement as
to recovery in those patients who have passed
through a protracted lethargy, with the cranial
nerve involvement peculiar to these cases.
Case ID, lethargic for three months, was seen
eight months after leaving the hospital. He had
been able for several months to carry on his
business, though under less exacting conditions
than before his illness ; physically he appeared
well, and his friends regarded him as having
made a splendid recovery. But I found that
mentally he had undergone a pronounced
change. From being an easy-going, cheerful,
optimistic individual, he had become faultfind-
ing, irritable, suspicious, tyrannical and selfish.
He showed no appreciation of the great sacri-
fices his illness had caused his family to make,
struck his wife, and treated his son as an out-
cast. His attitude has become definitely para-
noid. His pupils are still static and unequal,
and he is devoid, since his illness, of the sense
of smell. It is not improbable that he has suf-
fered permanent character deterioration due to
organic brain damage.
Case 7, a lethargic Parkinsonian type, was in
the hospital four months. I saw him three
months later, and physically he appeared well at
this time. But he was still unable to return to
work because of general muscular tremulous-
ness, insomnia, dizziness and anxiety. His pu-
pils were rigid and there was nystagmus. He
now presents the symptoms of disseminated
multiple sclerosis.
Case 14, in the hospital two months, presented,
on discharge, well advanced mental and physical
symptoms of disseminated sclerosis, which be-
gan to appear as he emerged from the lethargy.
This probably was a case of incipient sclerosis,
which progressed rapidly as a result of the en-
cephalitis.
In case 17, a woman of thirty-five, a most ag-
gravated condition of hystero-neurasthenia of
hypochondriacal character supervened during
convalescence. The patient looked unusually
promising until this developed. While she is
somewhat improved, now eight months after the
onset of her illness, one is justified in regarding
her future with some doubt. She was another
of the well developed Parkinsonian types.
Case 8, age 18, was in the hospital three
months, I again saw this patient three months
after discharge. In the hospital he had pre-
sented an extreme grade of the Parkinsonian
type. Muscular tremors and choreiform move-
ments preceded the onset of lethargy. During
the height of his muscular rigidity, no muscular
movement was possible in the face, except a
very slight separation of the jaws for taking
food. In its waxen rigidity his face was entirely
without expression. I found him, three months
after leaving the hospital, much improved in
physical appearance. But he complains of in-
somnia, and says he has "funny dreams about
things that happen the day before." Shortly
after going to bed he "feels paralyzed all over"
and as though "floating in space, or falling away
down." He says that at these times he can hear
what is going on but cannot move. His mother
says that in these attacks he groans and the
muscles about his mouth "twist and twitch."
These attacks occur almost nightly upon going
to bed. He con^lains of an involuntary jerking
of the left arm, and of flexion of the toes of the.
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458
THE PENNSYLVANIA MEDICAL JOURNAL
April, 1921
left foot. Jerking of the mouth to the left at
times accompanies these movements. Upon
grasping things, the movement of the arm is
stimulated and he has to let go, dropping the
article. These muscular spasms have prevented
him from taking up his work — that of a shoe-
maker. When walking he feels propelled to the
left.
Examination reveals, in addition to these
spasms, a Parkinsonian fades, deep reflexes,
mouth slightly drawn to left, dermographia and
a central nystagmus. Mentally he is indifferent
as to his condition, in marked contrast to his
concern about himself upon leaving the hospital.
He says that his memory is poor and gets no
better. He gets angry at the least little thing,
whereas before entering the hospital he was
especially amiable and gentle. His mother says
the irritability is an entirely new thing. This
young man is now a victim of epileptiform seiz-
ures and presents character deterioration in
keeping with epilepsy. I believe that his symp-
toms are due to permanent organic brain dam- •
age consequent upon the encephalitic pathology.
The fact is not to be overlooked that the men-
tal symptoms of anxiety, restlessness, apathy,
.somnolence, etc., are the common accompani-
ments of confusion and deliria, whatever the
cause, but there is a certain sequence and group-
ing of such symptoms in epidemic encephalitis
which is peculiar to the disease. Basing conclu-
sions therefore upon observations made in this
series, there seems sufficient grounds to warrant
the hypothesis that in cases of epidemic encepha-
litis whose progp-ess is unaltered by extraneous
disease processes, we have a characteristic ac-
companying mental symptomatology. This
symptomatology expresses itself, on the one
hand in terms of anxiety, restlessness, and in-
somnia ; on the other in terms of indifference,
quietude and somnolence. There is reason to
believe, that in the mental syndrome anxiety is
as characteristic of the encephalitic process, as
is the lethargy. This is evidenced by the almost
constant appearance of anxiety symptoms before
the lethargy sets in, and their reappearance as
the lethargy subsides ; also by the early occupa-
tion delirium, by anxiety drearhs and anxious
states of mind existing coincident with the leth-
argy, revealed when the patient is aroused, and
by the uninterrupted anxiety picture in non-
lethargic cases. It would seem that some form
of anxiety is the natural accompaniment of the
disease with its motor irritation and muscular
tension, and that the supervention of lethargy
is an incidental process depending upon the
degree of the basilar sensory involvement. Fur-
thermore our observations point to the conclu-
sion that those cases which have been marked by
protracted periods of deep lethargy with the
common accompanying neurologic impairment,
will show some degree of permanent mental
damage.
4616 Bayard Street
THE AUTOPSY FINDINGS IN EPIDEMIC
ENCEPHALITIS*
W. W. G. MACLACHLAN, M.D.
PITTSBURGH
During the past year, eight cases of epidemic
encephalitis have been recorded by the patho-
logical department of the medical school. The
autopsies were done by Drs, Klotz, Richey and
McMeans. It is my purpose to briefly describe
from a morphological point of view the gross
and microscopic changes observed in this group.
The lesions are of the central nervous system.
Naturally, in some of the cases where the pa-
tient had been unconscious for a considerable
period of time one would expect, and usually
did see a terminal broncho-pneumonia. Like-
wise, the presence of a chronic heart or kidney
lesion in the adults should not be considered un-
usual. These lesions are incidental and have
nothing to do with the pathological picture of
the acute encephalitis. Our remarks, therefore,
will pertain solely to the central nervous system
which appears to be the only visible site of the
disease in the materials studied.
Acute epidemic or lethargic encephalitis is of
infectious origin, but the nature of this infection
is not known. Its relation to the pandemic of
influenza is interesting as it was recognized after
the 1890 epidemic as well as after the past one,
and further the distribution of the two diseases
is also similar. But these facts by no means
throw light on the cause of the encephalitis.
Flexner cannot see any relation between the two
pandemics except an incidental one. Observa-
tions have been made to indicate that the disease
is transmissible to animals and further, that a
filtrable virus is responsible for the disease
which reminds one of the studies of Flexner
and his co-workers on acute poliomyelitis.* The
pathological lesions of epidemic encephalitis are
well known and have been accurately described
by many observers in all parts of the world.
These reports would indicate that the epidemic
was the same in this community as elsewhere.*
Seven of the eight cases occurred in males
varying in age from four to forty years. The
only female case was accompanied by pregnancy.
'Read before the Section oti Medicine of tlie Medical Society
of the State of Pennsylvania, Pittsburgh Session, October 7,
■ 920.
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April, 1921 AUTOPSY FINDINGS IN ENCEPHALITIS— MACLACHLAN
459
The duration of the illness was as a rule, about
two weeks, but in some it was longer, one being
four weeks wiiile in two cases death occurred
on the day of admission to the hospital after a
little more than twenty-four hours illness. Fatal
cases, therefore, may be of a fulminating type
or on the other hand of a chronic character.
The majority, however, lie between these ex-
tremes. Of the signs and symptoms of the dis-
ease, we shall not speak except to say that the
protean manifestations of this year's epidmic
depend to a great extent on the situation of the
lesion which may be anywhere from the cord to
the cortex.
One should recall that it is possible to have a
very serious, in fact, a fatal lesion of the brain
without any gross demonstrable evidence. The
autopsy findings in rabies are a good example.
Four of our eight cases showed no evidence of
any gross lesion in the brain. From the patho-
logical point of view the majority of cases of
acute epidemic encephalitis were diagnosed only
by microscopic sections of the brain tissue. One
can readily remember occasional occurrences in
the past where even after autopsy one wondered
why death had occurred. Certainly, it should
be the rule in the future in view of our encepha-
litis experience, never to except the absence of
gross lesions of the brain as indicating a normal
structure. This absence of gross pathology in
the brain has been referred to in many of the
reports of this pandemic. Where the clinical
picture was indefinite or unrecognized it would
be a very easy thing to entirely miss the pres-
ence of encephalitis, if one relied for diagnosis
merely on the gross character of the brain. It
only need be recalled that for a considerable
period at the onset of the epidemic in 1918 in
England, the disease was supposed to have been
botulism and numerous cases were reported as
such. Twice in our series of eight the death re-
port was put down as "cause unknown" even
after the autopsy, and not until sections from
the brain were examined did we arrive at the
exact diagnosis. Both of these patients had been
admitted to the hospital in semiconscious states,
suspected of being cases of methyl alcohol poi-
soning.
Petechial hemorrhages were noted in half of
the number. This is really the outstanding
gross finding in the brain in this disease. In
one the petechiae were numerous and diffusely
scattered, although very few were present in
the cerebellum. At times, these hemorrhages
were clumped, forming small areas usually sit-
uated in the gray matter of the cortex lying very
close to the surface as described by Buzzard and
Greenfield. The petechial hemorrhages were
pin point in size and varied in color from a
bright red to a chocolate brown. An occasional
petechia in the basal ganglia or pons was all that
could be noticed in three cases, and to see them
one had to look closely. The extensive and
diffuse distribution of petechial hemorrhages
was observed in the most acute case of this
series but in another clinically acute case, almost
as sharp as the one just mentioned, a grossly
normal brain was found at autopsy. One would,
therefore, infer from this small series that the
presence of petechial hemorrhages bears no rela-
tion to the virulence of the infection.
Congestion of the brain is often a difficult
matter to determine. To make an accurate ob-
servation one should always examine the head
first, as the cutting of the large vessels of the
neck usually drains off the venous blood. In
half of the cases, there was a moderate conges-
tion of the vessels, well seen in the meningeal
branches, and a diffuse congestion of the gray
matter appearing as a peculiar pink skin color
which is possibly also due to some associated
edema. Edema giving the substance a glassy
character was present in some degree in all of
the brains studied. The meninges were invaria-
bly free and appeared normal. The spinal fluid
was clear and not excessive in amount. The
ventricles were never dialted nor did they show
any evidence of ependymitis. This is the sum
of the gross pathology of the brain in our group
of encephalitis. Any acute infection with a
bacteriemia could produce the lesions described.
Fortunately, the study of sections presents more
definite findings.
We saw microscopic evidences of- an inflam-
matory reaction in every case. The variation in
the extent of the lesions and their distribution
were points of considerable interest. Further,
the type of cellular reaction was not only dif-
ferent in cases, but also differed in sections
taken from various situations of the same case.
This point we would emphasize. In every in-
stance where a hemorrhagic reaction was noted,
one also saw in other situations, leucocytic in-
filtration about the vessels. We can see no rea-
son why these different celluar responses are
not typical of the one infection and, therefore,
cannot follow Calhoun who regards the presence
of hemorrhage as not indicating epidemic en-
cephalitis.
The pons, basal ganglia and medulla are the
areas where lesions are most readily seen. We
found them in every case in one of these sites
and sometimes they were present in all. It is of
value and importance to cut several blocks of
tissue from suspected areas. Lesions have been
present in some sections of the midbrain and
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460
THE PENNSYLVANIA. MEDICAL JOURNAL
April, 1921
absent in others. Hence, one could readily miss
a localized inflammatory reaction if only a sin-
gle block or single section of a block were ex-
amined. In one of this group the cause of death
was put down as unknown even after the study
of sections of the brain. It was only by further
examination that one was able to see a very
typical but localized inflammatory cell reaction.
The cortical portion of the brain and the white
matter did not show the lesions as often or as
frankly as the basal part, but in the hemorrhagic
type it was true that in the cortex the lesions
were most apparent in the gross and under the
microscope. Cerebellar lesions were seen only
twice. The spinal cord was not examined in
these autopsies. The same type of reaction was
noted in the pia-arachnoid as in the brain in four
instances but it was never very marked.
The perivascular inflltration of inflammatory
cells of the vessels in the pons and basal ganglia
is probably the most typical lesion. This infil-
tration, as mentioned previously, is often very
localized. The reaction may be very slight or on
the other hand, well marked and often in one
field the two pictures can be seen. This peri-
vascular change is identical with that of acute
poliomyelitis. The cells of the infiltration are of
four types. Small lymphoid cells predominate,
polymorphonuclear leucocytes are at times pres-
ent in small numbers, while a few endothelial
leucocytes are usually seen. The plasma cells
are not numerous. The inflammatory reaction
is the acute nonsuppurative lesion. All descrip-
tions by various authors of the histological
changes refer to this classical reaction. Some
appear to have seen only plasma cells, in others
the polymorphonuclear leucocyte is not men-
tioned while the endothelial leucocyte (poly-
blasts and macrophages) gets little notice. The
personal equation in naming cells may possibly
account for the slight variation in the different
reports.
The petechial hemorrhages were, as the name
implies, collections of red blood cells. One was
struck by the absence of the leucocytes in these
hemorrhages. Three types of hemorrhage were
noted. Firstly, there were round and oval col-
lections of red blood cells free in the brain tis-
sue. When the hemorrhages had fused, their
outline was not so regular and the adjacent tis-
sue was irregularly invaded by the blood cells,
but never to any marked degree. These areas
were the ones which undoubtedly were seen in
the gross. A thrombosed vessel was not infre-
quently seen in the center of some of these
hemorrhages. Secondly, the red cells were lying
as a broad collar about the vessels in the peri-
vascular space but not invading the brain tissue
and thirdly, perivascular disintegrated red bhjod
cells with blood pigment taken up by the en-
dothelial leucocytes, were observed. This last
type was seen on two occasions. The endothe-
lial cells were never numerous nor was the blood
pigment ever abundant. Blood pigment was
never observed lying free in the tissues. The
presence of the blood pigment is in all probabil-
ity, an evidence of chronicity of the process and
certainly is proof that the petechial hemorrhages
of epidemic encephalitis are not agonal.
Another type of infiltration at times noted but
not so definite in character, was a diffuse scat-
tering of lymphoid cells throughout the brain.
These cells lay in the periphery of the capillaries,
at times, in small clumps of two or three. Oc-
casionally they appeared in rather long chains.
They could be clearly differentiated from the
neuroglia cells. The midbrain was more in-
volved by this process than the cortex.
The small vessels showed distinct lesions.
Where hemorrhage was marked we were always
able to see hyaline thrombi in the lumen of the
vessels which often appeared as the centre of a
hemorrhage. Some of the thrombi in places
showed strands of fibrin which could also be
recc^ized in the hemorrhagic areas about the
vessels. The vessel walls in the thrombosed
portions were necrotic, a good reason for the
escape of blood. In the less severe reaction it
appeared that the walls of the arterioles Were
swollen and hyaline in character. This change
was readily seen where the vessels were cut
longitudinally. The hyaline swollen walls in the
part less involved gradually melted into the
thrombus and its surrounding hemorrhage.
Thrombi were only observed when the petechial
hemorrhages were present. There was no evi-
dence of a leucocytic reaction in the wall of the
thrombosed vessels. It was therefore not an
arteritis in the ordinary sense of the term. This
vascular lesion has been given but the slightest
mention in the reported cases except for Buz-
zard and Greenfield who have described it in
considerable detail. We regard the vascular in-
volvement as being of considerable importance
for it possibly indicates the method of infection
of the brain.
We do not lay much stress on edema as seen
in the sections. It was not usually marked but
in all probably a certain amount was present.
Brain sections are not the best to speak of in
terms of edema. Postmortem change and tech-
nique can imitate this feature in a very exact
way. I prefer the gross recognition of edema
(glassy brain) when brain tissue is in question.
We were not often able to observe degenerated
nerve cells. This is by no means the easiest
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April, 1921
ENCEPHALITIS— DISCUSSION
461
lesion to recognize when but little morphological
change has occurred. Occasionally, very typical
isolated nerve cell destruction with endothelial
cell infiltration and replacement was observed,
but with nothing like th^ frequency or intensity
that is noted in acute poliomyelitis. Degenera-
tion of nerve cells was very easily seen in the
sections showing some of the substantia nigra.
Destruction of large pigment bearing ganglionic
cells was plainly shown by the scattering of the
pigment granules in the surrounding tissue. We
observed all stages from an apparently slight re-
action on the nerve cell with a few free pigment
granules to cells which were totally disinte-
grated, with endothelial leucocytes present about
the remains. We noted this involvement of the
substantia nigra in two cases but possibly if
more tissue from this portion of the brain had
been examined the lesion might have been dem-
onstrated in the majority. Harvier and Levaditi
have described the same type of lesion of this
pigmented portion of the brain. There was no
definite evidence of neuroglial cell proliferation
nor were there any signs of fibroblastic cell in-
crease arising from the vascular tissue.
CONCLUSIONS
1. The gross lesion of epidemic encephalitis
may be very evident, as diffuse hemorrhages or
entirely absent.
2. Microscopically all cases presented lesions.
3. There is evidence of a severe vascular
lesion in the brain as shown by the presence of
hyaline thrombi in the arterioles with necrosis of
the vessel wdls.
BIBLIOGRAPHY
1. Strauss, Hirsh6eld and Loewe, New York Med. Jour., Jan.,
1910, 109-722.
Mcintosh and Tumbull, British Jour, of Sxp. Path., 1920,
1-89.
2. Bassoe and Hassin, Arch, of Neurol, and Psychiatry, 19191
1-24.
Cafhoun, Arch, of Neurol, and Psychiatry, 1920. 3-1.
Buizard and Greenfield, Brain, 1919, 42, Pt. 4-30S.
Hammes and McKinley, Arch. Int. Med., 1920, 26-60.
Neal, Arch. Neurol, and Psychiatry, 1919, 2-271.
Marie and Tretiakoff, Bull, et Mem. de la soc. Med. des Hop
de Paris, 1918, 42-476.
Harvier and Levaditi, Bull, et H^m. de la soc. Med. des Hop
de Paris, 1920, 44-179.
DISCUSSION
Dr. Max. H. Weinberg (Pittsburgh) : I am very-
glad to note the attempt that Dr. Wholey has made to
analyze and interpret the mental symptoms, instead of
merely classifying and cataloguing them. We hope
that the physical symptoms of this disease will be given
as thorough a thrashing out as he has given to the
mental.
Dr. Wholey has laid stress on the euphoria. The
euphoria, as it seems to me, is merely an indifference.
It is not an exhiliration on the part of the patient ; he
is merely indifferent, he does not care what happens
to him. In order to get rid of the questioner, he says,
"I feel pretty good." Even if you stick a pin in his
forehead very deep, he does not move; not that he
does not feel it, but he is simply not concerned about it.
The same thing, perhaps, applies to the amnesic
period. A number of these patients lie several weeks
practically disoriented. They do not have a true
amnesia, it is really a relative amnesia.
I was glad to hear Dr. Wholey refer to manifesta-
tions of senile dementia. I recall two patients who
would jump up in the middle of the night and wander
around the hospital. But as the lethargy developed
and became marked, this symptom disappeared. This
senile tendency was very well characterized in the
paramyoclonus multiplex type of cases.
There is one thing that stands out more than any-
thing else in the mental syndrome and that is, that the
disease, attacking the brain cells, rather brings out the
characteristic and inherent defective tendencies of the
individual, be that anxiety, depression, dementia pre-
cox, or anything else. These are simply brought to the
surface by the toxic effect of the disease.
In the epidemic of 1918 we did not see such marked
results as during this last year. The sequellae of this
disease, as Dr. Wholey has pointed out, are really
awful, and now we see more and more of its effects.
The unstable individuals especially, seem to be marked-
ly effected, many of them remaining in permanent
psychosis. I just jotted down a few of these cases, to
give an example of what I mean.
I have one case of dementia precox, an end result of
encephalitis. When he took sick he was a typical case
of encephalitis of the dementia precox type. Finally,
after working with him for six or eight months when
all traces of the infection disappeared, he had to be
committed to an insane asylum as a case of dementia
ptecox.
Another case, a nurse, has developed hysteria. She
was kept for six weeks in a darkened room, darkened
especially for her. She wore dark glasses in addition
and wrapped towels around the glasses to shut out
any ray of light. For six weeks she could not stand a
ray of light or take a single step. She was given
psychic treatment and brought around in twelve days,
after which she left for a convalescent home.
Another case was a railroad clerk, a pretty capable
man. He did not have a very serious attack, yet at the
present time, six months after the onset of the disease
and when he is apparently well, he cannot be gotten
out of the house to go to work. The family physician
tried to remove this by persuasion, but as yet he has
not succeeded. He is still an invalid. The way I look
at it is that the mental symptoms are merely a result
of the combination of the toxin and the underlying in-
herent characteristics of the individual.
I was very much interested in what Dr. McCarthy
has said regarding the relation of influenza to en-
cephalitis. I do not agree with him that there is any
relation between influenza and lethargic encephalitis.
It was not only in 1889 that this condition was noted,
but even way back in 171 5 it was alluded to. How-
ever, the definite entity of the disease has not been
pointed out until 1916, some time before the recent in-
fluenza epidemic came on. There are many reasons
which tend to show these are two definite entities and
have little to do with one another.
Dr. George J. Wright (Pittsburgh) : I think we are
particularly fortunate in having three papers on this
subject from different points of view, the first largely
neurological, the second mental and the other the
pathological picture. The ones that interested me par-
ticularly were those which took up the neurological
and the pathological questions. I had considerable^ ex;-|
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THE PENNSYLVANIA MEDICAL JOURNAL
ApRit, 1921
perience with this disease last winter, seeing about
thirty cases, of which number about eleven died. That
may seem like an unusually high mortality, but it was
due to the fact that a great many of the cases came to
the St. Francis and Mercy Hospitals in bad condition.
We must recognize in the first place that this is dis-
tinctly, an organic disease. It is one of the neatest and
prettiest organic diseases of the nervous system that
we have ever had because of the protean manner in
which it expressed itself, and it was just on that ac-
count that we experienced our difficulties in learning
to understand this disease. At first the tendency was
to describe somewhat definite clinical pictures, and
those who were seeing many cases were following more
or less the clinical conceptions that we got from here
and there and elsewhere.
For example, the lethargic type was first described,
then the Parkinsonian type, and later on other types,
with the result that the neurologist was some weeks
and months behind the disease itself. We were ac-
tually handicapped I believe by the fact that certain
men were trying to classify the disease clinically.
Tilney, of New York, had twenty cases in the early
part of the epidemic, and attempted to make a classi-
fication on the basis of his experience. On looking up
the literature, he found that there were quite a num-
ber of types that he hadn't seen himself and he was
compelled to add four or five additional groups of
classification to his own. As long as we were trying to
classify the disease from a clinical standpoint we were
open to misconceptions, and I personally never got
anywhere until it finally came to me that this was a
distinctly organic disease that could affect any part of
the nervous system and that the clinical picture was
dependent on the localization of the lesions. So that
for myself at least I was compelled to adopt a purely
anatomical classification, and when I got that idea the
recognition of the disease was easier than before.
An anatomical classification would be an easy one
along such lines as this: cortical, ganglionic, cerebel-
lar, midbrain, pontine, medullar, spinal and peripheral
nerves. That means just this: that you might have
in any particular case signs of infection plus symptoms
pointing to a more or less focal disturbance of various
parts of the central and peripheral nervous system.
We have Dr. MacLachlan's findings in six cases
which he saw at autopsy. I think at least three of
those cases were my own. Not always is it possible to
correlate the pathological findings with the clinical
picture as we see it ; we can do it partially. We are
compelled to make some assumptions to fit the clinical
symptoms with the infection. In the first place, this is
a nonsuppurative type of inflammation; it is a real
inflammation. It is a real inflammation in contrast to
such a thing, for example, as botulism, which is largely
a severe degenerative process with necrosis of the ves-
sel wall with hemorrhage and the symptomology is
based on the destruction rather than on a true inflam-
mation. The same applies to those cases of polioen-
cephalitis which are due to alcoholism. We have there
the hemorrhagic type of thing rather than this non-
suppurative inflammatory condition. Pathologically
epidemic encephalitis presents a mild picture, or a rea-
sonably mild picture. We have a layer of small round
cells with some other types of cells without much
tendency to hemorrhage. A good many people have
not mentioned this hyaline thrombosis which Dr. Mac-
Lachtan has so clearly brought out. Some others have
insisted that this is a rather important thing. I wish
to emphasize that.
This picture, as far as the microscope is concerned,
looks mild; there are rarely gross hemorrhages. We
would not, therefore, expect to have a very gross
neurologic disturbance, a thing I believe is very im-
portant to remember. Most of the symptoms were of
the finer neurologic variety. In the brain stem there
are a great many structures and fibre paths crowded
in a small area and minute lesions could easily reveal
themselves by relatively slight clinical signs such as
disturbance of eye muscle balance, fine nystagmus, etc
Coarse paralytic phenomena were very rare in my ex-
perience.
We are not through with this disease yet; we are
still having difficulties in making our diagnoses, espe-
cially in the interpretation of the sequellae. From
time to time we see cases of tremor, eye muscle im-
balance, cerebellar disturbance, root pains which may
be the result of an old encephalitis, and yet the subse-
quent clinical history may prove we are mistaken. I
remember one case recently in which there was a clear
history of influenza and shortly after visual disturb-
ances which were found to be a left homonomous
hemianopsia. ' Aside from some slight sensory changes
with numbness, in the left arm and leg, nothing else
was found. The history seemed to indicate the lesion
was stationary, if not regressive, on which basis a
tentative interpretation of a scar of an old encephalitis
was made. Some months later a hemiphlegia devel-
oped with headache and vomiting, whereupon, of
course, a diagnosis of tumor was the only possible one.
In the same way what may seem to be an old en-
cephalitis may be disseminated sclerosis, various types
of neurosyphilis, etc. In all epidemics diagnoses are
apt to be too readily made, and we must not forget
the danger of making serious mistakes even when we
feel quite sure.
Dr. George E. Holtzapple (York) : In our section
of country we had a number of cases of this disease.
I will refer to one case only, that of a nurse, in whose
case we used a therapeutic measure, greatly to the re-
lief of the patient that I believe was not emphasized
in the papers read nor in the discussions which fol-
lowed. In this case the onset was with diplopia, head-
ache, impairment of appetite, slight stiffness of the
neck, no disturbance of the deep reflexes. These
symptoms prevailed for one week. During the begin-
ning of the second week the patient began to suffer
much pain and hyperesthesia over the upper part of
the thorax and shoulders and this extended over the
entire body. During the second week the patient be-
came somnolent and went gradually into deep stupor
and convulsions. We looked in vain over the litera-
ture for something to relieve her. A lumbar puncture
was done, and this relieved the patient wonderfully.
The spinal fluid was under great pressure. This meas-
ure soon restored the patient to consciousness and
relieved her almost completely of pain previously suf-
fered. She remained comfortable for five or six
hours, then gradually became worse with a return of
the pain, stupor and convulsions. Lumbar puncture
was done every 36 or 48 hours for about ten days, after
which it was no longer necessary. The patient made
a splendid recovery. I want to emphasize the impor-
tance of lumbar puncture as a therapeutic measure in
the treatment of this disease.
Dr. Lawrence Litchfield (Pittsburgh) : I rise to
support most emphatically what Dr. Holtzapple has
just said. There have been so many statements that
lumbar puncture had no therapeutic value in these
cases that I feel it is most timely to bring up the ques-
tion. I do not think that anyone who has seen a num-
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April, 1921
RUPTURE OF GALL BLADDER— MEREDITH
463
ber of these cases and has seen them improve again
and again after lumbar puncture needs to have this
fact brought home to him. I feel that lumbar punc-
ture offers the only opportunity to relieve these cases,
and that it will do so whenever the cerebrospinal fluid
is under pressure and in several cases it has seemed
to me to be a life saver.
I should like to mention a very interesting case in
which the symptoms were those of acute transverse
myelitis and in which a study of the case seemed to
make a diagnosis of encephalo-myelitis most probable.
The first symptoms were numbness and loss of power
in one arm followed by weakness in one leg, within a
few minutes; the weakness in the leg increased, ex-
tended to the other leg and within half an hour he
had a complete paraplegia. He was taken home, put
in bed and within a week or ten days developed large
bed sores over the sacrum.
Dk. WholEy (in closing) : I will say just a word in
connection with the discussion of Dr. Weinberg. His
remarks were very much to the point. He questioned
the correctness of the use of the term euphoria in
connection with the sense of well-being experienced by
many encephalitic patients. The term is used to
express a feeling of bodily comfort and the use of the
term is not restricted to any set of cases whose sense
of well-being depends upon any particular pathology
or toxicity. The fact of this sense of well-being being
dependent in encephalitis upon the shutting out of
sensory stimuli does not alter the correctness of the
use of the term euphoria as describing it. H a pa-
tient, as often happens in encephalitis, in spite of the
fact that he may have conditions present which ordi-
narily would produce pain, still feels well, the use of
the term euphoria is very applicable under such cir-
ctimstances.
It seems to me tha't Dr. Weinberg's objection to
saying these patients experience amnesic periods has
much the same fault as his objection to the use of the
term euphoria. Amnesia means loss of memory. At
times this occurs in toxic conditions such as patho-
logical alcoholism, or typhoid state, etc.; at times it
results from a blow on the head ; again it occurs in
epilepsy and may date from the onset of the causative
factor or may antedate this. We use the term broadly
to indicate a lapse of memory regardless of the pre-
cise conditions altering consciousness in such a way
to bring about this loss of memory.
I- agree entirely with the idea that in a disease such
as encephalitis we are often able to witness the
development of certain inherent potentialities existing
in the individual. In this way we see certain cases
presenting dementia precox symptoms, manic-depres-
sive epileptiform symptoms, etc., as the case may be.
This same thing happens in many toxic and exhaustive
states. It is because of this that we sometimes see
dementia precox or otherwise psychosis develop dur-
ing the puerperium or after typhoid and it is equally
true of encephalitis.
In my paper I have endeavored to stress the point
of symptoms taking on a grouping or arrangement
peculiarly found in encephalitis. The symptoms are
not new, but it is the manner in which they are
mobilized that is of interest and significance in this
disease.
E>R. MacLachlan (in closing) : With reference to
the personal equation in the naming of inflammatory
cells I think one has only to recall the discussion on
the endothelial leucocyte which was emphasized by
Mallory about twenty years ago. It has taken about
tliis time to actually have this cell generally recognized
as such. In the description of the inflammatory cell
reactions of this disease there is no question that the
names varied with the different observers for the
mononuclear cells. This is what I meant by personal
equation. I very much doubt that one could possibly
differentiate epidemic encephalitis from acute polio-
myelitis by the inflammatory perivascular inflamma-
tion. The one point which the pathological picture
brought out was the lack of lesions in the brain in
individuals that have most pronounced clinical signs.
SPONTANEOUS RUPTURE OF THE
GALL BLADDER WITH A REPORT
OF THREE CASES*
EVAN W. MEREDITH, M.D.
PITTSBURGH
In most acute inflammations of the gall blad-
der, there is a limited involvement of the peri-
toneum and while a similar condition in the ap-
pendix region is practically always looked upon
as an indication for immediate operation, it has
been customary in gall bladder surgery to treat
this variety of peritonitis expectantly and to
operate after the subsidence of the acute symp-
toms. Such a course is based upon the fact that
most cases of peritonitis about the gall bladder
tend to localize and retrogress due to the fact
that the integrity of the gall bladder wall is
maintained and no actual escape of infective ma-
terial or organisms occurs. The generous blood
supply of the gall bladder usually prevents that
degree of inflammation that leads to perforation
and gangrene, a condition so frequently en-
countered in inflammation of the appendix.
Diffuse nonlocalizing peritonitis due to dis-
ease of the biliary tract is of uncommon oc-
currence. Two types have been described:
perforative and non-perforative. In the perfor-
ative type, gross disease of the gall bladder or
ducts with actual perforation of these structures
is demonstrable at operation or autopsy. This
is the common type and has been exhaustively
discussed by McWilliams in 191 2. He collected
108 cases of perforation of the gall bladder or
ducts into the free peritoneal cavity, including
among these six cases of his own. He gives a
mortality of 48 per cent, and calculates the in-
cidence of this particular affection at one per
cent, of all gall bladder operations.
The writer has collected 25 cases from the
literature since 1912. The non-perforative type
is unique in that a diffuse peritonitis develops
without any demonstrable perforation either
actual or threatened in the biliary tract. Prac-
tically all these cases, however, have shown some
pathol(^ical change in the gall bladder or ducts.
Buchanan in 1912 under the caption "Bible
'Read before the Section on Surgery of the Medical Society
of the Sute of Pennsylvania, Pittsburgh Session, October 7,
■ 930.
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THE PENNSYLVANIA MEDICAL JOURNAL
April, 1921
Peritonitis" described this variety. He collected
from the literature 17 cases, including among
these one case of his own. In his discussion he
presents two pertinent questions.
1. Is the yellow fluid found in the peritoneal
cavity at operation, actually bile ?
2. If so, how did it get there in the absence
of an actual perforation? In the absence of
proof by chemical analysis of this fluid, these
questions cannot be satisfactorily answered. In
all reported cases, however, it has been assumed
by each operator that the fluid was actually bile
and that it came from some undiscoverable
perforation of the biliary tract. In both types
then, the outstanding features are: clinically,
the symptoms of diffuse peritonitis; pathologi-
cally, the presence in the peritoneal cavity of a
bile-stained fluid.
Normal, sterile bile is well tolerated by the
peritoneum as has been proved experimentally
in animals and clinically in man in traumatic
perforations of the gall bladder. It does, how-
ever, lessen the bactericidal properties of normal
blood serum. In view of this fact, the bacterial
content of the bile will determine the extent and
rapidity of -development in this variety of per-
forative peritonitis, the bile contaminating and
diminishing the defensive qualities of the peri-
toneal exudate.
DIAGNOSIS
This will be concerned mostly in differentiat-
ing it from other acute perforative lesions, as
the signs and symptoms are usually quite suffi-
cient to establish a diagnosis of peritonitis. If
seen early the local evidence in the right hypo-
chondrium may point to the gall bladder, though
at this time it is difficult to distinguish it from
cholecystitis. If the peritonitis is diffuse at the
time of observation, a history of previous gall-
stone colic will throw suspicion on the biliary
tract. The initial pain may simulate a perfo-
rated duodenal or gastric ulcer, while the effused
bile gravitating to the right iliac fossa will, as
happens in perforated duodenal ulcer, give rise
to symptoms simulating appendicitis. In fact,
the diagnosis of appendicitis with peritonitis has
been made in a large number of cases.
TREATMENT
Prompt operation is indicated as the reported
cases show the usual time and mortality ratio
that obtains in other perforative lesions of the
abdomen. The occasional occurrence of a per-
forative lesion of the gall bladder or ducts miU-
tates against any fixed rule for delayed operation
in gall bladder affections and throws suspicion
on those cases of cholecystitis in which the cus-
tomary peritoneal involvement is not promptly
limited by palliative measures. The grave con-
dition of many of these patients will limit sur-
gical interference to the minimum and chole-
cystotomy with free local drainage will be the
procedure of choice. Rubber tissue with or
without gauze in the form of a cigarette drain
will satisfy all the drainage requirements. Su-
prapubic drainage is seldom necessary.
Case I. A. Z., female, age 33. Admitted to hos-
pital for goitre operation. Three weeks after goitre
operation developed sudden severe pain in gall bladder
region, pain referred to shoulder. Marked tenderness
over gall bladder. Temperature 99, pulse 80, leucocytes
11,000. EHag^osts : acute cholecystitis.
Following day condition much worse, temperature
100, pulse 120, leucocytes 24,000. Abdomen showed
signs of generalized peritonitis. Tenderness most
marked on right side of abdomen, both upper and
lower quadrants. No jaundice.
Diagnosis: cholecystitis, diffuse peritonitis.
Operation: Rectus incision. Bile-stained fluid
escaped when abdomen was opened. Omentum bile-
stained. All serous surfaces much reddened. No ad-
hesions around gall bladder which was large, tense,
and almost black in appearance. No definite perfora-
tion was demonstrated. Gall bladder contained dark
tarry bile, no gross pus and no stones. Gall bladder
very friable and ruptured as soon as grasped by
forceps. Cholecystotomy. Free drainage.
Recovery.
Case 2. E. W., female, age 77. Definite history of
gall bladder disease. Forty-eight hours before admis-
sion severe upper abdominal pain with vomiting. On
admission, temperature loi, pulse no, respiration 24.
Slight jaundice. Entire abdomen rigid and tender.
Tenderness most marked on right side. No peristalsis.
Indefinite mass in right hypochondrium. Leucocytes
16,800.
Diagnosis : perforative cholecystitis with peritonitis.
Operation : Upper right rectus incision. Pus and
bile escaped on opening peritoneum. Gall bladder
large, red, with patches of lymph and gangrenous areas
on surface, from which oozed bile-stained fluid. The
peritonitis was of the diffuse type and extended be-
yond the limits of our observation. Gall bladder con-
tained pus, dark bile and three small stones. Chole-
cystotomy. Free drainage.
Recovery.
Case 3. J. W., male, age 45. Sudden severe pain in
abdomen six hours before admission. History of sev-
eral attacks of upper abdominal pain without jaundice
during past year. On admission temperature was 99,
pulse 70, respirations 20, leucocytes 22,000. No jaun-
dice. Abdomen tense, not distended, tenderness most
marked on right side. No peristalsis.
Diagnosis : Peritonitis, perforative in origin.
Operation: Upper rectus incision. On opening ab-
domen large quantity of clear yellow fluid resembling
bile escaped. Peritoneum injected. Gall bladder was
rather small, thickened, and intensely congested, and
had three necrotic areas on its free surface, one of
which was perforated and leaking bile-stained pus.
There were no adhesions about the gall bladder. Bile-
stained pus and two dozen small, faceted stones found
in gall bladder. Common duct, duodenum and stom-
ach were normal. Cholecystotomy. Free drainage.
Readmitted six months later for secondary chole-
cystectomy.
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April, 1921
REPAIR OF BILE PASSAGES— BEHREND
465
REPAIR AND ANASTOMOSIS OF THE
BILE PASSAGES FOR THE RELIEF
OF CHRONIC JAUNDICE*t
MOSES BEHREND, M.D.
PHILADELPHIA
Probably no class of cases upon which the
surgeon is called to operate is fraught with more
danger than that of cholemia. The mortality
following operation is high because the patients
are usually in a peculiarly toxic condition before
operation. The toxic effect of bile in the blood
gives rise to various manifestations, the most
notable before operation being the syndrome
known as Charcot fever, while after operation
we have the uncontrollable bleeding which has
been responsible for such high mortality. My-
ocardial degeneration is another cause of death.
On account of the bile which circulates through
all the tissues of the body it must be remembered
that other organs and tissues suffer likewise.
The patient whose blood clots in from five to
ten minutes is considered a good risk but it must
be borne in mind that even these cases will bleed
after operation. It is good policy to protect the
patient by means of a transfusion of blood be-
fore operation. Blood transfusion may even be
required after operation for the persistent bleed-
ing so common in cholemic patients. Calcium
lactate intravenously before or after operation
has given good results. It is also desirable to
use horse serum as a precautionary measure to
prevent hemorrhage.
Cholemia is due to the obstruction of the pas-
sage of bile through the common duct. The
most important factors causing obstruction are :
first, stones in different positions in the hepatic
and common ducts (Insert Fig. i) ; second, ad-
hesions external to the common and hepatic
ducts; third, adhesions within the hepatic and
common ducts (Insert A, Fig. 2) ; fourth, tu-
mors pressing from without (Insert A, Fig. 3) ;
Fifth, tumors at the papilla of Vater (Fig. i) ;
sixth, cirrhosis of the liver (Insert B, Fig. 3) ;
seventh, injuries to the common duct during the
operation of cholecystectomy (Inserts, Figs. 5
and 7).
The latter is without doubt the most impor-
tant, while at the same time it is the one cause
that can be most easily prevented. Many cases
of common duct injury have been reported,
though it is true that by no means all have found
their way into the literature. Eisendrath re-
cently has made an exhaustive study of the 51
'Read before the Section on Surgery of the Medical Society
of the State of Pennsylvania, Pittsburgh Session, October 7,
1920.
tDrawings made at Daniel Baugh Institute of Anatomy, Jef-
ferson Medical College. Clinical work performed at Jewish
and Mt. Sinai Hospitals.
cases reported by various surgeons. This is
comparatively a small percentage of the total
number of cholecystectomies performed.
The manner in which most surgeons perform
the operation of cholecystectomy cannot but be
fraught with danger to the common duct. The
only means of preventing injury to the common
duct is the use of a proper technic. This can be
obtained by the "open" method of operation.
The common duct can never be injured if the
structures within the gastro-hepatic omentum
are exposed to the eye. It has been shown in
the anatomical room that there are 25 per cent,
of variations in the relation of the ducts to each
other and to the blood vessels. A careful check-
ing up at operation reveals the same condition.
Surgeons who have witnessed the open opera-
tion have expressed themselves unalterably in
Fic, I. — Choledochoduodenostomy. The stomach and great
omentum have been thrown up over the abdomen. The trans-
verse meso-colon, the transverse colon and the duodenum are
seen. An opening has been made in the duodenum opposite
the papilla of Vater; a probe enters it. Circumscribing the
papilla is a tumor.
Fio. I. — Insert /4— Shows a stone blocking the common duct
at the papilla of Vater. Stones may be found in other portions
of the common and hepatic ducts causing obstructive symptoms.
favor of this method of operating, and since
they have performed the operation according to
the technic previously described, they have ex-
pressed their satisfaction with it. Therefore it
cannot be too strongly impressed on the profes-
sion, because many are loath to try new methods,
that the elimination of injuries to the common
duct can be accomplished by the open method of
performing a cholecystectomy.
Stones have been met in the course of the
hepatic and common ducts especially at the
papilla of Vater (Fig. i.) When stones are
located in this situation intense jaundice is
persistent if the stone completely blocks the
passage of bile to the duodenum. The symp-
toms of cholemia will supervene if the ob-
struction lasts long enough. The removal of
stones in this situation usually cures the patienLI
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THE PENNSYLVANIA MEDICAL JOURNAL
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provided the cholemia has not been of long dura-
tion which will naturally lead to a progressive
degeneration of the blood and vital organs. The
common duct in these cases is always greatly
dilated sometimes allowing the introduction of
the index finger, the walls are much thickened
and often on account of the dilation of the duct
they can be used when necessity arises for pur-
poses of anastomosis with other hollow organs.
One case of tumor at the papilla of Vater was
encountered. Considerable thickening at this
point prevented the passage of bile to the duo-
denum (See Fig. i). This case was that of a
woman about forty years of age. She had jaun-
dice for months but had always refused opera-
tion. We drained the common duct with a T
tube (Insert B, Fig. 2) and made an anasto-
mosis between the gall bladder and the stomach
(See Fig. 3).
Tumors causing pressure from without are
usually malignant. The diseased organ may be
the pancreas, gall bladder, or some portion of
the gastro-intestinjil tract near the common duct
(A, Fig. 3). The jaundice resulting from these
cases is a mixture of cachexia and jaundice.
They can be greatly benefited and their lives pro-
longed by sidetracking the flow of bile to another
viscus.
Adhesions alone may cause all the symptoms
of an injured common duct. These may be ex-
ternal to the ducts. In a patient illustrating this
point jaimdice was present for a long time. A
mass was felt in the hepatic region and a un-
favorable prognosis was given. At operation
many adhesions were found surrounding the
ducts. The liver was hard, especially in the
region of the hepatic duct. In this case we re-
lieved only the ducts of their adhesions. The
patient made a fine recovery, the jaundice dis-
appeared, she gained weight and has been well
the past two years.
Again adhesions may be within the ducts
(A, Fig. 2). In one case adhesions were situ-
ated at the junction of the right and left
hepatic ducts. The patient had had a chole-
cystectomy performed a year before ; the symp-
toms of cholemia were present three months
before the second operation. As usual in these
cases itching was a most annoying symptom.
After the common duct was reached it was
found collapsed. When opened, a grooved di-
rector met with resistance at the junction of the
right and left hepatic duct. By forcing the
director upwards the adhesions were relieved
and bile began to flow. An allegator forceps
was then used to make sure that the ducts were
patulous (Fig. 2). AT tube was used to drain
the common duct (B, Fig. 2).
Fic. 3. — Insert A. — Adhesions within the right and left hepatic ducts causing collapse of the common duct and ob-
structive jaundice.
Fic. 3. — The common duct opened (Choledochotomy), a probe was inserted which released the adhesion. Then the
bile began to flow.
Pic. 2. — Insert B. — Shows the common duct drained with a T tube.
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Aprh, 1921
REPAIR OF BILE PASSAGES— BEHREND
467
The various operations on the common duct
consume much time and it seems that no matter
how expert one becomes in this line of work the
operation can rarely be completed within an
hour. Many factors prevent rapid work, such
as adhesions which are present to a marked de-
gree, especially where the gall bladder has been
removed at a previous operation. Even if the
gall bladder has not been removed and the com-
mon duct is the seat of attack, adhesions are a
great hindrance to the operator. Again strict
hemostasis must be the rule on account of a
tendency of these patients to bleed. Every little
point must be caught. If we perform the vari-
ous anastomoses considerable time is required,
for the success of the operation is to a certain
extent in proportion to the amount of time con-
sumed.
The procedures employed naturally depend on
the conditions found. If the common duct has
been destroyed (Figs. 5 and 7) as a result
of a previous cholecystectomy an attempt may
be made to reform the duct by means of the
tissue surrounding the duct or the fascia lata
(Fig. 6). This procedure is not always success-
ful because the new duct made in this manner
will not always remain patulous. Another
method which we have employed consists in the
use of the rubber tube over which the surround-
ing structures are sewn (Fig. 7). The rubber
tube is of great service in these operations and
can be used in all the anastomoses of the bile
passages with the hollow viscera (Figs. 3, 4, 5
and 7). The writer has used them with good
effect and can recommend them. They are of
particular value in these repairs and anasto-
moses, because very often the angle of the anas-
tomosis is rather peculiar. In these situations
a patulous opening may be attained until heal-
ing is complete. Sometimes the rubber tube is
discharged quickly or it may remain in situ an
indefinite time. A T tube is used if we wish to
drain the common duct after its re-formation ; a
plain rubber tube may be used in all the anasto-
moses of the biliary passages to the hollow vis-
cera. Recently D. C. Balfour advocated the
use of the rubber tube in operations on the in-
testinal tract.
Where the common duct has been destroyed
the best procedure is the anastomosis of the
hepatic duct to the duodenum or stomach (Fig.
5). The dilation of the hepatic duct assists
greatly in completing the operation. A case
which derived great benefit from this operation
Pig. j. — Insert A. — A tumor pressing from without causing obstruction of the common duct.
Fic. 3. — Insert B. — Cirrhosis of the liver causing persistent jaundice.
Fic. 3. — Anastomosis of the stomach to the gall hiadder. (Cholecystgastrostomy.) A rubber tube may assist in the
completion of the anastomosis depending on the angle of the anastomosis.
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THE PENNSYLVANIA MEDICAL JOURNAL
April, 1921
was reported by us in the Annals of Surgery,
July, 1918. This patient is still living and en-
joying perfect health.
Fic. 4. — Anastomosis of the gall bladder to the duodenum for
the same conditions found in (Fig. 3), (Inserts A and B).
Cholecystduodenostomy. A rubber tube may be used here also
depending on the angle at which the anastomosis is made.
Fig. s- — Hepato-cholan((io-duodenostomy. Undoubt-
edly the operation of choice on account of its perma-
nency. To be performed whenever the common duct
has been destroyed.
Fig. 5. — Insert shows the hepatic duct as found at
operation. Patient living and well. Published in An-
naU of Surgery, July, 1918.
Conditions about the papilla of Vater require
that the common duct be opened first and an at-
tempt made to remove the obstruction by means
of curette or dilators if the obstruction be a
stone. At times this cannot be done. Then the
duodenum should be opened and the stone or
tumor dealt with through this opening (Fig. i).
Fig. 6. — Illustrates a method of reforming a common duct
that has been destroyed from the surrounding tissue or the
fascialata. (Choledocnorraphy.) See inserts Figs. 5 and 7.
Fig. 7. — Insert — Another form of destruction of common duct
seen at operation of cholecystectomy or soon thereafter.
Fig. 7. — Reformation of common duct with the aid of a rub-
ber tube. To complete the operation the surrounding tissue is
sewn around the tube. Same method is used as shown in Fig. 6.
The site of the operation is the second portion
of the duodenum in the region of the papilla of
Vater. The easiest methcxi of approach consists
in tlirowing the great omentum, stomach and
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April, 1921
GALL BLADDER— DISCUSSION
469
transverse colon upward when the duodenum
will be seen at the lowest right lateral portion of
the transverse meso-colon. In this operation
one must be exceedingly careful as to the technic
employed in closing the duodenum. Leakage
from a duodenal fistula is usually fatal. It is
remarkable how much weight patients lose in a
short time after the fistula is once established.
Karely is there a chance given to do a secondary
repair because the patients starve to death in a
comparatively short time. If the accident is
discovered in time, in addition to closing the
opening in the duodenum, a gastro-enterostomy
may have to be performed if the lumen of the
duodenum has been too much encroached upon.
When jaundice is due to tumors of the pan-
creas or an irremovable tumor at the papilla of
Vater, great relief can be given the patient by
the anastomosis of the gall bladder to the stom-
ach, or duodenum (Figs. 3 and 4). In the event
of a cholecystectomy having been performed the
conunon duct could be used instead of the gall
bladder.
In cirrhosis of the liver (B, Fig. 3) tem-
porary relief was given a patient by the anas-
tomosis of the stomach to the gall bladder.
There was a noticeable change in color and the
jaundice, which had looked more like argyria,
became less intense. The patient thought he
was more comfortable and his life was pro-
longed several months.
A case of chronic jaundice in which a pseudo
gall bladder was present is of considerable in-
terest. Three operations in all had been per-
formed on the bile passages. At the first opera-
tion a cholecystostomy was performed ; a year
later a cholecystectomy for a ruptured gall blad-
der at the site of the former drainage opening ;
a year later we again operated for the symptoms
of cholemia. At this* operation a pseudo gall
bladder was found as large as the original gall
bladder removed the previous year. This was
opened and it revealed a deeply pigmented dark
green surface, which did not appear to be a
mucous membrane. At the depths of this pouch,
bile could be seen flowing into it. No attempt
was made to uncover the common or hepatic bile
duct because the anastomosis of the pseudo gall
bladder to the stomach was the operation of
choice. The patient made a good recovery and
barring indiscretions in diet is quite comforta-
ble. The technic in this anastomosis was ex-
actly the same as that used in the anastomosis
of the stomach to the gall bladder.
Every case of chronic jaundice should be
operated on as quickly as possible. Moynihan
has called our attention to several cases that il-
lustrate this point. The internist studies these
cases too long so as to render them unfit for
operation on account of the peculiar toxemia
from which these patients suffer. Even if a
mass is felt one cannot be sure that carcinoma
exists. Many cases are not operated upon be-
cause they are considered hopeless. This cannot
be finally determined until the abdomen has been
opened. These patients have a miserable ex-
istence at best, due to the intense itching, there-
fore any operation that can give relief to their
symptoms must be welcome.
From the foregoing it should be evident to all
that the nicest judgment must be shown in the
selection of the proper operation to be per-
formed on cases suflFering from common duct
conditions. It is especially important in all these
operations to have a perfect technic. This is
impressed on us whenever we do a duodeno-
choledochotomy, since leakage after this opera-
tion is almost always fatal.
It is also desirable that all cases of cholemia
be referred to the surgeon as early as possible
because on this depends to a great degree the
ultimate recovery of the patient.
Finally it is imperative that every case should
be opened, for by this means only can a proper
disposition of the case be made; because many
cases seemingly hopeless and apparently suffer-
ing from a malignant condition have been cured
by a timely operation.
1427 North Broad Street.
REFERENCES
EiModrath D. Surg. Gyn. & Obstet., July, i»ao, Vol. XXXI,
Baliour D. C. Surg. Gyn. It Obstet., Aug., 1920, Vol. XXXI,
No. a, P. 184.
Moynihan B. G. GalUtones and Their Surgical Treatment.
DISCUSSION
On. John J. Cilbridb (Philadelphia) : We have lis-
tened to two very interesting and important papers.
In the first place, in speaking of Dr. Meredith's paper
there is no one who has had much experience with
spontaneous perforation of the gall bladder. Subacute
and chronic perforation of the gall bladder are not so
uncommon with the establishment of an internal, or
an external, biliary fistule. However, a study of the
histories of these acute cases has usually shown that
these patients have given a history of symptoms ref-
erable to the right upper abdomen covering a period
of three or four days preceding the perforation,' or
perhaps there has been a history of recurrent attacks
of gallstone colic. While it is most common in these
cases of perforation that gallstones are present, how-
ever, spontaneous perforation of the gall bladder has
occurred in the absence of gallstones.
A patient came under my observation about a year
ago, a young woman who, after giving birth to a
normal child in one of the hospitals, on her return
home at the end of two weeks developed pain all along
the right side of the abdomen. I saw her four or five
days later and at that time she was suffering from an
acute cholecystitis. I sent her to St. Agnes Hospital,
and the symptoms subsided in a measure for a couple
of days and then she suddenly developed symptoms
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THE PENNSYLVANIA MEDICAL JOURNAL
April, 1921
of acute peritonitis. At operation I found three small
perforations of the gall bladder. There were no stones
present. The point is this: in these cases, as was
shown, the mortality is very high. It seems to me it
is a question of diagnosis and the diagnosis is one of
peritonitis, and when one has a case of peritonitis to
deal with, one should not allow the case to go on,
hoping that some sudden turn in events will prove the
case to be not serious. There is no reason why there
should be a mortality of 40 or more per cent in these
cases, any more than we should have a 40 per cent
mortality in appendicitis. The gall bladder and biliary
passages are about due to receive a concentrated attack
similar to that which was g^ven to the appendix and to
duodenal and gastric ulcer. Then we may have earlier
diagnoses of these cases in the future.
Dr. Behrend in his paper made several statements to
which I cannot subscribe. "Charcots Syndrome," as
he calls it, he said is due to the retention of bile in the
blood, whereas it, i.e., the "Steeple" chart like fever,
is due to infection. Perhaps that is what he intended
to say. He spoke of adhesions within the biliary pas-
sages. Of course, in the strict sense of the term ad-
hesions do not form between surfaces of apposed
mucous membrane.
As to the anastomosis of the gall bladder to the stom-
ach I believe we should retain, as far as possible, the
physiologic function and not anastomose the gall blad-
der to the stomach except under extremely urgent ne-
cessity where one cannot anastomose the gall bladder
to the duodenum. The duodenum is nearest to the
grail bladder and I believe better results will be ob-
tained by the anastomosis of the gall bladder, or the
large ducts, directly into the duodenum. That is where
the bile belongs and where it performs its function.
I might also state an instance following operation on
the gall bladder that one may have suppression of bile.
I had a case of that kind. At the time of operation
I felt certain that I was introducing the tube into the
gall bladder, and thought later when no bile escaped
that I had gotten the drainage tube between the coats
of the gall bladder. (3n small doses of hydrochloric
acid bile began to flow. The use of rubber tubing to
bridge over a defect in the common, or hepatic duct, is
a delusion. You are going to have failure unless you
bring the mucosa of the hepatic duct or the common
duct, in apposition with the mucosa of the bowel or
stomach; you are going to have stricture result by
the formation of an impermeable fibrous cord. We
have accepted that method in the past without question
but we know that the procedure is not in accord with
the facts.
Dr. a. Ralston Mathbny (Pittsburgh) : Dr. Mere-
dith has mentioned the analogy between acute ap-
pendicitis and acute cholecystitis. His cases of
perforation were cases of acute cholecystitis. The
analogy is well placed because the condition must be
handled exactly the same way as in acute appendicitis.
All of us have had the experience of acute g^angrenous
cholecystitis with greatly tiiickened walls and on open-
ing the gall bladder after the removal have found
points of intpending perforation. Fortunately for the
patient protective adhesions form very rapidly in the
upper abdomen and, with the exception of cases where
the perforation takes place into the liver, nature usually
saves the patient from immediately fatal complications.
It has been our experience to have, in two cases, per-
foration extraperitoneally into the liver ending fatally
from liver abscess. Fully one-third of the gall bladder
has no peritoneal covering and perforation can occur
on that side as well as on the free side of the gall
bladder. There is no condition more difficult to diag-
nose than one of these cases of acute phlegmonous
cholecystitis and at operation it is necessary to handle
the viscus with great care to prevent rupture. It is
difficult to make traction and, on account of distended
thickened walls, sometimes necessary to evacuate the
contents before attempting removal.
One point of advantage in handling the gall bladder
when you cannot remove it from the cystic duct up-
ward is to work a stone towards the fundus and back
of the stone tie a large piece of heavy silk like a hang-
man's noose and use diis manner of traction. It is
remarkable how much traction can be made in this
way without tearing the walls as might be done by
forceps. The contents of the g;all bladder are infec-
tious, usually containing streptococci, and avoidance
of puncture is very desirable.
As to the question of accessibility, I think it is the
fault of the average surgeon to make the incision
entirely too short in grail bladder surgery. I read a
paper in Harrisburg some two or three years ago
showing the incision we use from the ensiform carti-
lage to the right of the umbilicus. It has all the ad-
vantages of other incisions and gives ample exposure
without sacrificing the nerve supply to the rectus mus-
cle which comes from the outside. The muscle can be
split You are in muscle tissue which gives good
closure and splendid exposure both to the ducts and
under surface of the liver and it has the advantage
that the suspensory ligament of the liver can be divided
between forceps and the lower section used as a
tractor.
In regard to Dr. ' Behrend's paper. Dr. Eisendrath
and Dr. Behrend have been working along the same
lines. It almost makes us afraid to do grail bladder
surgery after reading Dr. Eisendrath's article in which
he states that there is an anomalous arrangement in
^ per cent of all cases ; that is, double hepatic ducts,
anomalous hepatic artery, etc. These conditions make
the exposure recommended by Dr. Behrend very neces-
sary. I think the tendency in the future will be to open
the peritoneal fold early in the operation. Unfor-
tunately in a grreat many of the cases of long standing,
particularly cases of previous cholecystostomy, we
have almost an insurmountable barrier to any operation
except to begin in a retrograde manner and work down
to the cystic duct
Dr. John B. Deaver (Philadelphia) : Dr. Behrend
in his carefully prepared paper has called attention to
the control of postoperative hemorrhage in cases of
cholemia. While personally I often resort to the same
measures which he and . others use, such as blood
transfusion, the administration of calcium lactate,
horse serum, and the like, it is my experience that
none of these measures is really efficacious. If these
patients bleed, they bleed, and nothing will stop them
except perhaps reopening the wound and packing it
with gauze, and restricting the movements of the dia-
phragm by the rather free use of opium.
A great deal is written in textbooks and in papers
on the subject, regarding adhesions as the cause of
jautulice. With the exception of the adhesions that
often form after cholecystectomy, I cannot say that
my observations conform with those views. Jaundice is
nearly always due to obstruction by stone or by tumor,
principally cancer at the head of the pancreas.
As to injuring the common duct while doing a
cholecystectomy, this is at times practically unavoida-
ble where there is a great deal of pathology. I am, of
course, entirely in accord with Dr. Behrend in recom-
mending the "open method" of dealing with the corn-
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DIPHTHERIA TOXIN-ANTITOXIN— BAUER
471
Dion duct as a means of avoiding such injury, the more
especially as I have practiced this method for a num-
ber of years. Dr. Behrend himself has frequently
honored me with his presence at my clinics and has uo
doubt noticed that this is my invariable custom.
Stricture of the common duct, which Dr. Behrend
refers to, very often is the result of careless surgery,
such as grasping the cystic duct with hemostatic
forceps, or the cystic artery, if perchance it has been
severed. Sometimes it also results from wearing a T
tube ; or it may possibly be to inflammation in one of
the ducts per se. I have in mind a case of the latter
condition. Operation revealed marked stricture of the
hepatic duct, which at first admitted only the finest
probe, but which finally yielded to gradual dilatation
until the normal lumen of the duct was restored. The
patient was entirely cured of his symptoms and has
remained well several years.
In repair of the common duct, resection is often
necessary in the presence of stricture or where the
duct has been seriously injured by pathology: The
manner of repair, of course, depends upon conditions.
An end-to-end anastomosis is often of value; or it
may be better to do an anastomosis of the proximal
end of the duct to the duodenum by inserting a rubber
tube, the lower end of which should extend a short
distance into the duodenum, bringing the two ends of
the duct as close as possible to the suture line and
filling in the defect with great omentum. This, I
admit, is difficult and trying surgery and requires pa-
tience and judgment
I have nothing very favorable to say with regard to
anastomosing the stomach and the gal\ bladder. The
procedure to my mind is not a rational one and rarely
can be productive of good. I do not do it In my
very large experience I have done it only once in a
case of inoperable carcinoma of the pancreas.
Before concluding I should like to emphasize the
value of early operation in cases where there is rea-
sonable assurance that jaundice is due to a lesion of
the common duct. Oncoming jaundice is not, as is so
often claimed, a contraindication to operation. It not
only indicates operation but operation at this stage
offers a much better prognosis than after tl\,e jaundice
is well pronounced. It is these cases that present the
serious postoperative bleeding referred to at the be-
ginning of this discussion.
Dr. Bbhrenb (in closing) : Attention has been called
to the fact that the gall bladder should, if possible, be
anastomosed to the duodenum instead of the stomach.
Sometimes mechanical difficulties are so g^reat where
adhesions have bound down the duodenum that it is
safer to anastomose the gall bladder to the stomach
instead of the duodenum. It is remarkable how the
stomach will tolerate bile. In several of these cases
no vomiting occurred after operation where the gall
bladder was anastomosed to the stomach. That has
also been commented upon by other operators so that
it really makes very little difference whether the gall
bladder is anastomosed to the stomach or the duo-
denum.
One need never fear doing the operation of chole-
cystectomy if the points mentioned are fully carried
out Open up the gastrohepatic omentum and note
the anomalous anatomy of your bile ducts and blood
vessels. Anomalies occur in about 30 per cent of the
cases. It seems to me that not enough cases in which
the common duct has been destroyed, have befen re-
ported and I think that more of these cases should be
reported because it will put the surgeon on the alert
to perform the operation of cholecystectomy properly.
THE ERADICATION OF DIPHTHERIA
BY MEANS OF TOXIN-ANTITOXIN
FOLLOWING SCHICK TESTING*
EDWARD L. BAUER, M.D.
Department of Public Health
PHItADBLPHIA
Health records show that the eradication of
diphtheria by means of quarantine, isolation of
carriers and passive immunization, by them-
selves, will never be an accomplished fact, if in-
deed these procedures make any impression
worthy of note upon the incidence records. It
will not be necessary to go into statistical details
at this time to prove this assertion, for the
ground has already been thoroughly covered by
Zingher,* Byard,' Hull' and others who report
data in both New York and Pennsylvania. The
silver lining to the dark cloud, however, has been
unfolded by the correlation of the work of
Schick and Von Behring, augmented and made
practical by our distinguished colleague, Dr.
William H. Park. Dr. Park's combined use of
diphtheria toxin in the intracutaneous test of
Schick and of toxin-antitoxin mixtures of Von
Behring, has led to the recognition of the sus-
ceptible by means of Schick testing and his ac-
tive immunization by the use of toixin-antitoxin.
This is the answer that is clearly indicated by
sound logic and the already demonstrated facts,
to really reduce the diphtheria incidence.
It is common knowledge, or ought to be, that
a certain percentage of all individuals are im-
mune to diphtheria, and that this immunity is
due to an actual antitoxin content in the blood.
That the development of this antitoxin is pro-
gressive is also known, and the actual tmit
strength per cubic centimeter can be accurately
demonstrated by Romer's technique in any given
case. It is generally accepted that 1/30 of a
unit of antitoxin to each c. c. of blood will pro-
tect against diphtheria ; i/io of a unit certainly
will, and since Romer's technique is quite com-
plicated it obviously cannot be used routinely in
large numbers of cases. The Schick test, when
performed by the technique of Park,* does show,
when negative, that the individual has at least
i/io of a unit of antitoxin in his blood, and is
therefore immune. If the reaction is positive,
then the individual is regarded as susceptible,
not having enough antitoxin to immunize him.
The simultaneous performance of the Schick
and Romer's tests shows a consistently positive
Schick reaction in all who lack i/io of a unit of
antitoxin in their blood, and a negative Schick
'Read before the Section on Pediatrics of the Medical So-
ciety of the State of Pennsylvania, Pittsburgh Session, October
6, 1920.
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THE PENNSYLVANIA MEDICAL JOURNAL
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test will be recorded when there is more than
i/io of a unit in the blood.
The Schick test is performed by making an
injection of 1/50 of the minimum lethal dose of
diphtheria toxin diluted in 0.2 c. c. of normal
salt solution — always freshly prepared — into the
superficial layers of the skin. The flexor sur-
face of the left forearm is the location of choice
for the test. If the injection goes into the
deeper layers, a delayed reaction may occur, and
if it should be delivered under the skin, no reac-
tion can take place because of the rapid diflFusi(Mi
of the dose. We prefer a i c. c. Luer tuberculin
syringe and a 24-gauge J^-inch length needle,
and feel that an accurate test cannot be made
with a larger syringe. Needless to say, asepsis
should be observed.
Recently we reported before the Philadelphia
Pediatric Society" three thousand one hundred
sixty tests, and made the following observations :
that for all ages ive foimd one thousand sixty
susceptibles and two thousand one hundred non-
susceptibles, or 31.8 per cent, were susceptibles
giving positive reactions; that our highest per-
centage of positives was 72.5 per cent., occur-
ring in children from six months to three years ;
that the percentage of susceptibles steadily de-
creases until but 13.5 per cent, of adults tested
were found to be positive. It was noted that
entire families were either positive or negative,
exceptions being met with only in the case of
adults who might be negative while the children
were positive, or a negative found in a very
young infant, passively immunized by its
mother, while the other children Were positive.
Subsequently we performed one thousand more
tests and these children showed the same ap-
proximate percentages for their ages and con-
sistently showed the same features recorded in
the findings of our first three thousand one hun-
dred sixty. It must be distinctly and emphat-
ically understood that Schick testing will not at
any time discover carriers or is it of value in
solving the carrier problem. It has nothing to
do with carriers as such.
The case for Schick testing then rests upon its
consistency in repeated testing in any given in-
dividual, upon the distinct consistency of per-
centages obtained at various ages by competent
observers working independently, and the cor-
relation of the test findings with the blood anti-
toxin content as determined by Romer's tech-
nique. The Schick test does not in any way
confer any immunity, but does separate the im-
munes, whom we can therefore ignore, from the
nonimmunes that we seek with the object of
immimizing for as long a period as possible.
The test is therefore of distinct value if im-
munization is possible.
Heretofore we have used diphtheria antitoxin
to immunize all that were exposed to diphtheria;
in some cases with a frequency that made it tm-
comfortable and possibly dangerous. Realizing
the temporary nature of this passive immunity,
a better method was devised and foimd prac-
tical— the active immunization of susceptibles
with toxin-antitoxin. The immunity thus ob-
tained is slow in its development, but its benefits
are long standing. True, Schick testing and ac-
tive immunization should not be deferred in
their use until an epidemic or direct exposure to
diphtheria has taken place because of the length
of time necessary to make the reading in the
test, which is best interpreted at seventy-two
hours, and the development of the immunity, for
which about twelve weeks is required. Nor can
the toxin-antitoxin and diphtheria antitoxin be
used at the same time, because both immunities,
active and passive, cannot be developed simul-
taneously. The prpper procedure then is to test
all children without awaiting exposure and to
immunize susceptibles actively.
Will the passive immunity of early infancy as
transmitted by the mother to the child — pro-
vided that she has an immunity of her own that
she can transmit — interfere either with the test
or active immunization ? These children so im-
munized always give a negative Schick reaction,
but their tests become positive when they lose this
transferred immunity, usually at the end of six
months, but frequently enough of it lasts up to
two and in a few cases even up to three years.
We believe that toxin-antitoxin has protected
some of these past this age, but our work has
been limited to one hundred cases, all of which
have not as yet passed out of the period of in-
fancy. Since no ill effects attend the adminis-
traticm of toxin-antitoxin in these infants, we
are inclined to continue its use and if necessary,
following Schick testing, repeat it after the third
year. As yet I have had no infant that has re-
quired reimmunization because of a positive
Schick test. One drawback to this procedure is
the fact that three doses, i c. c. each, must be
given at weekly intervals to insure favorable
results.
In more than twelve hundred cases given
toxin-antitoxin, including all ages, we noted
several facts of considerable interest. Since our
work extends over a period of but one year, it
will be impossible to give any idea of the perma-
nency of active immunization. Suffice it that in
institutions where diphtheria was previously
constant and this combined procedure employed,
diphtheria does not now occur. We have noted
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April, 1921
DIPHTHERIA TOXIN-ANTITOXIN— BAUER
473
that young children give no constitutional reac-
tion to toxin-antitoxin. The older the individual
the more apt is a reaction to occur. This is due
to the bacillus proteins contained in the mixture,
and the reaction is more likely to occur in a per-
son who has a pseudo as well as a positive reac-
tion to the Schick test. At least 34 per cent, of
adults will give these pseudo reactions.
Children that react to toxin-antitoxin do so
only after the first dose, as a general rule, and
reactions to subsequent doses are milder, if they
occur at all. The statistics compiled as a result
of the work at Girard College, Philadelphia, are
significant. Five hundred forty-four of a total
of sixteen hundred boys received toxin-anti-
toxin. One hundred nineteen gave a reacticm
after the first dose ; of these, nineteen reacted
after the second dose, but more mildly, and after
the third dose nine of the nineteen gave even
milder reactions. None who did not give reac-
tions to the first dose gave any reactions to sub-
sequent ones. These boys ranged from six to
sixteen years of age, and as Dr. F. L. Greenwalt,
physician in charge at the college, expressed it,
"None of the reactions were as severe as many
that one sees following vaccination against
smallpox." Our observations on these and other
reactions in children lead us to consider this
•Statement a conservative conclusion judiciously
arrived at by a cautious observer.
Reverting to the question of the length of time
toxin-antitoxin affords immunity, Dr. Park* will
no doubt throw considerable light upon this
interesting phase. Gorter and Huinink,* by a
relatively easy method, showed that after two
years their cases had a demonstrable immunity,
and a sudden rise of anti-bodies following re-
injection with toxin-antitoxin after a period of
two years, led them to feel that the cells must
have acquired an immunity.
In an earlier communication' we have re-
ferred to other observers working in single in-
stitutions, but we should like to add at this time
Blum,^ who has kept the Hebrew Orphans'
Home of New York free of diphtheria for two
years. Armand-Delille and Marie,' who give
percentages in their Schick work similar to ours,
advise its introduction into the public schools
and orphanages, as well as into the army and
navy.
The work of the Philadelphia Department of
Public Health for the present has been confined
to the orphanages. Despite exposures, we have
had no diphtheria in those children upon whom
we have completed our work. Efforts are being
made to extend pur campaign to include work in
the health centres and schools. First, however,
we wish to firmly establish it beyond any per-
adventure and attack in those children that we
can follow up. Up to the present but one man
has been assigned to this work and he is pains-
takingly checked up by the chief medical inspec-
tor. Dr. A. A. Cairns, whose division has under-
taken the work.
A few words as to the value of this prophy-
laxsis in adults would be timely. Considering
the low percentage of adults that are susceptible,
we feel that they can be ignored, with the ex-
ception of those whose duties constantly expose
them to diphtheria and who might be an eco-
nomic burden if taken sick as a result of this
exposure. Needless to say, we refer to doctors
and nurses. The advantage of Schick testing all
probationers in training schools will at least aid
us in separating the immunes and nonimmunes,
and advising any susceptible who plans to do
contagious work to become actively immunized.
Dr. A. D. Whiting, medical director of the Ger-
mantown Dispensary and Hospital, finds it ad-
vantageous to follow this procedure, and it has
greatly aided in reducing nurse quarantine, time
lost from duty, and nurse shortage in his insti-
tution. We in turn are glad to do this work for
him because every hospital in the city has been
tied up at some time or other by diphtheria
among its nurses, and the city has had to care
for the nurse as well as throw protective agents
about the training schools, all of which is done
at considerable expense.
Since the greatest incidence of diphtheria oc-
curs principally in young childhood, and since
our regular records show a "dead level"* with
our present methods of prevention, it behooves
us to make this clearly demonstrated method —
Schick testing and active immunization of sus-
ceptibles — a universal practice, especially ammig
our young children, so that they will not suc-
cumb to this loathsome malady, and our health
reports will show a clean sheet in the diphtheria
incidence columns.
6ii2 Germantown Avenue.
REFERENCES
I. Zingber, A. Active Immunization o{ Infants Against Diph-
theria. American Journal Dis. of Child. i6: 83, 1918.
3. Bjrard, D. S. Diphtheria Prevention. Archives of Pedi-
atrics, 37: 22, 1920.
3. Hull, H. Diphtheria from the Public Health Standpoint.
Pa. Hed. Journal, 33: 638, 1920.
4. Park, Wm. H. New York Research . Lab. Publications,
etc., et al.
5. Bauer, E. L. Preliminary Report of Schick Testing and
Permanent Immunization Against Diphtheria in Three Thousand
Children. Therapeutic Gazette, July, 1920.
6. Gorter and Huinink. Active Immunization Against Diph-
theria. Archives de Medecine des Enfants, Paris, 23: 338, 1920.
Abstracts, J. A. M. A., 75, 349, 1920.
7. Blum, J. Active Immunization Against Diphtheria in a
Large Child Caring Institution. American Journal Diseases of
Children, 20: 22, 1920.
8. Armand-Delille and Harie. Schick Reaction. Bulletin De
L'Academie de Medicine, Paris, 83: 530, 1920. Abstract, J. A.
M. A., 75: 507, 1920.
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474
THE PENNSYLVANIA MEDICAL JOURNAL
April, 1921
THE PRACTICAL VALUE OF THE
TOXIN-ANTITOXIN INJECTIONS IN
THE IMMUNIZATION AGAINST
DIPHTHERIA AND OF THE
SCHICK TEST AS A MEANS
FOR IDENTIFYING
THOSE THAT ARE
SUSCEPTIBLE*
WILLIAM H. PARK, M.D.
NEW YORK CITY
Diphtheria antitoxin became generally availa-
ble in 1895. As an immunizing agent it was
found to be absolutely effective for a period of
from two to four weeks. The comparatively
short persistence of the antitoxin in the human
body is due to the fact that the antitoxin is pro-
duced in the horse and is a foreign protein. If
it had been developed in man it would confer
immunity for from nine to twelve months. In
treatment when given early and in a sufficient
dose it has been found to be remarkably success-
ful. In twenty years the previous average yearly
mortality of about 150 per 100,000 has been
cut down to 22. This change is chiefly due to
the use of antitoxin as a curative and immuniz-
ing agent. The prevention of diphtheria has
been less successful than its cure. The number
of cases per 100,000 has been decreased only
about one-third. Efforts during the past few
years to further lessen the number of deaths and
the amount of diphtheria by the more general
and .proper use of antitoxin have been largely
unavailing. Some of the reasons for this are
plain. One of the chief ones is evidently the
great number of healthy individuals who carry
in their throat diphtheria bacilli. Careful in-
vestigations have revealed the fact that at any
time during the winter more than one per cent,
of the population are diphtheria bacillus carriers
and more than one-half of all cases of diph-
theria develop in persons who have not been in
known contact with the disease. Even if labora-
tories could make throat cultures from every one
it would be impossible to isolate the number of
persons detected and even those found to be
free, at the time of the culture, would frequently
become carriers during the period of investiga-
tion. The value of cultures for other than
diagnostic purposes is largely limited to its use
in families aiid institutions. The effectiveness
of antitoxin as a general immunizing agent is
limited because of the short duration of the pas-
sive immunity. To be effectual the injections
would have to be given every three weeks. This
is utterly impracticable as a general immunizing
'Read before the Section on Pediatrics of the Medical So-
ciety of the State of Pennsylvania, Pittsburgh Session, October
6, 1920.
measure. We also have no prospects of so edu-
cating the public as to the necessity of the very
early used serum in treatment as to save a much
larger percentage than is now possible. Unfor-
tunately, the therapeutic use must always be
limited in its success because so many do not
realize soon enough the nature and seriousness
of the attack to seek early treatment and be-
cause so frequently early complicating infec-
tions such as those due to the streptococcus and
pneumococcus gain a headway which renders us
powerless to prevent the development of a
bronchopneumonia or other dangerous compli-
cation.
At the present moment, we realize that, in
spite of the wonderful results of the use of anti-
toxin, diphtheria is still a disease to be greatly
dreaded. When the health authorities, in New
York City, appreciated that we must expect each
year about 1,200 deaths from diphtheria and
17,000 cases, they began seriously to think of
the utilization of vaccination with a modified
diphtheria toxin as a necessary public health
measure. Active immunization, if successful,
would have the great advantage over passive
antitoxin immunization of having a much longer
duration. The first attempts to test its practical
value were begun in the fall of 1913.
TOXIN-ANTITOXIN VACCINE
Diphtheria toxin is so poisonous that in order
to immunize human beings or animals, it is nec-
essary to begin with tiny doses. The amount of
each successive dose may, with safety, be very
gradually increased. This process consumes
much time and unless carried on with the utmost
skill and patience it is not wholly safe. Experi-
menting with mixtures of toxin and antitoxin it
was found that the toxin could be neutralized
to an extent to cause no inflammatory reaction
when it was injected and yet leave in it the
power to stimulate the development of antitoxin.
It is true that any given amount of neutralized
toxin has much less effect than the same amount
of unchanged toxin but this difference was not
important because the harmlessness of the neu-
tralized toxin permitted several thousand times
as much to be given safely at the initial dose as
of the pure toxin. The usual injection for all
ages is approximately 400 fatal doses for a half
grown guinea pig to which has been added just
sufficient antitoxin to rob it of all deleterious
action. This is about four units of antitoxin.
The injection usually contains 1 c. c. of fluid and
is made subcutaneously. A second and third in-
jection of the same amount made at weekly
intervals add greatly to the quantity of the anti-
toxin development.
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April, 1921
DIPHTHERIA— SCHICK TEST— PARK
475
THE LOCAL AND CONSTITUTIONAL REACTION
The diphtheria toxin-antitoxin mixture con-
tains, besides the neutralized toxin, a considera-
ble amount of protein substance. This is partly
formed of the proteins originally present in the
broth in which the bacilli grew and partly from
the autolysed substance of some of the older
bacilli in the cultures. The reaction to the injec-
tion is similar to the typhoid vaccine but it is of
less severity.
The element of age is very important. The
infant in the great majority of cases shows
neither local nor constitutional reacticm, while
among small children some ten per cent, show a
disturbance, and older children and adults, ex-
hibit in perhaps 30 per cent, of the cases con-
siderable local swelling and more or less definite
constitutional disturbance with a rise of one to
nine degrees of temperature as a rule. Within
twenty-four hours and always within seventy-
two hours all disturbance is over. No other
deleterious results have occurred among the
many thousands we have injected. Children of
ages between the periods mentioned vary in the
amount of reaction according to their age. The
youngest children show the least, and the oldest
the most, disturbance.
POSSIBLE DANGERS
A preparation properly prepared and tested is
absolutely safe for all periods. As time passes
it becomes slightly ovemeutralized and loses
slightly in its effectiveness. The accident we re-
ported was due to an error in sending out a toxic
preparation.
THE IMMUNIZATION RESPONSE IN SUSCEPTIBLE
CHILDREN
Those persons who are naturally immune
against diphtheria are usually so from antitoxin
but may be so from the possession of other pro-
tective substances. The antitoxin we can meas-
ure by the Schick test, but we have no practical
way to detect the bactericidal substances. Chil-
dren who recover from diphtheria usually have
for some weeks a positive Schick test unless
they have received antitoxin. This proves that
there are two types of protecting antibodies de-
veloped after an attack.
THE IMMUNIZING RESULTS
These are measured by the percentage of non-
immunes which become immune and by the
persistance of the immunity. The antitoxin de-
velopment is slow to start and gradual in its in-
crease. Few show appreciable antitoxin in less
than three weeks after the first injection. The
majority respond during the second month. A
few do not become fully immune before the end
of the sixth month. Eiach injection adds to the
stimulus and to the accumulation of antitoxin.
The response in 500 children of an age between
five and ten years who were carefully observed
gave the following results :
•"■it
SSb
V
is
9
'1
Oh
0
0 0 S a
0 sS 0
"cJ.S
0
gB-2
««!C
. K
|u2
i
ik.^^
I
a39
I7S
73
a
89
80
90
3
30 1
191
95
These figures approximately agree with our
results in additional thousands of cases at ages
from six months to fifteen years. In young in-
fants who are but a few days old and who are
still retaining the full amount of their parents'
antitoxin transferred to them passively before
birth, we have not had successful results.
Tested one year afterwards only about thirty
per cent, were fotmd to be immune. This is
about the same as among those not treated. It
is interesting that some 2,400 infants of an age
under one week have been injected with abso-
lutely no bad effect. This certainly proves the
safety of the preparation.
THE DURATION OF IMMUNITY
Our observations have covered a period of
nearly five years and up to the present time the
immunity has persisted in more than ninety-
eight per cent, of the cases who developed anti-
toxic immunity. It seems as if the stimulus of
the injections had possibly aroused dormant cell
activities to produce antitoxin and that this pro-
duction having once started continued without
further specific impulse.
CAUSE OF NATURAL IMMUNITY
The great majority of people living in cities
develop antitoxin before reaching adult life.
There are many reasons which cause us to be-
lieve that this is not due to the fact that they
have, at some time, been carriers. We have ab-
solutely no knowledge of the stimulus which
excites the cells to produce natural antitoxin.
The fact that a greater percentage of city as
contrasted with country inhabitants are natu-
rally immune might be partially due to so many
being at one time or another carriers. This at
best can only be a partial explanation. It seems
more likely that the population of cities tends to
become more and more composed of those who
are naturally immune to diphtheria.
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476
THE PENNSYLVANIA MEDICAL JOURNAL
April, 1921
THE USE OP THE SHICK REACTION TO INDICATE
THE NECESSITY EOR AND THE PERMANENCE
OE ANTITOXIN IMMUNITY
This paper considers only the uses of toxin-
antitoxin vaccine and of antitoxic serum in the
prevention of diphtheria. The Shick test is our
only means of determining the presence of anti-
toxic immunity. It is necessary that this test be
performed with the greatest care, otherwise the
results will be misleading. The laboratory must
furnish not only a toxin that is of the proper
strength but this must be supplied in a manner
that the physician will finally inject the exact
amount. A test carried out by Dr. Zinzher re-
cently demonstrated that the outfits sent out by
the majority of biological companies were fre-
quently very faulty. The toxin used must also
be of the proper age as well as strength. A
lethal dose of a well aged toxin is more severe
than one of a fresh toxin. The antitoxin neu-
tralizing value of the toxin rather than the
minimal fatal dose is probably the safer guide.
The physician must be certain that the fluid is
delivered intracutaneously and that the resulting
effect is observed for a sufficient time.
When the Schick test is properly carried out
it is extremely dependable. If at different times
different strengths of toxin are used the results
will necessarily vary. The apparent change of
negative Schick reactions to positive Schick re-
actions in children over two years of age is
explained largely, if not wholly, by the toxin
utilized and the technique employed. Drs.
Zinzher and Schroder who have done the tests
in institutions year after year, have not found
a variation, from year to year, of over four per
cent. Whether even this four per cent, repre-
sents a real fluctuation in the amount of anti-
toxin in the children, or rather a slight variation
in the strength of the toxin used, we are uncer-
tain.
We have never observed a case of undoubted
clinical diphtheria in a child which had given a
negative reaction in a test carried out by a quali-
fied person. There have been a few cases of
suspected tonsillar diphtheria with positive cul-
tures. Most of these recovered without anti-
toxin and they, in no way, differed from similar
cases in which no diphtheria bacilli were present.
It seems correct to regard them as carriers of
diphtheria bacilli who developed tonsillitis from
other microorganisms.
DISCUSSION
Dr. Edward Martin (Harrisburg) : Dr. Park rep-
resents in an extraordinary fashion what the labora-
tory man, who combines his work with the clinician,
can accomplish. He is doing for diphtheria what Rus-
sell of the army did for typhoid fever.
As your representative and as your executive agent
in the lessening of disease and mortality, I can tell you
how and in what ways Pennsylvania has been follow-
ing the path laid down by Dr. Park, and so well
illustrated by Dr. Bauer in his admirable paper de-
scribing his work in one or two institutions.
It is obvious that we have an infection which can be
controlled. We have investigated for now many
months every diphtheria fatality. Deaths are due to
failure in early diagnosis or failure to protect by
prompt and adequate dosage or both. The lack of
early diagnosis came in part from the fact that we had
no right to force the parents to report a sore throat.
We have now acquired that right and parents who
have not called in a doctor can be penalized if they do
not report. Diagnostic failures are also due to the
fact that the doctors are sometimes casual in their
examination and to the very real fact that the diagnosis
of a case of infection of the throat in little babies is
sometimes difficult This has been helped by sending
out requests that every case of persistent, recurring
croup be treated as probable diphtheria. Our laws, if
enforced, protect against those who are careless or
those who hesitate to subject themselves to quarantine.
When you have the grave responsibility of life and
death, of the very honor of your profession, you are a
little slow to take up any new matter until you are
quite sure it is safe and quite sure it is efficient
Antitoxin is now a free agency to any member of
the profession in the State of Pennsylvania; there is
no charge. In regard to the Schick test and permanent
immunization, the state will furnish material for this.
We consider Dr. Park our counsel and are guided
by him. We take nothing that he does not endorse
nor do anything of which he does not approve. He is
the one authority in this country and whenever any of
you are willing to become familiar with his technique
and would like to take up this study, the state will
help in every way and furnish material endorsed by
our distinguished guest We are not yet prepared to
urge as a state measure of control the universal use
of toxin-antitoxin as controlled by the Schick test
Dr. Mver Sous-Cohen (Philadelphia) : When we
speak of immunity in diphtheria we should remember
that there are many factors concerned in immunity —
agglutinins, opsonins and bactericidins as well as anti-
toxins. It is possible that each of these defensive
factors may play some part in protecting an individual
against infection with the diphtheria bacillus. The
Schick test demonstrates only the presence or absence
of sufficient antitoxin. It shows whether or not anti-
toxic immunity is present We are hardly justified,
however, in stating that an individual responding posi-
tively to it, is susceptible to diphtheria. It is possible
that some of those who give a positive Schick test may
possess sufficient of the other defensive factors to ren-
der them immune.
At the Mastbaum Laboratory of the Jewish Hospital
of Philadelphia, Oeo. D. Heist, Solomon Solis-Cohen
and I have studied the relationship between the bac-
tericidal power of whole blood against the diphtheria
bacillus and the presence or absence of natural diph-
theria antitoxin in the same individual, as determined
by the Schick test
Two years ago we described a test which shows in
wtro the relative susceptibility of animals to pneu-
monia, acute anterior poliomyelitis and meningitis.
Whole, fresh uncoagulated blood as it comes from the
vessel is brought in contact with small numbers of
bacteria in ascending dilutions adhering to the inner
walls of capillary glass tubes. The bacteria and blood
Digitized by
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April, 1921
MASTOID OPERATION— COATES
477
are sealed in the tubes and incubated for twenty-four
hours, at the end of which time they are blown out and
examined microscopically. If the blood has no bac-
tericidal action on the bacteria, the latter multiply
rapidly ; if it is bactericidal, they are killed and fail to
grow. This property was not present in defibrinated
blood or serum.
Using this method we were able to show that the
whole blood of the pigeon and chicken, which are im-
mune to pneumiococcal infection, destroys virulent
pneumococci in vitro; whereas in the whole blood of
the highly susceptible mouse and rabbit pneumococci
grow vigorously. We likewise showed that the globoid
bodies are destroyed by the whole blood of the rabbit,
which is immune to poliomyelitis, but grow well in the
whole blood of the susceptible human being. Simi-
larly Matsunami and Kolmer found meningococci to
grow vigorously in the whole blood of the mouse,
which is susceptible, but little or not at all in the whole
blood of the rabbit, which is immune to meningococcic
infection.
We have introduced the whole blood of guinea pigs,
which are susceptible to diphtheria infection, and of
rats, which are immune, in capillary tubes containing
ascending dilutions of Loeffler cultures of diphtheria
bacilli in broth and in toxin-broth. The diphtheria
bacilli grew vigorously in the whole blood of all the
guinea pigs but poorly or not at all in the whole blood
of the rats. Schick tests were then performed on
forty-five children and at the same time their whole
blood was tested with diphtheria bacilli in different
dilutions. No definite correlation was demonstrated
between a negative Schick test and high bactericidal
power or between a positive Schick test and low bac-
tericidal power, although on the whole the diphtheria
bacilli grew better in the blood of those children that
gave positive Schick tests. We can conclude from
these experiments that bactericidal power and antitoxic
power against the diphtheria bacillus do not always co-
exist in the same individual, as one person may have
high bactericidal and low antitoxic power and vice
versa.
We are about to determine whether the administra-
tion of toxin-antitoxin produces any change in the
bactericidal power of the whole blood of the children
giving positive Schick tests and to make further studies
to discover what relationship high bactericidal power
against the diphtheria bacillus bears to immunity to
diphtheria infection in human beings. In view, how-
ever, of the apparent protective value of bactericidal
power in the immune rat, it might be well, meanwhile,
to avoid regarding as susceptible individuals who lack
antitoxic power but who have high bactericidal power
against the diphtheria bacillus.
Dr. Bauer (in closing) : There are so many tech-
nical points about I>r. Cohen's tests in regard to the
bactericidal power of the blood and the diphtheria
bacillus that would tend to make us skeptical of the
possible accuracy of routine dinicalwork along those
lines, and therefore it would not be quite the practical
thing, first to test the patient's blood for a bactericidal
property and then determine the antitoxin content of
the blood. Supposing we had a person with sufficient
antitoxin in the blood, then the presence of organisms
would not matter since the toxin is taken care of ade-
quately. If, however, the individual does not haVe the
antitoxin necessary, then the toxin will reach the blood
stream, be disseminated, causing diphtheria before the
blood gets near the bacilli, or the bacilli get into the
blood. Therefore the child depends upon its antitoxin
content for protection against diphtheria.
Dr. Park (in closing) : I agree that it is wise to
give antitoxin in doubtful cases of diphtheria. The
harm that might result from serum unnecessarily given
is so slight when compared with the good that results
from its use when needed. The question as to whether
it is possible for a child having sufficient antitoxin to
give a negative Schick to develop diphtheria is difficult
to answer in an absolute sense. I have personally
never seen such a child develop what I would designate
clinical diphtheria, but there have been doubtful cases
with positive cultures which others would call diph-
theria. For instance, lately seven children developed
severe tonsillitis with croupous patches. Two of these
had no diphtheria bacilli while the others had them.
These two and one of those showing diphtheria bacilli
received no antitoxin and recovered equally quickly
with those receiving it. On the one side we have five
of the seven having diphtheria bacilli and on the other
side, the fact that two did not have the bacilli and that
all had a negative Schick reaction. Also that the three
recovered without any antitoxin and that this recovery
was as rapid as in the others where it was given. I am
sure that if we grant the possibility that occasionally
very slight diphtheria does develop, there never could
be toxemia in these cases. Practically we can depend
upon a n^^ative Schick test to safeguard a child from
diphtheria. Dr. Cohen's statement as to the bactericidal
power of the blood interested me greatly. I am not
sure that all are aware that persons recovering from
diphtheria have a positive Schick test in most cases,
unless antitoxin has been given. This shows that re-
covery is usually due to bactericidal substances and not
to antitoxin. A child with a negative Schick test has
antitoxic immunity and may also have bactericidal im-
munity while a child with a positive Schick test has no
antitoxic immunty, but like the other may have bac-
tericidal immunity. The one is not only immune now
but probably for life; the other has a doubtful fluc-
tuating immunity both for the present and future.
In regard to the question of the carrier, I think most
of us who have worked with that question of getting
rid of carriers have become pessimistic about the use
of various things. Personally we do not do anything
in New York except take out the tonsils and use
cleanliness. The staphylococcus spray did not work
out in our cases.
We introduce the toxin-antitoxin with a fine needle
of one quarter to one half inch in length. The Schick
test. is a much more difficult matter. The physician
will see the development of the small white area in the
skin if the injection was properly made. The test is a
Schick test only when the toxin is injected into the
skin. Then the fluid is held in the area long enough
to act.
A DISCUSSION OF THE BLOOD CLOT
DRESSING FOR THE SIMPLE
MASTOID OPERATION*
GEORGE MORRISON COATES, A.B., M.D.,
F.A.C.S.
PHILADELPHIA
For a number of years past the writer has
frequently been asked if the blood clot dressing
for the simple mastoid operation was not en-
tirely discredited and obsolete. So often has
•Read before the Section on Eye, Ear, Nose and Throat Dis-
eases of the Medical Society of the Sute of Pennsylvania,
Pittsburgh Session, October s, 1930.
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THE PENNSYLVANIA MEDICAL JOURNAL
April, 1921
this occurred that he almost b^an to think that
it must be so, but a number of articles having
appeared on the subject, a revived interest
seemed to be shown which prompted him to
bring this subject before you once more for a
frank discussion of its merits and demerits,
without extravagant claims for its infallibility
or overwhelming superiority, having well in
mind a paper on the subject, read before this
section some years ago by a member, now de-
ceased, that aroused considerable unfavorable
comment.
The idea of using coagulated blood to fill in
the dead bone spaces after a simple mastoid ex-
enteration is generally attributed to Sprague of
Providence, R. I., but was first made practical
by Blake, of Boston, in 1906. Reik, of Balti-
more, has been its most consistent exponent,
though others have from time to time written on
the subject. Reik's paper entitled "The Ideal
Mastoid Operation" appeared in 1916 and in
June of this year, before the American Otologi-
cal Society, he reaffirmed all his views as ex-
pressed at that time. He favors the complete
blood clot method and takes issue with those
who, like myself, prefer in many cases to use a
modification.
There are three main ways of using coagu-
lated blod to fill in the excavated mastoid. The
original idea, that of Blake and Reik, is to allow
the entire cavity to become filled with blood and
to close the skin incision tightly without drain-
age. The next method is the employment of
the blod clot secondarily to packing of from one
to ten days with a secondary closure of the skin
incision. The third method, and the one most
often employed by the writer, is to drain the
middle ear externally through the blood clot, the
technique otherwise being the same as in method
No. I.
When should the blood clot dressing be 'em-
ployed and in what class of cases ? Reik says in
all, while others limit its use to those cases where
postauricular drainage of the middle ear can be
dispensed with. This latter reason does not
hold if our modification is used, but we make a
further obvious exception — namely where for
any reas.on, such as suspected intracranial in-
volvement, it is desired to keep the operative
field under observation, or where an intra- or
extra-dural abscess, or an infected lateral sinus
appears as a complication.
The technique of the different types is simple
in the extreme, but there are a few definite
points common to all that must be complied with
to make success reasonably sure. In the first
place, aseptis must be as rigid as though operat-
ing in a clean belly or on the brain. Reik, in-
deed, discards the usual iodine preparation and
uses the well known soap and water, ether and
bichloride method, but at any rate the skin must
be made and kept as aseptic as possible, the ex-
ternal canal included, the hands and gloves of
the operator, nurses and assistants and the in-
struments must be watched with scrupulous care
during the entire course of the operation. In-
struments should be washed in carbolic solution
followed by sterile w^ater as soon as once used.
A thorough exenteration must be done, leaving
no possibly infected cell, fragment of softened
or infected bone or mucous membrane to cause
infection of the clot. There is no fear of de-
formity in making the excavation as large as
may be necessary since this method is particu-
larly adapted to avoid this very thing. Granting
then these essentials, which should hold for any
mastoid operation, no matter what the method
may be, the different types are as follows :
The simple primary blood clot: The wound is
flushed with hot salt solution but as a rule no
chemical sterilization is employed. Formerly
the wound was cleaned with bichloride, by per-
oxide of hydrogen and alcohol 6r by iodine, but
Reik has reached the conclusion that these at-
tempts at sterilization often defeat their object
_ by preventing coagulation of the clot, a conclu-
sion arrived at independently by the author, so
that now salt solution alone is used. After this
cleaning, the artery clamps and retractors are
removed and the wound allowed to fill with
blood, the skin incision being closed by a sub-
cutaneous silver wire suture by Reik, by metal
clamps by others, and in our clinic ordinary in-
terrupted fine silk worm gut sutures, or a con-
tinuous silk mattress suture employed. A dry
dressing is usually placed over the wound, and
the external canal packed in the usual manner.
The method of secondary closure has been re-
cently advocated by Davis, of New York, who
sterilizes his wound with antiseptics as far as
possible, makes a free incision in the membrana
tympani, enlarges the auditus and flushes out the
middle ear with three per cent.' iodine, warm al-
cohol and saline solution. He then packs the
mastoid in the usual manner with iodoform
gauze for twenty-four hours to complete his
sterilization. The skin incision is closed almost
to the lower angle. In twenty-four hours the
gauze is withdrawn, thus causing enough bleed-
ing to fill the cavity, or if this is not enough, a
cut is made in the margin of the flap to supply
the deficiency, and the opening is closed with
adhesive plaster. He uses interrupted silk worm
gut sutures which are removed on the third day.
The third method, that in a measure combines
primary closure with postauricular drainage is
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MASTOID OPERATION— COATES
479
as follows: It has long seemed to the writer
that complete closure of the mastoid wound
without provision for middle ear drainage was
imdesirable in many cases, and that often it was
the drainage that saved the tympanum from per-
manent damage. After much hesitation, it was
decided to attempt to drain the middle ear, at the
same time utilizing the blood clot to obtain quick
healing and to prevent deformity. The method
employed was to complete the operation, without
incising the membrana tympani and to place in
the antrum, with its inner end against the antral
orifice of the aditus, a cigarette drain about 3/16
of an inch thick. Considerable experimentation
developed the fact that for uniform results this
drain should be made of folded strips of gauze,
not packed too tightly, surrounded by thin, soft
rubber tissue cemented at the edge. Such a
drain is easily manufactured by the operating
room nurse and kept in stock, ready sterilized
for use. About one and a half inches is re-
quired, the drain being brought to the skin sur-
face directly external to the antrum, i. e., by the
shortest route to the skin surface. The cavity
is now allowed to fill with blood and the skin
edges sutured with interrupted silk worm gut
or a continuous mattress suture of silk em-
ployed. Care must be taken that the inner end
of the drain does not become loosened from its
contact with the aditus during the sewing, and it
is frequently advisable to pass one of the su-
tures through the edge of the drain to prevent
this occurrence both at the time and during the
course of dressing. For an ordinary case of
mastoiditis without much edema a dry dressing
is used and for one with much edema and in-
flammation one wet in hot normal saline or weak
bichloride solution gives the best results. The
outer dressing is changed as soon as soiled, but
the fluffed gaiue next to the wound need not be
changed for three days in ordinary cases. At
that time as many of the sutures are removed as
can safely be done without gaping of the wound
and the remainder on the fourth or fifth day,
always painting with iodine before drawing
them through the skin. The rule for removal of
the drain is to wait for twenty-four hours after
the middle ear becomes dry, but if this does not
occur in five or six days, and the drain is not
delivering much secretion, it is then removed.
When the drain can be removed early, i. e., in
from two days to a week, the skin edges come
together promptly and the scar soon becomes
linear, no permanent record of its insertion re-
maining. If it remains longer, forming a fistu-
lous tract through the organized blood clot, one
injection of bismuth paste usually suffices to
close it.
In the beginning it did not seem to the writer
good surgery to hope for organization of a blood
clot in an infected cavity with an opening (the
aditus) into a suppurating middle ear, but events
proved him wrong. Neither did it seem proba-
ble that a drain could be used successfully
through the unorganized blood clot but results
showed that this could also be done.
The ease with which these methods can be
used is one of the chief attractions and in this
respect methods one and three surpass method
two in that one removal of packing is there re-
quired. In number three the cigarette drain
slips out so easily that the patient is unaware of
the event. These methods require nothing in
the way of special technique that the ordinary
operation does not require and no longer time is
needed.
But how about results which are, after all,
what we are interested in ? It is not denied that
in many cases that are packed in the modem
way, a quick recovery is made with little or no
deformity. There is usually, however, pain
when the packing is changed and often a long
time is required for healing and an extensive
deformity results. With a successful blood clot
dressing all this is obviated, the patient, being
discharged on or before the seventh day with a
dry ear, a closed wound and no deformity. The
line of incision is, of course, plainly visible and
red, but in the course of a couple of months, can
scarcely be seen without a magnifying glass.
Sometimes, of course, by the combined drainage
and blood clot method, a longer time is required
in a successful case, but at no time is there any
painful packing or dressing, and the most timid
child or adult gives no trouble.
The ultimate results are at least equally as
good as those obtained by any other method, and
I am inclined to think, much better. In some
hundreds of cases where this method has been
used, I recollect but one that came to operation
again. That was this winter, four years after
the original operation and it was found that the
antrum had not been obliterated and had become
reinfected, a perforation through the outer table
resulting. On exposure of the mastoid process
the appearance of the outer table was in all re-
spects that of an unoperated mastoid, though
my notes of the previous operation showed a
complete exenteration. On removing this, how-
ever, the inner table was at once encountered,
there remaining no pneumatic spaces except the
antrum. This result was no doubt due to in-
complete cleaning of the antrum or to the drain
having been removed prematurely either by ac-
cident or design. A second blood clot dressing
was successful. Many of these cases haivebeea. ^^I^
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THE PENNSYLVANIA MEDICAL JOURNAL
April, 1921
under observation now for years and have re-
mained cured with little or no damage to hear-
ing. X-ray studies of a number of these cases
this winter at intervals ranging from four
months to four years after operation show ap-
parently normal non-cellular mastoids. Appar-
ently the organized blood clot becomes ossified
and to a great extent takes on the external form
of the mastoid cortex but the air spaces are not
replaced.
The writer has limited his use of the unmodi-
fied blood clot dressing to those cases of so-
called primary mastoiditis where the preceeding
middle ear infection was so slight as to have
escaped notice or so transitory in character as to
have practically ceased before the mastoid was
opened. These cases were relatively few in
number but favorable results under these cir-
cumstances were about loo per cent. H. O.
Reik and the late Christian R. Holmes claim
about 80 per cent, successful primary closures
in all types of cases under ordinary conditions.
With the modified method described above, it is
tho.ught that the percentage is higher although it
takes a slightly longer time to attain it.
The advantages of these methods have been
enumerated above but may be mentioned again
here. They are quickness and permanency of
healing, preservation of the hearing function,
freedom from deformity and immunity to pain.
There are no disadvantages except that the
wovmd cannot be kept open for observation
where further trouble is suspected.
Now suppose the clot becomes infected, as it
does at times. Rarerly does the entire clot dis-
integrate but if it does the wound is simply
cleaned out and the case packed in the ordinary
manner. No time has been lost and no addi-
tional hazard added, the wound in fact granu-
lating more quickly. Usually, however, but a
portion of the clot liquifies, so that by removal
of a stitch or slightly separating the skin edges
enough drainage is obtained to clean the small
cavity and the cases go on to recovery with
but little delay. If an intracranial complication
develops, the partially organized clot can be
rapidly removed and the parts inspected or ex-
plored through a sterile wound.
Failure will occur at times and the experience
gained in two years army service has helped
clear up some points in the writer's mind. In
the early days of the service at Camp Sevier the
blood clot operation proved so constantly un-
successful that it was abandoned entirely for
over seventy mastoids. Operating conditions
were such in this camp that perfect asepsis could
not be maintained, the infective agent was large-
ly a pneumococcus following measels and pneu-
monia, the patients were for the most part men
of remarkably poor physique in bad physical
condition and quite largely hookworm hosts. In
addition the instrumentarium was so inadequate
that it was difficult at first to do a completely
clean mastoidectomy. On transfer six months
later to another base hospital which served a di-
vision of superbly conditioned troops, where the
operating room service was of the highest order
and the ward nursing excellent, no failures at
all were encountered, although a few minor in-
fections took place, and the blood clot method
was used in all the mastoidectomies dcme there
except a case of extra dural abscess. There
were in all about 20 cases. During the winter
of 1917-18 when the failures above recorded
were taking place at Camp Sevier, the service
at the Pennsylvania Hospital, under Dr. M. S.
Ersner, with some 60 or 70 operations, reported
no failures with the same technique. This last
winter, in uncomplicated cases, the modified
dressing was used with partial failure in a few
cases, due probably, to faulty first dressings. A
niunber of cases of complete primary closure
were all successful, the time of convalescence
averaging about seven days. At Camp Hancock
in 1918 numbers of cases were discharged to
duty on the seventh and eighth days and all had
a short convalescence and no deformity.
The cause of failure at the camp first men-
tioned was undoubtedly due to faulty technique,
poor sterilization of instruments, dressings, su-
tures and operating room together with a bad
epidemic of a virulent organism in poorly nour-
ished men. The morbidity and morality rate in
the pneumonia cases at that time bears out the
latter statement. Where such handicaps did not
exist, as at Camp Hancock, the average was as
good as in civil practice. Major C. R. Holmes,
at Camp Sheridan, had a very similar experi-
ence.
Reik claims as a frequent cause of failure an
imperfect cleansing of the' mastoid process
thereby leaving infected material to cause infec-
tion of the clot. This is imdoubtedly true, and
yet this method has been used in my presence
on only half performed exenterations with per-
fect results. It is surprising how much infection
can, at times, be taken care of by the blood, but
extreme care in the operative technique is of
course of supreme importance.
After-care is no less important, and where
these cases are left for residents or careless as-
sistants to dress, infection will take place in a
large number. If the operator dresses his own
cases, he will secure a much larger percentage
of prompt cures, and there is so little trouble
connected with the dressings that he should
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MASTOID OPERATION— DISCUSSION
481
often do this. Gloves should be worn, instru-
ments sterile, the skin painted with iodine before
removing sutures and these latter removed at
the earliest possible moment. Otherwise a care-
ful, cleanly, gentle changing of dressings is all
that is required.
It seems probable that cases that have run a
prolonged subacute course, even with extensive
destruction of bone, do better than those of the
fulminating type and those seen in virulent epi-
demics. Reik and Holmes claim about 80 per
cent, of perfect results in all classes and the
former writer still calls it the "Ideal Mastoid
Operation" after twenty years experience with
it. And, as a rule, those who have really tried
the method out, agree with him.
DISCUSSION
Dr. Matthew S. Ersner (Philadelphia) : I wish to
congratulate Doctor Coates upon the splendid manner
in which he has presented the subject.. It represents
great skill, keen observation, extreme painstaking,
broadmindedness, and a vast amount of experience.
The total number of simple non-complicated mas-
toid operations using the blood clot fiiethod, operated
by myself is over two hundred. There are several
points we must bear in mind before an operation is
performed. Are we jeopardizing the life of the patient
by carrying out a surgical procedure to which we are
partial? This can readily be dispensed v/iih by an-
swering NO in capital letters.
We know that various immune products are con-
stantly circulating in the blood stream in the form of
opsonins, amboceptors, agglutinins and leucocytes. It
is upon these vital substances that one's life depends
and as the disease progresses in favor of the patient
these increase in proportion and thus recovery results.
This holds true in intravascular blood; why cannot
the same principle be applied to blood outside of the
blood vessel?
In recent papers written by Drs. George B. Heist,
Solomon Solis-Cohen and Meyer Solis-Cohcn (The
Journal of Immunology, Vol. 3, No. 4, July, 1918) it
is proved that the bactericidal action of whole blood
extravascular is not decreased. They found that the
penumococci failed to multiply in whole blood of a
patient recovering from lobar pneumonia. This work
has been further substantiated by men like Metchnikoff
and Kolmer.
During my work with animal experimentation in the
laboratory I often wondered why more cultures were
not contaminated with the blood drawn from the mar-
ginal vein of the rabbit. I have also thought a great
deal as to why more infections do not result when
one's finger is pricked with some sharp object. We
have all experienced this and all followed the laity in
squeezing the part stuck so as to force the blood out
of the scarified area and in the majority of instances
we deliberately place that finger in the mouth, which
is infested with hordes of organisms, and then draw
the blood out of it. Theoretically we should discour-
age this procedure on the ground that the blood will
act as a culture media for the organisms surround-
ing the wound; but practically, we encourage this, as
it was mentioned previously that whole blood extra-
vascular retains its bactericidal properties and thus de<
stroys an organism that may have been present on the
surface of the wound.
Taking this as a simile, the same process actually
takes place with our blood clot dressing. It is under-
stood that the mastoid technique is carried out to the
highest degree of efficiency so as not to leave any
necrotic bone. This is further carried out by thorough
cleansing of the mastoid cavity with normal saline
solution so as to wash out any particles of infected
tissue. The hemostasis and clamps are removed from
the incisual area and with a clean currette the raw
surfaces of the soft tissue are lightly scraped so as to
encour^e bleeding. The blood in itself contains many
bactericidal properties and apparently becomes more
charged when exposed to air, as I have often noticed
that when there is some delay in closing up of the
wound during the optfration we seldom get infection as
a result.
The function of the blood clot: Mechanically it fills
up the dead space of the mastoid cavity which the gen-
eral surgeon dreads so much. When the blood coagu-
lates organization takes place in the clot and fibrinous
tissue is formed. This acts as a temporary scaffold
until granulation tissue forms from the bone which in
the course of time is replaced by fibre connective tis-
sue. Ostioblasts then are sent forth endeavoring to fill
the cavity.
In many x-ray studies of postoperative mastoids
ranging from several months to four years, we have
found that the mastoid cavity was partially or com-
pletely, filled with osseous tissue. In two instances,
one of which I reoperated upon, and the other in
which I assisted Dr. George M. Coates, we found some
osseous tissue but did not find the air spaces as we see
them in primary mastoid operations.
The surgeons who follow the school of packing the
mastoid wound no doubt obtain good cosmetic results,
partially due to the blood extravasation filling up tha
cavity caused by the removal of the packing, and thus
the blood clot dressing is done on a smaller scale
without the surgeons being aware of this.
Prognosis for healing: According to my statistics,
eighty to eighty-five per cent, of the patients will be
well in five to seven days. On the third or fourth day
most of the sutures are removed, leaving only one or
two retention sutures so as to prevent any gaping of
the wound. At this dressing the middle ear is ex-
amined and if it is free from pus the cigarette drain
is removed from the antrum-and the small opening is
allowed to close. The remaining sutures are removed
on the fifth or sixth day and the patient is ready to be
discharged from the hospital without a bandage. We
cannot emphasize too strongly the middle ear drainage.
The drain is placed in the antrum and is allowed to
protrude through the incision by the shortest possible
route directly opposite the antrum.
Why do so many failures result when the blood clot
method is employed? Most men insert the drain for
dependent drainage, a kink appears at the antrum in
the proximal end of the drain and a long fistulous
tract is formed along the course of the blood clot
which surrounds the drain and it is therefore difficult
to close up.
Among my reasons for advocating the blood clot
method are: (a) rapidity of cure; (b) very little an-
noyance to the patient (only at the time when sutures
are removed) ; (c) absolutely no deformity, as the
scar is hardly noticeable.
What happens when the clot becomes infected?
In very few instances does the blood clot completely
break down ; however, when smears were made when
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THE PENNSYLVANIA MEDICAL JOURNAL
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the blood clot disintegrated no organisms were found.
All that is necessary to do is to revert to the old
method and pack. We really give the patient the benefit
of the doubt and thus avoid the inconvenience to the
patient caused by packing and save the time required
by the packing method which invariably takes at least
three and four weeks and as a result leaves the patient
with a deep mastoid depression.
In all cases where there was a great deal of necrosis
and destruction of mastoid cells with the typical post-
auricular edema, etc., one may rest assured, if a com-
plete exenteration of the mastoid cells was performed
the blood clot will hold in ninety-nine per cent., while
in early mastoiditis where there is only slight destruc-
tion of the mastoid cells the percentage of success with
the blod clot runs between eighty and eighty-five. The
only reasons I can give to explain this are :
1. Complete walling off of the diseased cells from
the healthy ones (just the same as takes place in a
localized abscess) in the older cases.
2. The tissues surrounding the diseased area have
developed a protective circle.
3. The blood possesses great bactericidal properties
and it is therefore rational to utilize the blod in the
dead space.
As I mentioned before, the whole blood is bac-
tericidal when extravascular, then why should we not
avail ourselves of these natural resources and utilize
them for the benefit of the patient instead of adhering
as a dogma to the ancient history of packing ?
Dr. Mver Sous-Cohen (Philadelphia) : It is im-
portant to bear several things in mind when consider-
ing that factor of immunity that we speak of as the
bactericidal power of whole blood. In the first place,
in our work in the Mastbaum Research Laboratory
of the Jewish Hospital it has been shown that this is
apparently a property possessed only by fresh whole
blood before it coagulates, and absent from defibri-
nated blood or blood serum. In the second place, while
we found whole blood bactericidal to all non-path-
ogenic organisms, its bactericidal power to the different
pathogenic organisms varied with the species and in
human beings with the individual.
Let me illustrate: When small numbers of pneu-
mococci are seeded in pigeon or chicken blood before
it coagulates the pneumococci are killed. The pigeon
and chicken, it will be recalled, are immune to pneu-
mococcic infection. The mouse and rabbit, however,
are highly susceptible. Pneumococci seeded in their
blood before it coagulates grow with great vigor. But
the rabbit is immune to anterior poliomyelitis and its
whofe blood kills the globoid bodies which grow ex-
ceedingly well in the blood of human beings, who are
susceptible. The rabbit is likewise immune to nienin-
gococcic infection and its whole blood does not permit
the growth of meningococci, which grow luxuriantly
in the whole blood of the susceptible mouse. Similarly,
diphtheria bacilli grow in the whole blood of the sus-
ceptible guinea-pig, but are destroyed by the whole
blood of the immune rat. All these organisms, how-
ever, grow well in the fresh defibrinated blood of both
immune and susceptible species. Non-pathogenic or-
ganisms, on the other hand, quite uniformly failed to
grow in uncoagulated blood of all species and indi-
viduals tested. We made use of this properly several
years ago when making an autogenous vaccine for a
man of thirty-six who had had a purulent aural dis-
charge since infancy, which ordinary treatment and
stock vaccines had failed to clear up. Two organisms
grew upon the blood-agar plate but one, apparently a
contamination, overgrew the other so that we were
unable to separate them. We inoculated the mixed
culture in whole blood, whereupon one promptly dis-
appeared, so that we were enabled to make a vaccine
from the other and effect a cure.
The thought occurred to me that by planting in a
patient's blood the organisms present in a discharge or
on an infected area, we might be able to distinguish
those for which his blood possessed or lacked bac-
tericidal power and could then include in our autogen-
ous vaccine only those organisms for which the
patient's blood lacked bactericidal power. Before the
Section on Medicine this afternoon I am reporting
a series of cases studied in this way. Among them are
four of aural discharge. From one a gram-bacillus
and staphylococcus albus were obtained, both of which
grew in the patient's whole blood. In the second case
streptococcus viridans and staphylococcus aureus were
isolated, the former disappearing when cultured in the
patient's whole blood, the latter growing with great
vigor. Staphylococcus albus and a gram-badllus were
isolated from the aural discharge of the third case, the
latter disappearing and the former growing luxuriantly
when cultured in the patient's whole Mood. In the
fourth case streptococcus viridans and a diphtheroid
bacillus grew on the blood-agar plate, but only the
latter grew in the patient's whole blood.
My personal feeling in regard to the cases reported
by Doctor Coates is that the fresh whole blood with
which he floods* the seat of operation probably pro-
tects the wound from those contaminating organisms
to which the patient's blood is bactericidal. It may fail
to protect from the organism that caused the infec-
tion; because the very fact of infection would seem to
indicate that the patient's blood had low or no bac-
tericidal power against the infecting organism. In
the presence of a slight degree of bactericidal power,
however, against the infecting organism, it is quite
possible that the large amount of blood used may de-
stroy the small number of organisms that may be left
after Etoctor Coates' thorough cleaning out It has
recently been shown by Block, Fowler and Pierce that
the organisms are destroyed in five minutes.
The mechanical framework of the clot may be an
important factor in the regeneration of bone tissue and
in the excellent cosmetic results obtained by Doctor
Coates. But his rapid cure of the primary infection I
would attribute chiefly to his thorough removal of in-
fected material, his drainage, and the protection from
secondary infection and a possible destruction of any
remaining primary infecting organisms afforded by the
blood dressing.
Bactericidal power may vary in degree, being very
slight in some cases. It is quite possible that the mild
cases in which Doctor Coates uses the unmodified clot
dressings with such good results and the cases that have
run a prolonged subacute course, that do so well, are
associated with some slight degree of bactericidal
power against the infecting organism, which may ac-
count both for their mildness or subacute course and
for their ability to do without drainage. There is
probably a complete absence of bactericidal power
against the infecting organism in fulminating cases
and those seen in virulent epidemics, especially when
the patient is poorly nourished or the subject of an-
other infection. A virulent infection has even a
tendency to lower bactericidal power against other or-
ganisms. In such cases one might expect the blood
clot to furnish an excellent culture medium for the
infecting organism and to lose some of its bactericidal
power against the secondary organisms. This may
explain some of the failures, especially with the
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April, 1921
DACRYOCYSTITIS— McCREADY
483
method of Blake and Reik. It may even have con-
tributed as much as the lack of asepsis to the failures
of camp Sevier.
Dr. John F. Gulp (Harrisburg) : I think this sec-
tion is peculiarly indebted to Doctor Coates for call-
ing our attention again to this method of blood clot
dressing after a mastoidectomy. If I did not know
Doctor Coates to be an absolutely honest and reliable
man after an acquaintance of many years, 1 should be
very much inclined to doubt his statistics ; but know-
ing him to be an honest man we must accept them as
true.
Quite a number of years ago, in 1916, Doctor Reik,
of Baltimore, who was a most earnest advocate of this
method of operation, wrote a masterly paper and gave
results that were absolutely astounding. I tried this
method in a number of instances, the results were so
uniformly disappointing that I finally gave it up. My
experience I think is the experience of a great many
men who do this particular line of work. 1, however,
did not use the method that Doctor Coates has used
of draining the cavity of the middle ear through the
antrum by this cigarette dizain. I simply closed the
wound and immediately got reinfection.
Very often we believe we get better results from our
work than we really do. I am not discrediting what
Doctor Coates has to say, but I do know that very
frequently when our patients leave us we think we
have gotten satisfactory results, and I know I have
seen four cases operated on by this method that came
from one of its most earnest advocates. One was a
perfect result, and the other three very evidently
showed a breaking down of the blood clot leaving a
targe cavity. Of course, as Doctor Coates says, should
the clot became infected, it does no particular harm,
but it causes some discomfort to the patient and an-
noyance to the operator.
I know Doctor Coates wanted to emphasize the fact
that there are certain cases where this method should
not be used — ^where you may have intracranial compli-
cation, where you have extra-dural complications or
involvement of the lateral sinus.
One thing I am not quite clear about, but I am sure
he will clear this up. I understood him to say that in
certain cases where the opening in the drum mem-
brane had healed that he did not make a secondary
incision of the drum to give drainage through the ear
canal. In the light of Doctor Coates' findings we
would be justified in giving this operation a further
trial, and I want to commend it to each of the mem-
bers of this Section. I do think, however, that there
is one thing in which we sometimes get a little lax,
and that is in our asepsis. We realize that this is an
infected cavity anyhow and think maybe a little some-
thing else getting in the wound will not make much
difference, but in this method you must be sure of
your asepsis and you must be on your tiptoes all the
time. I hope we will all try it and get as good results
as Doctor Coates has obtained.
Dr. Coates (in closing) : I have no quarrel with any
man for using any method that gives him good results.
I have used all of them, and when I began to use this
method in the army it was a complete failure. I gave
it up and went back to the old-fashioned packing
method, which was also a failure as far as quick heal-
ing and cosmetic results went But when we went to'
a place where we had ordinary asepsis, where we had
better conditions to work under and better patients to
work with, we had no failures at all. Doctor Culp
was in charge of the work in that division before me
and I think he can testify that the troops were in good
physical condition.
When we first began dQing the blood clot operation
we did not know much about the bactericidal qualities
of the blood, but it seemed to us that it had some
bactericidal power and did not become infected.
Some of these dressings have broken down, of course.
We do not claim perfect success. All we do claim is
that when it is successful, the case is short, it heals
without deformity, without pain and without dress-
ings, and you all know that the after-dressing, in a
child or in any case, is a nightmare, and there is con-
stant danger of more infection.
Doctor Culp says he would not believe my statistics
if he did not know me. That's rig^t. I would not,
either. Statistics are employed to find the things we
are looking for, and for that reason I have been care-
ful about my statistics and I think they are correct.
They may be overestimated, but they are somewhere
near right If I did not get 80 per cent, maybe I got
60 per cent, and if not 60 per cent., even only 50 per
cent would not keep me from, using this method.
When it goes wrong, no harm is done; the patient is
no worse off.
Doctor Culp asked about incising the membrane. In
a case where the middle ear infection is gone I do not
incise the drum. If, however, the case has a bulging
drum, it is incised before the case comes to operation.
We are sure, in other words, that the case has good
drainage before it is operated upon for mastoiditis.
INTRANASAL OPERATION FOR
DACRYOCYSTITIS*
J. HOMER McCREADY, M.D.
PITTSBURGH
In presenting this paper before the section 1
wish to make it clear that I am not an ophthal-
mologist but a rhinologist. All my cases were
diagnosed and referred for operation by oph-
thalmologists. Members of the medical profes-
sion are cooperating more every day, which is
not only better for the public, but it creates a
closer fellowship among the doctors.
Caldwell in 1893 was the first to open the
lacrimal canal. West by his extensive study of
this subject and his numerous opefations, is
really the father of this intranasal operation.
His first operation was in 1908 which was fol-
lowed by an article published in 1910. West's
initial operations were on the naso-lacrimal duct
but later he found it advisable to include the
lacrimal sac. Since presenting his paper to the
profession, many operators have entered the
field, some with entirely new methods of pro-
cedure, others with various modifications of
West's original operations. Yankauer, Mosher,
Chamberlain, Benedict and Barlow, Weiner and
Saner all differ more or less in the technic. The
operation advocated by the various surgeons can
'Read before the Section on Eye, Ear, Nose and Throat Dis-
eases of the Medical Society of the State of Pennsylvania,
Pittsburgh Session, October s, 1940. / ' ^-^^-^^-rl^^
Digitized by VjOOQIC
484
THE PENNSYLVANIA MEDICAL JOURNAL
April, 1921
easily be found in the recent literature and I will
not attempt to abstract them in this paper.
Opening the lacrimal sac intranasally is indi-
cated in any chronic inflammation of the sac,
caused in most cases by one or more strictures
of the naso-lacrimal .duct. It is contraindi-
cated in acute inflammation of the lacrimal sac.
Of course, epiphora, caused by strictures in the
canaliculus, will not be benefited by this opera-
tion. West has performed this operation in
every possible sort of disease affecting the lac-
rimal apparatus.
The advantages of the intranasal method over
the external method are, according to West, as
follows: (i) Physiological function of the path
for the tears is again restored so that not only
a suppuration of the sac, a lacrimal fistula or
phlegmon is healed, but also the tears flow nor-
mally through the nose; (2) A later epiphora is
accordingly avoided; (3) A so-called cure by
probing is rendered unnecessary ; (4) The lacri-
mal gland is spared, and (5) A skin incision
with eventual scar is avoided.
The operation that I perform was first dem-
onstrated to me by Dr. Ingersoll, of Rochester,
N. Y., in 1916, and is very much similar to the
method used by Benedict and Barlow.
First, a lacrimal probe is inserted into the
inferior punctum and then passed through the
canaliculus and lacrimal sac into the nasolacri-
mal duct as far as it will go, and allowed to
remain there for several reasons, (ist) It gives
you direction, and (2d) it is used afterwards
to push the sac into the subsequent nasal open-
ing. The probe in all my cases was always
passed by the consulting ophthalmologist Next
a horizontal incision is made through the' mucous
membrane and periosteum, beginning above the
superior part of the anterior end of the-mWdlc
turbinate and extending anteriorly for about
half an inch. A similar incision is made parallel
just above the attachment of the inferior tur-
binate. A vertical incision connects the hori-
zontals. This flap is dissected back, the hinge
being posterior. The flap including both mucous
membrane and periosteum is pushed back and
tucked under the middle turbinate. The de-
nuded bone is now plainly visible. By means of
a special long handled chisel an opening about
three-eights of an inch in diameter is made an-
terior to the upper portion of the middle tur-
binate. The lacrimal probe is now withdrawn
within the sac. Then an assistant makes pres-
sure on the probe so as to cause the sac to bulge
within the nasal opening. The sac is now seized
with a pair of long bladed tissue forceps and its
nasal aspect removed by means of scissors or a
small knife. The probe can now be seen and
pushed into the nasal opening. A window is
made in your mucous membrane and periosteal
flap so as to be just adjacent to the bony open-
ing. The flap is replaced to its original position
and held in place for twenty-four hours by pack-
ing.
This operation can be done both under local
or general anesthesia. Under local anesthesia
I always apply a 10 per cent, solution of co-
caine and i-iooo solution of adrenalin chloride
on the mucous surface and inject under the
periosteum, one-half of i per cent, novocain.
Under general anesthesia I merely pencil with
i-iooo adrenalin chloride solution. Of course
local anesthesia is the ideal method, although I
have performed two of my iterations under
general anesthesia.
The success or failure of the operation de-
pends on the after treatment. The nose should
be kept free from crusts and thick secretion as
much as possible. Granulation around the open-
ing should be cauterized with a strong silver
nitrate solution (40 to 50 per cent.) or a pure
trichloracetic acid. In the majority of my cases
I used the trichloracetic acid. The ophthal-
mologist should see the case every day or at
least every other day and flush the sac through
the canaliculus with boric acid solution. Unless
the case receives careful after treatment for at
least three or four weeks the final result will not
be satisfactory. The main criticism of this
operation is that the opening cannot be kept
patulous. This, however, can be accomplished,
if it receives the proper after treatment, but the
opening will close if the operation is performed-
and the patient neglected.
The difficulties of the operation, are: ist, i
small anterior nare^; 2d, a large inferior turbi;,
nate; 3d, a large .^terior end of the.,ipjddlij;
turbinate ; 4th, a s^tal defection ; 5th, an intnufc
nasal convex asped^ of the nasal process of thiS"
superior maxilla. In a large roomy nostril' the
operation is comparatively easy.
I have operated on only eleven cases: six had
suppuration of the sac, one had suppuration
with external fistula, three Had epiphora. In
one case I failed to find the sac on account of a
very much depressed and thickened nasal process
due to the patient having been kicked by a horse
three years previously. Of the ten cases really
operated upon eight were cured, one developed
erysipelas six days afterwards and was trans-
ferred to the municipal hospital and never re-
ported back again for examination, one was
benefited but not entirely relieved. After the
patients were discharged, which varied from four
to eight weeks, they were instructed to report
back if they noticed a return of the symptoms.
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April, 1921
DACRYOCYSTITIS— DISCUSSION
485
Of the eight cases reported cured not one has
returned for reexamination.
DISCUSSION
Dr. William CAMPBa,L Posey (Philadelphia) : I am
not a rhinologist, I am an ophdialmologist. I have
never done this operation, nor could I do it. Most
ophthalmologists have been very anxious, indeed, to
have some form of operation devised whereby the tears
might be made to flow naturally from the eye into the
nose. Last year Dr. Mosher, of Boston, came to
Philadelphia and spoke about his operation, and after
he had finished I asked him whether he found it neces-
sary to probe his cases to keep the parts open, and he
said that he did in nearly every case find it necessary
to pass a probe at intervals of several weeks or months
in order that the opening from the sac into the nose
might not be closed. Now the author has just said
that he did not find probing necessary in his cases and
he claimed cure for eight, that is to say, he stated that
after a lapse of from four to eight weeks none of
these cases came back to him for treatment. I have
operated on a good many sac cases in my life, and a
good many have not come back to me. I should like to
feel they had all been cured.
We treat simple epiphora usually by dilating the duct
and washing out the sac. In many cases we find tlie
stricture is not in <he lacrimo-nasal duct itself, but in
the canaliculus just where it empties into the sac;
unless this be dilated you will not cure your case. I
believe if there is any considerable disease of the
mucous membrane of the sac it is much better to get
rid of the sac. It is true that after the removal of
the sac the eye will water in the wind, etc., but the
troublesome mucous which remained in the conjunc-
tival cul-de-sac prior to the operation and which ir-
ritated the mucous membrane and caused the steady
flow of tears, is removed. I doubt very much if the
eye that is operated upon waters much more in the
wind than its sound fellow. I believe that all these
intranasal operations should be given a fair trial, for
if they can be properly developed whereby the patient
will not have to be probed, the mucous membrane can
be restored to normal and the tears made to flow nor-
mally through into the nose, a great step will be made
in .the surgery of this region ; therefore it is folly for
us to decry operations of this kind.
I for one, therefore, shall continue to send such
cases as I deem fit — those in which there is not too
great disease of the mucous membrane and too much
distension of the sac — ^to the rhinological clinics for
operations-.. I have never found it necessary to take
out the lacrimal gland in any case of persistent lacri-
raation following the removal of the sac.
Dr. GeoRce W. Stimson (Pittsburgh) : In consider-
ing the various intranasal operations for the cure of
dacrocystitis, I should like to mention an operation
suggested several years ago by Dr. F. M. Hanger, of
Staunton, Virginia, and published in the "Laryngo-
scope," January, 1915. It is simple, rational and easy
to perform and has given uniformly good results in
the hands of the originator and in one case of my own
particularly, of which I beg leave to give a brief report.
The operation consists essentially of converting the
nasolacrimal duct from a closed tube into an open
gutter by removing that portion of the lateral nasal
wall that forms the inner wall of the duct, from its
exit under the lower turbinal up through the stenosed
portion, which is usually just below the sac, to or into
the sac itself.
Mrs. H. C. S., white, 58 years old, had been troubled
with epiphora of the right eye for over seven years,
and had received all the usual treatment including
probing, with no effeU. A year and a half before I
saw her she developed a lacrimal abscess, which rup-
tured below the inner canthus with the formation of a
fistula that continued to discharge pus and tears up to
the time of her visit
Operation: one per cent, cocaine solution was in-
stilled into the right eye, a few drops of equal parts
20 per cent, cocaine and epinephrin were injected into
the lacrimal sac, the canaliculus was slit and a probe
passed down to the floor of the nose by the late Dr.
T. J. Moran, who referred the case to me. Under
cocaine and epinephrin anesthesia I then removed
the anterior end of the lower turbinal, bringring into
view the lower end of the probe which was to be used
as a guide. Gradually withdrawing the probe, the male
end of the punch-forceps was introduced into the
lower end of the canal and following in its wake the
entire inner wall was removed — converting the duct
into an open gutter — clear up through the stricture and
into the sac itself; after which the probe practically
fell into the nose in a horizontal position with no re-
sistance whatever. The fistula at the inner canthus
was curetted and touched with iodine. • There was
practically no after-treatment. Being from a distance
the patient was kept in the hospital for eleven days.
There was no epiphora nor any discharge from the
fistula (which healed over promptly) from the day of
the operation. Heard from six months later, she re-
ported that she was still perfectly well. The operation
was quickly and easily performed, with little or no
pain or bleeding, no shock of reaction, and the result
was most gratifying.
As a large percentage of these cases are cured by
slitting the canaliculus, probing, etc, it is only after
these measures have failed that operative intervention
becomes justifiable. The choice then lies between
extirpation of the sac and some form of intranasal
operation (dacryocystorhinostomy) that will establish
drainage of the lacrimal sac into the nose.
The former has the objection that there is mutila-
tion, an external skin incision with resulting scar
formation, interference with or destruction of the
physiological function of the lacrimal apparatus,
strophy of the lacrimal glands with possible dryness
of the cornea and its consequences, and failure to cure
the epiphora, which may necessitate the removal pf the
glands. , '
In the latter there is no scar, the physilogicaf func-
tion of the lacrimal apparatus is undisturbed, a path-
way for the tears is restored and drainage of the sac
established, so that not only a suppuration of the sac,
a lacrimal fistula or a phlegmon is healed, but the tears
flow normally into the nose, and the epiphora is cured.
For these reasons it would seem that some form of
intranasal operation is certainly the operation of choice
in the cure of dacryocystitis.
Dr. Luther C. Peter (Philadelphia) : Doctor Posey
covered the ground which I had hoped to, with the
exception of one point, and that is infections after this
operation. Even in normal lacrimal drainage we fre-
quently find eye infections which travel from the nose
through the lacrimal sac, and in the operation advised
by Doctor McCready the drainage is freer. Naturally
the results depend upon the ability to keep open the
drainage.
I should like to ask Doctor McCready how long
after this operation he has been able to observe his
patients — the longest period.
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486
THE PENNSYLVANIA MEDICAL JOURNAL
April, 1921
A further point is that brought up by Doctor Simp-
son after excision of the sac. So far as I can see, this
leaves no bad results. A scar is not visible after exci-
sion of the sac if it is properly performed. Increased
lacrimation is only annoying when the patient is ex-
posed to cold or windy weather. I have never seen a
case of dry cornea as a result of excision, and I feel
very strongly that excision of the sac is the operation
of choice and the operation as proposed by Doctor
McCready and others a second choice if excision is
refused by the patient
Dr. GeoRGE H. Cross (Chester) : Mention has been
made by the previous speaker, of the unfavorable scar,
following the extirpation of the lachrymal sac, as one
of the principal reasons in favor of the intranasal
operation. I do not do any nose and throat work, but
am of the opinion that the best operation at our com-
mand, is the extirpation of the sac, following which I
have not seen any marked scarring, the vascular sup-
ply of this r^ion being such that the scar practically
always disappears, so I fail to see where Dr. Mc-
Cready's operation in this respect has any advantage
over the extirpation of the sac.
I was present with Dr. Posey at the meeting when
Dr. Harris P. Mosher, of Boston, gave us such an
interesting description of his operation, and brought
with him many specimens, showing the various stages,
and illustrating the different steps. I was impressed
with the fact that he said, after the operation it was
very often necessary to probe for months and even
permanently. A paper on an intranasal operation by
Drs. Meyer Wiener and William E. Sauer, which bears
on this subject, was read at New Orleans in April,
and in talking to Dr. Ziegler about this operation, he
said frankly that he had inadvertantly performed this
operation twenty years ago and had been sorry for it
ever since ; that the operation had not yielded perma-
nent results. The lack of results in these operations,
I think in all probability is due to the destruction of
the capillarity. The large opening into the nasal cavity
prevents natural secretion and suction, and has the
decided disadvantage of allowing the secretions of the
nose to be forced into the conjunctival cul- de sac, fol-
lowing violent blowing of the nose or sneezing, at
times producing corneal ulceration and we get as much
tearing as before the operation. If there is a great
excess of tears following the removal of the sac, we
may resort to the removal of a portion of the lac-
rimal gland, so while I am anxious to see an opera-
tion which will be more practical 'than the extirpation
of the sac, I am sorry to say that I have not as yet seen
an operation that takes its place.
Dr. McCready (in closing) : I saw one case two
years after I had operated on both sides and she did
not have a bit of trouble. I will admit however that
the present operations for dacryocystitis have quite a
few Weak points and the technique will probably be
greatly improved in the future. At present there are
many ways of doing this intranasal operation and my
method may be inferior to others. The whole question
is whether the intranasal operation has any advantage
over the external operation. If it has I cannot see
v/hy, with improved technique, we might not bring our
success up to at least ninety per cent.
SELECTIONS
NEW AND NONOFFICIAL REMEDIES
Salicaine. — A brand of saligenin complying with the
N. N. R. standards. Calco Chemical Co., Bound
Brook, N. J. (Jour. A. M. A., Jan. 8, 1921, p. 113).
AURICULAR FIBRILLATION*
ROSS V. PATTERSON, M.D.
Associate Professor of Medicine, Jefferson Medical College
PHILADELPHIA
Introduction. Auricular fibrillation, consid-
ered from the clinical standpoint, is the most
important mechanical derangement of the heart.
It is the most frequent cause of disordered heart
action associated with the symptoms and other
signs of cardiac failure. Not far from 70 per
cent, of cardiac patients admitted to the wards
of hospitals, with marked impairment or rupture
of compensation, and various degrees of circula-
tory failure, exhibit this derangement of the
cardiac mechanism. It has very properly come
to be regarded as a clinical entity. It belongs to
the ultimate sequelae of inflammatory and
.sclerotic endocarditis and valve lesions, myo-
cardial degenerations, and circulatory stress
from various causes ; it is often the immediate
cause of cardiac failure, and it has, in addition,
important diagnostic, prognostic and therapeutic
bearings. The present paper is an attempt to
emphasize some of the more important practical
clinical aspects of this condition.
Etiology. The causes of auricular fibrilla-
tion are to be found in those lesions, processes
and conditions which weaken or throw marked
strain upon the walls of the auricles, structures
which are anatomically unfitted to withstand
marked stress, or to compensate advanced le-
sions. Most of the etiological factors are of a
chronic character. Obstruction at the mitral
orifice is a condition which produces auricular
-Stress in marked degree ; first upon the left side ;
ultimately also upon the right. Auricular dilata-
tion and hypertrophy occurs early ; and eventu-
ally, overdilatation and fibrillation are very
frequent results of mitral stenosis." The inci-
dence of auricular fibrillation is greater in mitral
stenosis than in any other valvular disease, but
mitral insufficiency, primary sclerosis and de-
generation of the heart muscle, associated with
arteriosclerosis and hypertension, are also im-
portant causes; the toxins of both acute and
chronic diseases such as those of diphtheria and
pneumonia, gout and uremia, and the intoxica-
tion of lead, may each and all be etiological
factors.
Essential Nature. An intimate knowledge of
the mechanism of normal cardiac action is a
first essential to a comprehension of its various
mechanical derangements and disorders. Au-
*Read at a meeting of the Philadelphia County Medical So-
ciety, January 26, 1921.
Digitized by
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April, 1921
SELECTIONS
487
ricular fibrillation occasions a profound derange-
ment of the normal cardiac mechanism, by
reason of the overdiliation of the auricular
walls, fibrous overgrowth, and ftmctional dis-
sociation of their muscle fibres. The auricles no
longer act as efficient contracting chambers, but
stand in a position of permanoit diastole, acting
merely as reservoirs for the blood which reaches
them from their tributary veins. Cut off from
the control normally exercised by the sinoauricu-
lar node, the individual muscle fibres, or groups
of them, continue to contract as a result of self-
generated stimuli. Coordinate contraction of
the whole mass of auricular muscular tissue
ceases, however; incessant activity, confusion,
disorder and delirium reign in the auricles.
Their function of completing ventricular filling
at the end of diastole is entirely lost. A much
more important effect than failure to fill the
ventricles is occasioned by the generation of
multitudinous, irregular and abnormal stimuli
to contraction, those originating near the auricu-
loventricular node of Tawara, being taken up
by that structure and thence successively con-
ducted to the bundle of His, its primary
branches, and through their many ramifications,
ultimately reaching the walls of the ventricles.
If the function of the conduction system re-
mains unimpaired, the ventricles literally will
receive showers of haphazard stimuli, producing
a rapidity of rate, and irregularity of action, and
variability of force of contraction which tax
their capacity to extreme limits. Mafly of the
stimuli will altogether fail to excite the ven-
tricles to contract ; others will excite them to a
feeble contraction, but, owing to a short preced-
ing rest period, the contraction will be of suffi-
cient force to produce only a very small pulse
wave ; while in still other cases, the contractions
will be so feeble, and the amount of blood in the
ventricles so small, as to produce no pulse wave
whatever, the ventricles contracting, but with in-
sufficient force to overcome the pressure in the
aorta and, therefore, to open the aortic cusps.
The disordered action of the ventricles is occa-
sioned by the excessive number of supraven-
tricular stimuli transmitted to them from the
disorderly auricles. If the dissociation of au-
ricular muscle fibres is of extreme grade, each
individual fibre in direct or indirect relation to
the auriculoventricular node, potentially is a
focus of origin of an abnormal stimulus. The
stimuli will, therefore, be generated in great
numbers. On the other hand, groups of fibres
may retain a contraction association, and the
functional grouping of the fibres greatly lessen
the mimber of stimuli transmitted to the ventri-
cles by way of the conduction system. Accord-
ingly, the rate will be relatively less. A further
modification of the ventricular response may re-
sult from interference with the conduction func-
tion. The bundle of His shares in a liability to
damage from those influences which produce
sclerosis of the myocardium, fatty degeneration,
calcareous deposition, and other changes. Vari-
ous grades of heart block may be induced there-
by, producing associated auricular fibrillation
and partial heart block. Occasionally the block
is almost complete. The ventricular contrac-
tions are reduced in number in proportion to the
degree of block. To a certain extent, the block
is beneficial in reducing the circulatory effects
attendant upon over-stimulation of the ventri-
cles. A useful therapeutic suggestion is con-
tained in a knowledge of the facts just presented.
The thought here thrown out will be developed
more fully in the discussion of the treatment.
General Circulatory Effects, Symptoms and
Signs. The chief circulatory effects in extreme
grades of this disorder are a lowering of arterial
pressure, and a tendency to its transference over
to the venous system through the pulmonary
circuit. As a result, there will occur congestion
of the lungs, engorgement of the entire venous
system, general visceral congestions and often
the outpouring of the fluid portion of the blood
into the subcutaneous tissues and serous cavi-
ties of the body. Auricular fibrillation, there-
fore, produces marked disorder of the cardiac
contraction, circulatory failure of advanced de-
gree and, owing to the congestion of the viscera,
interference with the function of many organs,
the function of the lungs being early and se-
verely affected. In extreme grades, the symp-
toms are those of rupture of compensation —
cyanosis, edema, dyspnea, and the usual evi-
dences of impaired function of the kidneys,
stomach, liver, and other organs, a pulse ex-
tremely rapid in rate, and wholly irregular in
character, the beats varying both as to sequence
and force.
Palpation and auscultation at the apex reveal
the disorder of the ventricular action. It will be
noted, in many cases, that the number of beats
counted at the apex, and the number of beats
simultaneously counted at the wrist will show a
marked divergence, so that the heart beats, as
compared with the pulse beats, may show a dif-
ference of as many as thirty, or forty, or more,
per minute — a finding referred to as pulse defi-
cit, a phenomenon occasioned by the failure of
many weak ventricular contractions to produce
a palpable pulse wave at the wrist. The irregu-
larity at the apex is quite as evident as at the
radial artery ; it is obvious that the intensity of
the heart sounds upon auscultation will var
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quite as much as the volume of the radial pulse
on palpation. The occasional failure of ven-
tricular contraction to raise the aortic cusps, and
hence the absence of a second sound following
the first sound, together with the disordered
sequence and force of contraction, produce a
medley of heart sounds heard in no other condi-
tion.
It is to be noted that, as a fiirther result of
auricular failure presystolic murmurs dependent
upon auricular contraction and presystolic in-
tensifications of diastolic murmurs, likewise de-
pendents upon auricular contraction, will both
disappear with the onset of this disorder.
Effects Upon the Heart, the Course and Dura-
tion. It is, of course, obvious that a heart, the
seat of some chronic, progressive, sclerotic or
degenerative process out of which the auricular
damage has grown, will be seriously embar-
rassed in the performance of its work by the
perversion of normal auricular function, as well
as by the enormous additional burden imposed
upon it as a consequence of over-excitation of
the ventricles by way of the conduction system.
Obviously, the auricular overdistension and dis-
order are the outgrowth of incorrigible anatomi-
cal and histological changes. The condition,
therefore, once established, tends to persist.
Complete cardiac exhaustion will occur early in
extreme cases, unless ventricular action is
brought within the range of normal rate limits.
The outlook is dependent, not only upon our
ability to control the ventricles, but also upon
the degree of damage which they have suffered
as a result of the influence of causes which have
also affected the auricles, and perhaps the ar-
teries and other organs as well. Like other
cardiac conditions, the prognosis is largely a
myocardial question, due importance being ac-
corded to the mechanical and dynamic consid-
erations affecting the heart, blood vessels, and
their contents. Notwithstanding the incorrigi-
ble nature of the auricular, histological and
anatomical condition, much may be done to con-
trol the rate. However, in most cases, the dis-
orderly action, while it may under treatment
become less evident, will persist until the end of
the chapter. The outlook in individual cases, as
regards the immediate future, is usually good.
The effects of treatment are often brilliant.
Urgent acute symptoms may often be quickly
controlled if the essential nature of the derange-
ment is thoroughly understood, and the treat-
ment applied with discrimination. Many cases
go on for years, although in hospital practice
three years is, perhaps, an average expectation.
This is, in part, due to the serious damage suf-
fered by the heart before coming under medical
observation and direction. Exceptional cases
may live for a dozen years, or mofe. Rarely,
indeed, recovery takes place and normal mechan-
ism is restored for a period.
The Recognition of Auricular Fibrillation.
There is no mystery and nb very great difficulty
in the recognitiorf of auricular fibrillation. As
with other clinical conditions, an intimate knowl-
edge of the etiology conduces to a recognition
of the disorder, when present. The diagnosis of
heart conditions involves an etiological, ana-
tomical, functional, and mechanical diagnosis.
Auricular fibrillation is the most marked me-
chanical derangement of the heart. It is asso-
ciated with various anatomical changes affecting
the endocardium and myocardium. Marked de-
grees of circulatory failure usually bring this
disorder to notice. In fact, the added difficulties
thrown upon the heart by it, are often the im-
mediate cause of the myocardial breakdown, re-
sulting in various grades of circulatory failure.
Fibrillation of the auricles may be present for a
short time, without occasioning persistent symp-
toms of cardiac insufficiency but, even during
this time, shortness of breath on moderate exer-
tion, precordial discomfort, and the conscious-
ness of disorderly or rapid action of the heart
described by patients as palpitation, are usually
present. In the majority of cases, both the dis-
order and the incapacity are well characterized.
The ordinary symptoms of impaired or rupture
of compensation are associated with an exceed-
ingly rapid, irregular, and insufficient heart ac-
tion, producing a light irregularity of the pulse
beats.
I again take occasion to point out the impor-
tance of distinguishing between heart rate and
pulse rate. The irregularity of both is complete
and persistent. There is no other mechanical
derangement of the heart in which, with a rapid
rate, both the heart and pulse are markedly ir-
regular. This form of cardiac arrhythmia is to
be distinguished from all other arrhythmias in
that, with an increase in rate, the disordered
action becomes more evident. It is, however,
evident under all conditions. The pulse deficit,
representing the difference between the number
of beats which may be palpated at the apex and
the wrist simultaneously, tends to disappear with
a decrease in rate. The irregularity will become
much less evident with a reduction in rate, but
will, nevertheless, be clearly recognized upon
careful clinical examination.
Attention has already been directed to the
effect of sclerosis of the bundle of His, produc-
ing combined partial heart block and auricular
fibrillation, the decreased function of the bnndle
tending to inhibit the transmission of the multi-
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tudinous impulses from the auricle to the ven-
tricles, and, therefore, reducing in proportion to
the degree of interference with conduction, the
rate of the ventricle. In extreme cases, com-
plete heart block may be associated. Whether
the function of the bundle remains unimpaired,
or be interfered with to some degree, the ven-
tricular contraction will be irregular, but the
irregularity will be less evident in rates of from
sixty to seventy per minute, than in cases in
which the rate is twice these numbers. All other
forms of cardiac irregularity tend to disappear
with an increasing rate; few of them occur
with pulse rates beyond 120 per minute, and then
only at infrequent intervals. There are very
few circumstances in which any irregularity of
a pulse having a rate beyond 120 can be ac-
counted for in any other way. A rapid and
wholly irregular pulse, associated with signs of
cardiac failure, is always due to fibrillation of
the auricles.
Treatment. Notwithstanding its serious na-
ture, one may generally assume an optimistic
attitude as regards the immediate future of those
affected with this derangement. There is no
condition in which the physician may so easily
gain a reputation, if he will but familiarize him-
self with the principles of treatment, and ad-
minister remedies with judicial discrimination.
It is due to its effects in this condition that digi-
talis owes its reputation as a wonder worker.
Treatment for the restoration of the circula-
tory balance by the institution of such measures
as rest, depletion by purges, venesection, and the
treatment of special symptoms due to visceral
congestion and venous engorgement should, of
course, be utilized. I .shall do no more than
mention them, however, since I wish particu-
larly to focus attention upon the principles un-
derlying the use of digitalis and its cogeners, in
order that the indications for their administra-
tion and their proper effects may be clearly pre-
sented.
Digitalis, or an allied drug, should be admin-
istered in every case of auricular fibrillation in
which, while the patient is at rest, the heart rate
exceeds one hundred per minute. It exerts its
beneficial effects chiefly by exercising a specific
depressive effect upon the function of conduc-
tivity of the bundle of His, thereby inducing a
degree of partial heart block so that the number
of stimuli transmitted from the auricles to the
ventricles is reduced and the ventricular contrac-
tions become normal in rate. As soon as this
result is accomplished, the use of digitalis should
either be discontinued, or the amount greatly les-
sened. Drugs other than digitalis may be used.
As a rule, they are inferior. Those that are
useful affect the mechanism of the heart in ex-
actly the same way as does digitalis.
The treatment, therefore, consists in the ad-
ministration of a member of this group which
will, in the manner indicated, bring the heart
rate under control. Let me again say that I
refer to the heart rate, and not the pulse rate. I
do not attach as much importance to the choice
of the pharmaceutical preparation of digitalis
as do some of my confreres. There is more
wisdom to be shown in a knowledge of the prin-
ciples underlying the use of the drug, than in the
selection of its form. For the most part, I make
use of a good preparation of the tincture of
digitalis. In cases in which the disorder is ex-
treme and the indications are quickly to bring
the heart under control, an initial dose of a dram
of the tincture may be given, followed by an
equal amount in each twenty-four hours, divided
into three or four doses. If favorable effects
are not observed in four or five days, the dose
may be increased.
It is not to be forgotten that digitalis is a poison,
and that signs of intoxication from its admin-
istration may occur. Such effects are shown by
a rather sudden development of nausea, vomit-
ing, diarrhoea, headache, and an aversion to the
drug. Often, coincidentally, there is a pairing
or grouping of the beats — ^the so-called digitalis
coupling. These symptoms indicate that full
tolerance of the drug has been reached and a
condition of saturation developed. There is
often a coincident rapid fall of heart rate. Digi-
talis administration should then be discontinued
until toxic effects have disappeared. The heart
rate should be carefully watched, and if, after
two or three days, with a lessening of digitalis
effects, the heart rate begins to ascend, small
doses, sufficient to "hold" the heart at about the
normal rate, should be given. In an extreme
grade of disorder, full digitalis effects may be
obtained in from four to twenty days— most
often at or near seven days. With a few days
total discontinuance it will usually be found
necessary to administer lessened amounts.
The rest period in bed should be prolonged
beyond the relief of symptoms, in order that the
overworked ventricular myocardium may regain
its tone, and the function of other organs be re-
stored. With the patient oiit of bed, the amotmt
of digitalis which he will require must be deter-
mined by careful study. Most of the cases will
require digitalis continuously or intermittently
for the rest of their lives. The amount varies.
Sometimes as little as five minums of the tinc-
ture per diem will be all that is required. In
other cases, this amount three times a day, or
even a larger quantity, may be indicated. Pa-
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tients themselves, if intelligent, and properly
instructed, will, under the guidance of their phy-
sicians, often help solve this problem. Their
activities should be restricted to such an extent
as will bring them within the limits of a very
much lessened cardiac capacity. Their subse-
quent general management is, of course, of the
greatest importance, bu^its discussion is beyond
the limits fixed for this paper.
MISUSE OF VACCINES, HAY FEVER
POLLENS AND PROTEIDS
MATTHEW S. ERSNER, M.D.
Assistant OtoUrjngologist, Pennsylvania Hospital; Associate
Professor in Otolo^, Post-Graduate Department,
University of Pennsylvania
It is not my motive to criticize nor do I have
any contentions to destroy. I simply wish to
call the attention of the profession to the fact
that we should not lay too much stress on vac-
cines, nor should we promise the patient com-
plete cure, as there is no remedy available where-
by such promises can surely be made good. It
is also important to be honest with ourselves and
not to be overenthusiastic or draw conclusions
too rapidly.
Vaccines. Vaccine therapy is a great asset in
otolaryngology but care must be taken not to
misuse it as there are certain periods during the
course of diseases pertaining to the ear, nose
and throat where certain specific rules should be
observed. In acute mastoiditis, acute rhinitis,
acute otitis media and acute sinusitis there is an
increase in the polymorphonuclear leukocytes.
In the early stages of these diseases the stock or
autogenous vaccines should be administered and
will be beneficial if given in small progressive
doses.
The reason for using vaccines cautiously at
this stage is not to overburden the vital resist-
ance of the body which in its turn is already
endeavoring to overcome the infection. In acute
conditions, just enough vaccine should be ad-
ministered to act as a stimulant to keep up the
good work that the body is striving to accom-
plish.
To illustrate : The following are the approxi-
mate doses for the initial treatment: strepto-
cocci, 15 to 20 million; pneumococci, 15 to 20
million; staphlylococci, 25 to 75 million; b-
pseudo diphtheria and b-pyoceanous, 25 to 50
million, and friedlander, 25 to 50 million. We
must bear in mind that in children the dosage
proportions differ according to body weight and
must be guided accordingly. It is interesting to
make cytological studies of the discharges in
acute purulent conditions of the ear, nose and
throat. In the early stages there is a leukocy-
tosis present in the blood and a leukocytosis of
the polymorphonuclear variety is also present in
the various secretions obtained from the nose,
throat and ear. As the condition progresses
from the acute to the subacute and chronic
stages there is a change taking place in the white
blood picture as well as in the secretions. The
leukoc)rtes diminish in the blood. In the secre-
tions there is a constant increase in the mono-
nuclear leukocytes which in the course of time
almost completely replace the polymorphonu-
clear variety. Repeated examinations of the
secretions should therefore be made so as to
watch the proportionate increase in the mono-
nuclears and the diminution in the polymor-
phonuclear leukocytes as the mononuclear
leukosis is significant of chronicity. We know
from past experience that the polymorphonu-
clear leukocyte is the cell which carries the bur-
den of infection and is the great index of vital
resistance. I believe the reason why certain
conditions become chronic is due to the fact that
there is a disappearance of the polymorphonu-
clear leukocytes and an increase in the lympho-
cytes. We must therefore administer large
doses of vaccine during the chronic stage of any
ear, nose and throat ailment so as to encourj^e
a leukocytosis.
Hay Fever Pollens. In 1914 several com-
mercial firms made a "great splash" and claimed
that brilliant results were obtained with pollen
extracts administered for hay fever. The pro-
fession became very enthusiastic and it brought
on a state of affairs which can readily be called
( if I may take the liberty of expressing myself
in this manner) "Pollenitis." We all gave pol-
lens. The most ridiculous part of the situation
was that the firms supplied every physician with
individual pollen extracts upon request for the
purpose of performing skin tests to determine
the specific pollens to which he or she might be
susceptable. After determining that a certain
patient was susceptable to, we will say ragweed
for example, they supplied us with a mixture of
four or five pollens in the same suspension,
which they claimed belonged to that special
group. I am unable to understand why they
supplied us with individual pollens for the tests
and in return gave us a conglamoration of pol-
lens in the one suspension to administer. I was
in line with the rest of the physicians, enthused
as the rest and "chucked" everyone full of pol-
lens. Somehow my results were not satisfac-
tory and I did not permit myself to flow along
with the tide nor content myself with a sporadic
good result obtained, or be satisfied when one or
two patients occasionally claimed slight allevia-
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tion of the symptoms. I gave this subject con-
siderable thought as one cannot help doing when
we consider that about one per cent, of the popu-
lation in the United States is susceptable to hay
fever and that twenty per cent, of these patients
develop asthma as a complication.
The latter patients are worrisome to me and
are to everyone else. How are we going to cur-
tail this condition? The thought has slowly
crept into my mind and I have often expressed
it at various medical meetings, "Is hay fever,
and its sequel asthma, due to deficient protec-
tive substances in the body (anaphylaxis), or is
it due to the fact that the patient is oversatu-
rated with the toxins so that the phenomena of
hay fever and asthma result?" We know from
experience that a change of location, for hay
fever patients is very valuable. We also know
that when certain patients are susceptable to cer-
tain proteid food dyscrasias, if that food is re-
moved from the diet, the patient will improve.
I wish to quote a case :
While in Dr. Coates' office in 191 7, a baby
girl, age 3, who was under the constant care of
the family physician, had recurrent attacks of
asthma. Her tonsils and adenoids had been re-
moved by a very prominent otolarynologist in
this city but the asthmatic attacks did not cease.
The child was fed on a highly nutritious, easily
digested food, among which were eggs and milk
and she absolutely abstained from meats. It
was found that preceeding the asthmatic attack
there was an erythematous rash. We learned
by process of food exclusion that the erythema
and asthma were caused by the eggs and upon
removal of these from the diet recovery was
imeventful and the child has not had another
attack since. This verifies the fact that when
a patient developes hay fever, asthma or a cer-
tain food dyscrasia such as hives, etc., the body
at that time is over saturated with the proteid to
which they react.
The problem confronting us is not only sus-
ceptability to these substances, but we are facing
a phenomenon whereby the body is over satu-
rated with these toxins. To administer pollens
during the acute stage of hay fever is adding
a torch to the fire already burning. Dr. Coates
and I have found that patients do not respond
well to pollens administered during the attack of
hay fever; in fact they often become worse.
The process of overcoming proteid disturb-
ances is not only one of developing an immunity
by inoculation but one of desensitization. It,
therefore, behooves us not to administer any
pollens or proteids during the attack, as the pa-
tient at that time already has enough toxins to
be thrown off by the body. To deliberately fill
him up with pollens at this time is a mistake and
should be avoided.
It is the writer's practice to administer pollens
to those giving a history of hay fever at least
three months before the attack comes on and to
cease administering them at least five or six
weeks before the attack is due. During the pe-
riod of the attack, I begin with slowly pr<^res-
sive doses of mixed stock vaccine so as to build
up the resistance of the individual against the
rhinitis which is concomitant with hay fever.
When a patient applies for treatment during the
attack, I do not administer pollens but I inoculate
him with mixed stock vaccines and thus abort
the extreme symptoms which follow hay fever,
or shorten the duration of the attack. Since fol-
lowing this routine, my results have been most
gratifying.
In a recent conversation with a physician
closely associated with an asthma clinic, I learned
of some occurrences that made me believe that
overenthusiasm has overtaken a great many of
these workers. It appears that various asthmatic
conditions not presenting the typical chest phe-
nomena are often treated with proteid substances
where other underlying factors have been over-
looked. We have cardiac asthma and renal
asthma and one must not forget the various nasal
obstructions, such as polypoid turbinates, etc.,
which may be the underlying factor. I offer the
following cases as illustrations :
Case I. Mrs. K., age 52, came into my office
giving a history of having suffered with asthma
for the past six years. The attacks are most se-
vere upon exertion and often worse at night.
This patient was treated in one of the asthma
clinics and was instructed not to sleep on feather
pillows. After practicing this for several months
she found no improvement in her condition. She
came to me for a rhinologic examination and not
finding any pathology in the nose, I asked her
whether her feet were swollen. To my astonish-
ment I found both her foWer extremities adema-
tous. I referred her to a medical man and he re-
ported to me that the patient had a cardiac in-
sufficiency with a great deal of renal disturbance.
He also found a great many granular casts and
hyaline in the urine. It is evident therefore that
we should not always plunge at the first thing
that comes to hand, such as pollens and proteid
substances. We must determine definitely if
there are any nasal obstructions such as afore-
mentioned, and if so, operative interference
should be instituted. In the meantime take from
the diet those foods reacted to, if possible, until
the acute condition subsides. We also must con-
sider the possibility of focal infection.
Case 2. Mrs. D., age 40, mother of four chil-
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dren, for the past nine years has been subject
to asthmatic attacks several times a year, inde-
pendent of season and diet, usually coming on at
night and often preceded by epigastric pain and
nausea but no vomiting. Rhinological examina-
tion negative. Radiography of teeth negative. I
referred this patient to an internist for study and
he suspected cholecystitis, which was verified on
the operating table, a cholecystectomy being per-
formed for an empyema of the gall bladder. The
patient has made an uneventful recovery and has
not had another attack of asthma since.
Should the condition prove to be a true proteid
anaphylaxis, treatment by desenitization should
begin during the quiescent stage, thus desenitiz-
ing the individual to future attacks.
Summary. — i. Vaccines are valuable in oto-
laryngology and should be administered in small
doses in the early stage so as to act as stimulants.
2. In chronic conditions large doses should be
administered so as to stimulate leukocytosis.
3. In acute ear, nose and throat conditions the
predominant cell found in the secretions is the
polymorphonuclear leukocyte, while in the
chronic conditions the mononuclear lymphocyte
predominates. As the lymphocyte is increasing
and the polymorphonuclear leukocjrte is decreas-
ing in the secretions, large doses of vaccines
should be administered so as to stimulate leuko-
cytosis.
4. Do not administer pollens during the acute
attack of hay fever, as the patient at that time is
already saturated with toxins and upon inoculat-
ing him with pollens he often becomes worse.
5. Administration of pollens should begin
about three months before the attack and cease
six weeks before the attack is due.
6. During the attack, I should suggest admin-
istering bacterial vaccines in small doses so as
to stimulate an immunity against rhinitis which
is concomitant with hay fever. • '.
7. In asthma it is important to determine any
underlying factors such as nasal obstruction, car-
diac and renal disease and focal inf ectiop and not
depend exclusively upon the proteid tests and
desenitization.
1729 Pine Street.
THE HOSPITAL, THE PROFESSION
AND THE LAITY
J. W. KENNEDY, M.D.
PHILADELPHIA
For nearly forty years the Joseph Price Hos-
pital has probably been the largest private sur-
gical charity in this country, and also the oldest
institution of its kind in the country. As the
mantle of this institution has fallen on my shoul-
ders since the death of Dr. Price, I am in the un-
fortunate position to say a good deal about the
trials of the hospital. If Joseph Price had not
been the most unique character in American
medicine, his institution would have remained in
existence but a very short time. Few in the pro-
fession or among the laity are sufficiently gen-
erous to credit any one with the conduct of a
hospital as a private enterprise without suspicion
that such is conducted for private gain.
No man living or dead, to my knowledge, did
so much surgical charity as the late Joseph Price.
Probably a hundred times have I seen him turn
down an office full of pay patients, many of them
from outside the state, to go to some suburban
hospital to operate on a charity patient ; and yet
there was no man of my acquaintance whose per-
sonal expense was so great, nor did he have a dol-
lar invested which earned him a cent. I want to
bring out the fact that he was the most accessible
man to the poor in his profession and yet car-
ried the greatest financial burden. He never be-
came a man of means. That splendid spirit of
save-t he-life, be a doctor, was what kept his
institution alive in spite of financial deficit. If
you are a surgeon, a member of the board of
managers, housekeeper or laundress of any chari-
table hospital, you have had experiences which
are most common to those who have served in
any one of these trying positions. The superin-
tendent of any charitable hospital has a more
difficult position to fill than the President of the
United States, although he may be harrassed by
an irascible or incompetent congress.
The spirit toward the hospital is all wrong. It
is wrong from the standpoint of the laity and
much more so from that of many members of
our profession. It seems almost impossible to
teach the laity or the profession that the benefi-
cence of the hospital is of the quality of the grace
of God but must be sustained by the charity of
men and women. This lack of personal interest
by those citizens who are a part of any hospital
community, comes through ignorance, selfishness
or dishonesty. Ask the superintendent of any
hospital under which one of these three accusa-
tions almost any particular act of hostility to-
ward hospital management comes. He or she
can be very explicit. There has been displayed
ignorance, selfishness or dishonesty in the par-
ticular case. Ninety-five per cent, of the com-
plaints are not due to the fault of the hospital
but to some irregularity in the mind or action of
the one who complains. He is probably one of
those who gives nothing to, does nothing for, but
expects much from the institution. He has
closed his eyes to financial support and wails loud
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and long about neglect of his patient or member
of his family.
The hospital has just those abilities which the
particular community is willing to put into it.
It is not a factory of health regeneration run in-
dependently of the community in which it exists.
From necessity the hospital is a parasite of noble
intention and should not be pauperized by an im-
posing profession or laity. It is encumbent upon
the medical profession to teach the laity of their
community that the hospital is a charity for the
very poor and that they who can pay and do not
are more criminal than the one who steals your
watch.
I regret to say that a good number of my pro-
fession have no real responsible interest in the
hospital, which should be looked upon by them
with the greatest interest and protection. For a
physician to advise a patient who is able to pay
for hospital services not to do so, is guilty of
professional crime and he has betrayed his trust
as man and physician. I am too familiar with
just this sort of betrayal of professional man-
hood. I have been asked to operate free of
charge and keep the patient in my hospital free
of hospital expense and have known that these
same physicians have made a good charge for
witnessing the operation. It is not an uncommon
thing to have a physician send his patient to the
hospital as a ward patient where some small
charge is made for hospital expense, and have
that patient tell me he or she could well afford to
pay for a private room and operating fee. I
have never been able to understand this spirit in
a member of our profession. He certainly does
not ingratiate himself to a greater degree with
his patient ; he gets in wrong. I bring this side
of tlie profession out not so much to scold as to
forcibly shame these derelict members of our
profession. It might be necessary to tell some
members of the laity that they way receive just
the abilities from any hospital which they as a
community are willing to put into it, but it
should not be necessary to tell any thinking mem-
ber of my profession such. The greater the edu-
cation, the greater and more harmful the quack.
Every physician should be in touch with the nu-
merous trials of the average hospital ; and yet as
I have shown, many turn their backs on their
professional home.
There is not a physician who may chance to
read this paper but has a number of times com-
plained on account of some neglect his patient
may have suffered while in a hospital and justly
may he make such complaint. There is from
necessity a great degree of neglect due to the fact
that the hospitals do not have and cannot get
sufficient professional and labor help. The su-
perintendents are given a force of X quantity
which may represent twenty-five per cent, of
.that which is necessary to perform one hundred
per cent, efficiency. I know it cannot be done.
I am the institution and I further know just how
much help it takes to properly nurse any patient
who has had some major operation and I want
to tell the profession that a great number of pa-
tients are dying from the lack of postoperative
care due to the lack of possible nursing and not
from the spirit and true soul of the institution.
I could become very personal and explicit in this
matter of the postoperative death due to neglect
on account of an insufficient number of nurses,
if the reader is interested in the grave question.
For instance, during my twenty years' asso-
ciation with the Joseph Price Hospital it has been
a West Point rule that no patient who has under-
gone an abdominal operation is left for a single
second during the first twenty-four hours ; with
the result that from many thousands of abdomi-
nal operations there has been but one death from
a postoperative pneumonia. I give the credit to
the nursing and not to the surgery.
The restless patient during the first few hours
following the operation exposes himself to chill
while the skin is relaxed and leaking, with the
result that the lungs and kidneys must take the
blow. Nothing less than this is proper nursing ;
not one second should the patient be left. Each
year I find it more difficult to properly nurse my
patients. The State Board requires so many
hours devoted to the theory of nursing, lectures,
laboratory and special courses, that it is next to
impossible to obtain much help from the student
nurse and thus the hours of practical nursing
have grown to the minimum while the theory has
increased to the maximum. This has of course
militated against the amount of attention any
hospital corps of nurses in training can give the
patient. This has made it most trying to hospital
managements.
The only other side to such discussion is, are
we making better nurses by the substitution of
theoretical for a greater d^ree of practical edu-
cation ? It is not just that I should go into this
differential discussion here. I have my opinion
based upon results in my institution.
I do want to add a word of caution to those
who are serving on such a board and are no
longer participating in the actual work of the
profession as physician or nurse, that they must
not entirely rob us of the help of the pupil nurse.
You can educate the common sense out of any
one.
The question of the professional nurse is one
of the most serious of the profession. We can-
not get along without her and the standards are .
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THE PENNSYLVANIA MEDICAL JOURNAL
ApRit, 1921
being raised so that we cannot get her. During
this era the hospitals are suffering; no one is
being properly nursed. Necessity will in time,
adjust the matter, but in the meantime let us
have common sense and wisdom and not put
'such a premium upon standardization that we
completely make impossible the most necessary
adjunct to our profession. Those who are dic-
tating the policies of the professional nurse must
remain practical themselves, and must be regu-
lated first by the purpose of the nurse, next by
her education, and finally, of course, by the care
and protection due the nurse in her work.
The professional nurse must be expected to be
elastic as to her hours. It is very grave and un-
professional to -establish a union among nurses
as to the definite number of hours she will serve
her patient. The moment this is done the soul
of her profession is gone. It is encumbent upon
the physician to see that the nurse has her hours
of rest and sleep and it is just as encumbent upon
the nurse to see that her patient is provided with
proper protection during the nurse's hours of
rest and recreation. You have killed all that is
worth while in the spirit of nursing when you
begin to teach the nurse that she is nursing one-
half or one-third of any patient. She must be
taught the legitimate charity of her profession ;
she must occasionally give her services. I feel
that the nurse should be the best paid of the em-
ployed whenever it is possible, but charity must
be in her makeup.
Now in regard to the laity in their relation to
the hospital. Most of them have no relation so
far as any real sympathy or cooperation goes. I
could write a volume on the outrages of the laity
which have unfortunately been my experience.
After operating and keeping a patient in my hos-
pital for weeks free of charge, I have been
threatened with law suits a number of times on
account of the loss of an undergarment not
worth a dollar. I have referred in a previous
publication to a millionaire who used the tele-
phone in my hospital and said to me with pre-
sumptuous pride, that he supposed there would be
no phone charge as he was a heavy contributor
to the institution. He did not recognize in me
the only contributor the institution had. I have
again referred to this incident, as I have seen
hundreds of times just such impositions from
the vulgar rich. I have many times operated on
their favorite cook, Mary or Sarah, and have
been told by them the great value and importance
of this cook in the welfare of his family, but his
interest in that important cook ended there. It
is quite remarkable that these men who live so
much in the dollars and cents have such conven-
ient memories.
To that generous public who do so often come
to the rescue of the public hospital, I want to pay
the highest tribute. They, make the institution
possible. The very best use of money left to
charity can be gotten from that left to hospitals.
I never see extreme extravagance but that I
measure the degree of waste by the good it might
have done if given to some poorly nourished
hospital. The hospitals all over the country are
financially wrecked, they must have more money.
It is said that forty of thel largest hospitals in
New York are failing to the extent of three mil-
lion dollars yearly to meet their expenses. This
is so with all their possible aids. America's
wealth is so often referred to and yet we know
that a very large per cent, of the hospitals of our
country have a constant struggle with finance.
During the war even in this country, thousands
of people died from the want of attention. This
scarcity of intelligent help was accentuated dur-
ing the terrible epidemic, the true pathology of
which I believe is still unknown. Those who
were not associated by intimate relation with hos-
pital work during the war, knew little or nothing
of its trials. There was much unnecessary and
illegitimate abuse the hospital had to bear, which
came from a citizenship of the most reprehensible
character of which I have any knowledge. The
man who remained in America and made use of
the exigencies incident to the great war to amass
wealth, was certainly not an American and was
as much a traitor as the man who cowardly
sneaked from the ranks. I refer to the type of
man we so often read about who went to Wash-
ington for a dollar a year and raised the selling
prices of the product his home factory was pro-
ducing three or four hundred per cent. I do not
like the way he spells charity and his mark of
distinguished citizenship does not spell hero to
me. The hospitals paid this distinguished gentle-
man his illegitimate three or four hundred per
cent, and at the same time took care of many of
his employees for charity or a large per cent,
charity. I do not like to be double-teamed.
Dr. Price often said that many of the great
corporations were the biggest paupers with
which he had to contend. This is still so. If the
compensation law has appeased this man's con-
science (provided he has any), I should like to
tell him he is in no way paying for the hospital
care of his employees. The hospital still extends
him its charity and helps pay for his yacht on the
Mediterranean. If the reader could just become
a hospital for a few moments he would under-
stand what I am writing.
Let us drop the millionaire and say something
about the laborer or man of less means and we
will find he also cannot be accused of hospitali-
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MEDICAL COLLEGES OF PENNSYLVANIA
495
tis so far as his idea of protection to the insti-
tution goes. As a class, labor during the war
was contemptible. We were compelled to pay
enormous wages and were not able to get one-
third of a day's work from the employee. They
did not have the spirit of the helpful unit during
the trying times. The charity of the hospital
meant little to them. During the war the mer-
chants practically stood as a solid phalanx and
demanded of the hospitals the last cent and in
most instances the ordinary hospital reduction
which existed in times prior to the war, was not
even granted. The old-time feeling of charity
toward the hospitals by the entire community is
gone, and instead of its being a legitimate para-
site upon the community, the community has be-
come a parasite upon the hospital. I have re-
ceived numerous letters from patients who had
been treated in the Joseph Price Hospital and
who had not paid the institution for services ren-
dered. When asked to meet a small obligation
they responded, saying they thought their ac-
count was charged to charity, but if they must
pay the bill they could. Analyze this and you
have a very prevalent feeling toward the hos-
pitals. The patient admits ability to pay and
commits himself by admission that charity is a
legitimate social condition for those who can pay.
There is no legitimate reason why a single
man, woman or child should be neglected in this
new and rich country if manhood would assert
itself. Selfishness and dishonesty is the black
and hideous thing which storms our noblest
charities. The philosophers of our great social
questions talked much in varied discussions about
the high cost of living, supply and demand, etc.,
but one knows that even under our very eyes
good food was dumped into the river in order to
keep prices up, in spite of the fact that we were
paying three or four times as much as we should.
I have another solution of the high cost of .liv-
ing and that solution exists in the souls of men.
1 do not know enough about business to discuss
the relative merits of government ownership and
corporate interests but business methods must re-
main merciful to the needs of men or the country
must step in.
The physician is the most influential citizen in
liis community. He must take a conspicuous
position in the social questions of his coun-
try. He most knows the family needs, which
after all are the real national questions of
any country. Never in the history of the
world was there a greater necessity for a firm
stand for law-abiding citizenship. The phy-
sician must be one of those units from which
radiate humanity's blessings. The political and
business world is drunk with selfish politics.
They have temporarily dulled our splendor. The
world is sick. There is not a thinking physician
but who must know that America has it within
her reach at this very hour to be the greatest
physician of all time. She will be that physician
and take her chair at the great Conference of
Nations which must deal with the humanity of
the future. Certainly, certainly America will be
that physician. Politics, capital and labor are
having a dishonest reign. Capital will never re-
form labor and labor will never reform capital ;
but honesty and kindness inbred in our children
will reform these savages. To reform manhood
the reform must begin with the child, and this is
where our profession must show and assert its
all-powerful influence.
241 No. 18th Street.
THE MEDICAL COLLEGES OF
PENNSYLVANIA
ESTABLISHMENT OF RESERVE OFFI-
CERS' TRAINING CORPS UNIT
AT THE JEFFERSON MEDI-
CAL COLLEGE
The JeflFerson Medical College has established
and completed the organization of a Medical
Corps Unit of the Reserve Officers' Training
Corps, Senior Division, under the direction of
Major John T. Aydelotte, M. C, detailed to the
college by the Surgeon-general of the U. S.
Army, as Professor of Military Science and
Tactics.
Units of the R. O. T. C. are instituted under
authority of the Army Reorganization Act of
June 4, 1920. The Jefferson Unit is one of five
units established in the medical schools of the
United States at the invitation of the Surgeon
General. Other units have been established in
medical schools situated in St. Louis, Chicago,
Minneapolis, and Washington. The main pur-
pose of the corps is to provide special instruction
and training in military science and tactics to a
selected group of regular medical students, who
will, upon the satisfactory completion of both the
regular and specified courses, be prepared to
qualify for commissions as officers in either the
Medical Corps, or the Medical Reserve Corps,
of the United States Army. A special course
of instruction is given by a regular officer of the
Medical Corps, U. S. A., specially detailed for
the purpose by the Surgeon-General, which does
not in any way interfere with the regular medi-
cal instruction, but constitutes, in fact, a valuable
addition to it. Those enrolled in the unit are not
required to wear uniforms, or to be under mili-
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THE PENNSYLVANIA MEDICAL JOURNAL
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tary regulations while at the medical college. At
the end of the freshman year, R. O. T. C. stu-
dents will have the opportunity to attend a six
weeks' summer camp, where outdoor drills and
recreation are combined with lectures and in-
struction covering the duties of medical officers
in the field. The student will live under field
conditions, and will receive instruction in dis-
cipline, character, and military bearing; the hy-
giene and preparation of food, and the care of
military camps, including disposal of waste, and
the detection and destruction of mosquitoes and
flies.
Attendance upon the summer camp following
the first year is voluntary; but, following the
sophomore year, the Professor of Military Sci-
ence and Tactics, in cooperation with the Dean of
the Medical School, will select from among the
military students those who are eligible to con-
tinue in the R. O. T. C. course during the last
two years. Those who elect to attend the en-
campment during the vacation period following
the freshman year, will receive commutation of
traveling expenses, uniforms, equipment and ra-
tions. Junior and Senior students who have com-
pleted the first and second year courses satisfac-
torily, and are enrolled in the advanced courses,
will receive commutation of rations amounting to
about $16.00 per month, throughout both years,
including the intervening summer vacation ; and,
in addition, $30.00 a month, traveling expenses,
board, quarters, and rhedical care while they are
in attendance at the six weeks' summer camp fol-
lowing the Junior year. It is believed that these
allowances will be of considerable help in enab-
ling students to pursue the medical course, and to
provide for the future a generous supply of well
trained medical officers who will become either
regular or reserve medical officers of the army.
The two summer vacation encampments will both
be held at the Medical Field Service School, Car-
lisle, Pennsylvania, which was formerly the well-
known Carlisle Indian Training School. The
surroundings are particularly beautiful and at-
tractive; the buildings, athletic field, recreation
grounds, and general arrangement make it an
ideal and attractive military school for medical
officers.
R. O. T. C. Units are established as a pre-
paredness measure. They represent a plan on
the part of the government and medical colleges,
to cooperate in training medical men for the dis-
charge of military obligations, which they, as
citizens, must assume when called to the colors
in time of war. The course, in itself, contains
much instruction that is of value to medical stu-
dents in sanitary science and hygiene, quite apart
from the military instruction. It is thought that
the opportunity for a profitable and health en-
gendering vacation, under very pleasant sur-
roundings and circumstances, without expense to
the student, is also a feature of very consider-
able importance and attractiveness to the student
body.
A total of 59 students of the Jefferson Medi-
cal College have enrolled in the corps. The en-
rollment of an equal number each year will even-
tually result in a body numbering over 200 mili-
tary students who will receive special training be-
yond that of the regular medical course, fitting
them for military service in case of need, and en-
abling them to enter the Medical Corps, or the
Medical Reserve Corps of the United States
Army. The acceptance of a commission at the
termination of the course is encouraged, but is in
no way obligatory.
Ross V. Patterson, Dean.
PITTSBURGH ACADEMY OF
MEDICINE
ABSTRACTS
THE LOCALIZATION OF ACUTE FOCAL
INFECTIONS
Ds. F. W. Mathewsom
I have classed as acute focal infections, all infec-
tions giving rise to acute diseases such as acute rheu-
matic fever, phlebitis, pyelitis, cystitis, acute laryngitis,
endocarditis, etc
I have demonstrated to my own satisfaction that in
this class of diseases in which focal infection is a
cause, there occurs a very short time previously an
acute focal infection which had been latent
Using this theory as a basis for my study, I have
been able to work out a few simple rules which have
been of great help to me in localizing focal infections.
These rules can best be illustrated by the following
reports of cases occurring in my practice :
In July, 1919, a man came to my o£Bce with a well
defined attack of acute rheumatic fever of thirty-six
hours' duration. His tonsils were negative as to focal
infection, never having been inflamed. His teeth were
negative by inspection and there was no tenderness on
tapping. None were devitalized. There were no evi-
dences of ear trouble, sinus trouble or disease of any
other organ which might have been the source of the
disease. The patient was ordered to bed and the next
day another search for a focal infection was made and
none found, except that the patient called my attention
to a small pimple on the back of his left hand, which
he had first noticed at the onset of his sickness. It
was so small and insignificant in appearance that I
dismissed it at once as a possible focal infection.
His rheumatic symptoms were more severe than on
the previous day. On the third day, much to my sur-
prise, the rheumatism had entirely disappeared, his
temperature was normal, and the pimple which he had
had from the onset had become a large boil. To ex-
plain this we ne.ed only refer to the definition of in-
flammation as found in the Principles of Surgery. The
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PITTSBURGH ACADEMY OF MEDICINE
497
inflanunatory reaction in this infection of the hand ad-
vanced only to the first stages, that of dilatation of the
blood vessels and hyperemia, and remained at that
stage for some unexplained reason for three days,
allowing the bacteria to enter the blood stream. At
the end of three days the stages of stasis and exuda-
tion appeared, a barrier, as it were, was formed arotmd
the focal infection, no more bacteria entered the blood
stream and the rheumatic fever subsided immediately.
Infections of the teeth in which a complete inflam-
matory reaction occurs, result in local abscesses, with
pain, fever, heat, redness and swelling. Suppuration
follows, the abscess opens and there is usually no con-
stitutional disease. Infections of the teeth in which a
complete inflanunatory reaction does not occur become
focal infections and produce constitutional disease.
Apical infections of this character show very few
local symptoms. There is slight sensitiveness on tap-
ping the tooth with a metallic instnmient if the tooth
is vital. I have almost come to the conclusion that the
diseases having the most severe symptoms come irom
the least sensitive teeth. The following case illus'
trates this very well. In September, 1918, I was called
to see a female patient, age thirty, occupation clerk,
who had been sick for three days. A diagnosis of
acute rheumatic fever was easily made. In addition to
the usual symptoms of this disease there was scat-
tered over the body more than a hundred nodular ele-
vations in the skin resemUing small boils. These were
very sensitive and altogether it was the most severe
case of rheumatic fever I had ever seen.
Examination for focal infection of the tonsils was
negative. Examination of the teeth showed noany of
them to be decayed. One tooth, the left lower first
molar, was slightly sensitive to tapping, and contained
quite a large cavity. It was so slightly sensitive, that I,
at that time, three years ago, could scarcely convince
myself that such severe symptoms could come from it
On the following day I extracted the tooth, and on the
next day the jaw was very much swollen and very
painful, and I felt that I had located the focal infec-
tion. Four days later the patient was up and has had
no rheumatism since.
This tooth had no abscess sac at the root, yet the
infection was there. Our dentists are quite inclined to
think that if they extract a tooth with a pus sac at
the root that they have reached the source of all
trouble. A pus sac is evidence of a complete inflam-
matory reaction, and the pus does not pass from the
sac to the blood stream. The worst apical infections
have no pus sacs and the roots after extraction may
appear quite normal.
Focal infection of the tonsils is usually limited in
the individual to one tonsil. The symptoms are usually
slight pain in one tonsil, slight tenderness on pressure
over the tonsil externally and at times pain in the side
of the neck corresponding to the affected tonsil. These
symptoms may be present for a variable time before
the onset of a constitutional disease, but usually they
are present but a few days. The following case illus-
trates this type of infection.
I was called in the night to see a woman fifty- four
years of age who had never had any serious illness,
and had always had good health with the exception of
many attacks of tonsilitis before the age of thirty.
Four or five days previous to the present sickness, she
had felt severe pain in the left tonsil, with tenderness
on pressure externally and considerable pain and stiff-
ness in the neck. Her present symptoms were extreme
weakness, palpitation, shortness of breath, cyanosis,
and very rapid pulse, all the symptoms having come
on suddenly. A diagnosis of acute endocarditis was
made. She improved slowly and in one week she had
a well defined mitral murmur. After ten days she de-
veloped acute rheumatic fever of moderate severity
which lasted for six weeks, with slight remissions. At
the end of ten weeks the patient was up and around but
still suffered much pain. The tonsil was still painful
and sensitive. At this time it was decided to have the
tonsils removed, which was done. The patient im-
proved very rapidly and in a very short time was free
from all pain. This is the only case of acute rheumatic
fever in a series of sixteen cases that has been allowed
to run a complete course, the other cases all being
cured within two weeks by the removal of their focal
infections, apical infection being removed as soon as
located and tonsillar cases with the first remission of
symptoms.
The next case report shows how an apical focal in-
fection may give rise to an acute disease which may
run its prescribed course, then remain latent for a pe-
riod of time, to become active again and produce dis-
ease in entirely different tissues.
A young man aged twenty-four, occupation oil
pumper, came to my office in November, 1920, suffer-
ing from acute laryngitis. He was coughing day and
night and could get no sleep. The disease had per-
sisted for one month and treatment by another physi-
cian had given him no relief. Four days previously
an erythematous rash had appeared over the entire
surface of both forearms. His history showed that he
had had an attack of acute rheumatic fever during the
months of-April and May, 1920, which lasted about six
weeks. During four weeks of this time he had an
erythematous skin eruption over both lower legs simi-
lar to that appearing on his arms with the present
attack.
After recovering from the rheumatic fever in the
spring of 1920, his physician advised him to go to the
dentist to have his bad teeth extracted. This he did
and the dentist did as well as he knew and removed all
that he thought were diseased. The man then went
back to his work in the oil field and had good health
until the onset of his laryngitis in October, 1920.
The fact that the patient had the same type of skin
eruption with the laryngitis that he had with the rheu-
matic fever suggested very strongly to me that the two
diseases had arisen from the same focal infection.
Examination of the teeth showed the right lateral
tooth to be crowded, partly turned, and dead. It was
very sensitive by tapping. All the other teeth appeared
normal.
He was then given a note to the dentist to remove
the right lateral tooth. The tooth was removed in the
morning but before evening the patient was compelled
to go to bed with what appeared to be an attack of
acute rheumatic fever. There was severe pain, high
temperature, general stiffness, and slight swelling in
the knee joints. These symptoms persisted for three
days when they rapidly disappeared. His laryngitis
and skin eruption also disappeared, and to this date
none of the symptoms has reappeared.
If we, as physicians, expect good results in these
cases we must first localize the infection. We cannot
expect the dentists who have never been trained in
medicine to do this for us. It is well to remember the
possibility of having two distinct focal infections in the
same individual, each producing different disease con-
ditions. The following case is a good illustration:
I was called in consultation to see a girl nineteen
years old who had been sick four months. She gave
a history of influenza and at that time had a very sorely
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498
THE PENNSYLVANIA MEDICAL JOURNAL
April, 1921
throat, followed by an acute thyroiditis. This was fol-
lowed by mild rheumatic symptoms and at the time I
was called, she was suffering severely from neuritis.
She was slightly jaundiced, had much stomach distress,
many joints pained, rapid pulse, slight elevation of
temperature, otlargement of thyroid and an appearance
of general sepsis.
A focal infection was suspected at once. The teeth
were found to be in good condition with only one fill-
ing, this being in the center of the left lower first
molar. The tonsils were found to be chronically in-
flamed and both were sensitive by external pressure.
Removal of the tonsils was advised and carried out
immediately.
The patient was quite sick for one week following
their removal. She then improved rapidly, gained
much in weight, and all her former symptoms disap-
peared except the neuritis. This persisted with occa-
sional new attacks for four months following the ton-
sil operation, when it was decided that there must be
another focal infection present. An x-ray picture of
the tooth that contained the fiUing showed a very large
abscess at the root. The tooth was extracted and the
patient ordered to bed. A very severe reaction fol-
lowed its extraction, which lasted one week, with a
great increase in the neuritis. At the end of a week
the symptoms subsided and the patient was allowed to
be up with strict orders to do no work. However, she
felt so well that she decided to help with the house-
cleaning, and the following day developed a pyelitis of
the right kidney, which was a long time getting well.
The neuritis disappeared gradually and there were no
new attacks.
The above case brings out another point of great im-
portance— that of keeping the patient at rest for a
suflicient time after the extraction of abscessed teeth.
Focal infections should always be kept in mind when
we are treating patients with the more chronic condi-
tions such as diabetes, B right's disease and tubercu-
losis. We are prone to have our minds centered on
the disease entirely and forget that other factors may
be at work and tearing down as fast or faster than
we are building up. The following case illustrates this
quite forcibly.
I was called to see a female patient, age twenty-one,
in 1919, in whom a diagnosis of pulmonary tuberculosis
involving the left apex, had been made two years be-
fore. At this time she was suffering from acute otitis
media which rapidly developed into an acute mastoid.
She was sent to the hospital and operated. She was
there a long time and then sent to a tuberculosis
sanitarium. From there she went to Florida. From
Florida back North to the hospital again for more
mastoid treatment. From the hospital she was or-
dered to another sanatorium, but her money was all
spent so she did not go, but came back home instead,
and placed herself under my care after two years' ab-
sence. This was in December, 1920.
On examination she seemed very septic. The lesion
in the left lung had made some progress, but not as
much as I had expected from her general appearance.
Her evening temperature was 100°. She was coughing
a great deal and expectorating quite large quantities
of yellow mucous. Her appetite was poor, she had
lost some weight and was very much discouraged. She
was placed in bed and the ordinary tuberculous treat-
ment carried out. At the end of three weeks she had
not improved. About this time she developed an attack
of acute laryngitis with a high temperature and quite
alarming symptoms, requiring large doses of opiates to
control the cough and pain. She partially recovered
from the attack, and one day volunteered the infor-
mation that her two lower wisdom teeth were very
sore and had troubled her at intervals for three years.
Examination showed them to be crowded, sensitive on
tapping and there was pus oozing from the surrotmd-
ing gums.
They were extracted at her home the following day.
A quite severe reaction followed which lasted five
days. Following this ail the symptoms subsided, the
temperature dropped to normal, the appetite returned,
and the patient said that for the first time in two
years she felt that she was getting well. It is still
too soon in this case to determine end results, but
from all present indications, they should be favorable.
During the past three years I have observed seven-
teen cases of acute rheumatic fever. Ten cases were
caused by focal infections of the teeth, five cases from
tonsils, one from a boil and one diagnosed as coming
from a long standing bronchitis.
Nine of the ten cases having apical infections were
localized accurately the first time. In each case one
tooth only was affected. In eight of the cases the in-
fected tooth was extracted. In one case the abscess
was drained. All of these cases were diagnosed within
four days of the onset and all were well five days
after the removal of the focal infection.
The tenth case showing apical infection required the
removal of the third tooth before the infection was
removed. These three teeth were alt devitalized. This
patient was sick two weeks.
Careful subsequent examination of the above ten
cases shows them all to be free from heart lesions,
and to be entirely free from pain.
Of the five tonsil cases, four infections were defi-
nitely located in one tonsil. The fifth case was un-
determined, as I had not at that time learned to localize
infections. Four of the cases were operated, and were
cured of their rheumatic symptoms. One was oper-
ated after an attack of rheumatic fever, one during a
remission one week after the onset, and two during
a remission two weeks after the onset. One was not
operated. All have heart lesions.
This series of cases had brought to my mind quite
forcibly the fact that these tonsil cases are complicated
by heart lesions very early in the disease and often
before the onset of the rheumatic fever, and that we
should localize these infections as early as possible
and have them removed.
I have found the most important factor in the locali-
zation of the lesions to be a careful history of the
focal infection. The history of the focal infection
should correspond very closely as to time, and course,
to the history of the disease. If I find that they do
not pull together I usually know that I am on the
wrong track. The next most important factor as re-
gards teeth is sensitiveness to tapping and soreness
when biting. Pain may or not be a factor. Usually
it is not a factor. If there are two or more sensitive
teeth present, the history of the onset will tell me
which one to suspect. In one case I disregarded the
history and made a localization from the appearance of
the tooth and failed.
Devitalized teeth, of which unfortunately there are
many, must be x-rayed. However a careful history
in these cases will help much, for a tooth which has
been devitalized because of infection at the time of
treatment by the dentist, will naturally be more dan-
gerous than one not infected at the time. This one
point has helped me decide correctly in several cases.
The patient usually remembers quite well which teeth
gave him the most trouble. i • ■
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PITTSBURGH ACADEMY OF MEDICINE
499
THE USE OF VEGETABLE PROTEINS IN
CHRONIC DISEASES
Dr. J. M. Thornb
' Stimulated by the occasional benefit from animal
protein hypodermic injections in chronic infections,
arthritis, etc., the hypodermic administration of vege-
table protein was used in a series of chronic cases at
the Presbyterian Hospital.
Material Used: Two per cent, solutions made from
either alfalfa seed or meal, hemp seed, mustard seed,
millett seed, rape seed, clover seed, cotton seed and
timothy seed or mixtures of any, of the above.
Preparation :
Powdered plant (or seed) loo grammes
Sol. Acid Nitric (10%) 80 c.c.
Water 1 litre.
Boil 4 hours, filter, neutralize with sodium
hydroxide solution, standardize by the
Rjeldahl nitrogen test, seal in ampules and
sterilize on each of three days.
Dosage: The dose is }i c.c. increased gradually to
I c.c. or more, injected subcutaneously every other day.
Physiological Action: In the main an improved
blood picture, i. e., marked increase in the red cor-
puscles and the lymphocytes, especially the large
mononuclears, also of hemoglobin. As a rule by start-
ing with small doses, there is no reaction after ad-
ministration, though it is possible to get anaphylaxis
from large doses in one not immunized. The effects
are safer and better from gradually increased dose,
than from an "anaphylactic shock."
Indications: Any chronic disease, characterized by
anemia, or deterioration of the quality of the blood;
therefore in chronic infections as arthritis, tubercu-
losis, and cancer. Also said to be of use in asthma
and psoriasis.
Case I. Dr. A., physician, age 54. Carcinoma of
stomach. Operated at Mayo Clinic. Recurrence within
three months. Protein injections every other day for
about three weeks. Died.
Case II. Miss A., age 48. Seamstress. Carcinoma
of both breasts involving axillas and supraclavicular
glands. Mayos refused to operate. Has received pro-
tein injections for about one year, is going about fairly
free from pain, without cachectic appearance and with
normal to supranormal blood picture. The tumors re-
main about stationary.
Case III. Miss Kate M., age 46. Single, Teacher.
Entered the Presbyterian Hospital about a year ago
for chronic multiple arthritis and sciatica. She was
given a series of protein injections without any ap-
parent benefit. Her tonsils have been removed, and
search for source of focal infection continued in teeth,
etc. To-day she is convalescing from three weeks of
elevated temperature, the only cause of which being
acute nephritis.
Case IV. Robert B., age 19. Chronic arthritis. No
focal infection found. Bedfast 2 years. Marked de-
formity of joints. Protein injection three weeks with
slight benefit.
1/26/21 Before Protein
Reds 3,950,000 4,870,000
Hemo 50% 30 85%
White 20,600 13,600 9,000
Small 14.5 '22
Large 5 7
Trans. 1.5
Poly. 78 67
Eosin 3
Baso I I
Conclusion: The question as to whether we should
depend upon protein injections in cancer in the early
stages, of course, arises. I would say that we should
hold fast to that which we know to be of value — sur-
gery, radium and x-ray ; that there can be no objection
to the use of these means together with the protein
injections; that in inoperable and recurrent cases this
treatment offers the only hope — ^a measure of relief
from debility, cachexia, pain and odorous discharge,
and occasional disintegration and disappearance of the
tumor, with apparent cure.
THE TREATMENT OF FRACTURES OF THE
SHAFT OF THE FEMUR BY PEARSON'S
METHOD OF CALIPER EXTENSION
WITH DEMONSTRATION OF
THE FRACTURE BED AND
REPORT OF CASES
Dr. John D. Singley and Dr. Morris Slocum
That the anatomical and functional results of the
treatment of this facture, both simple and compound,
by former methods have been far from satisfactory, is
well known.
No other fracture offers the same difficulties to re-
duction and maintenance of the fragments in position.
The anatomy of the part — a relatively small single
bone set in the midst of a large powerful group of
muscles — is the primary cause of difficult reduction.
In the past we have been fairly well satisfied with
the results obtained in fractures of the middle third
when treated with Buck's extension, a weight of 20 to
30 pounds, a counter-extension obtained by elevation
of the foot of the bed, lateral splints and rotation
straps. But to obtain good or fair results in this man-
ner required an enormous amount of care and atten-
tion on the part of nurses and orderlies and constant
daily supervision and adjustment by the surgeon. The
patients, too, were anything but comfortable. The long
immobilization of the knee and ankle resulted in more
or less fixation of these joints which required months
to overcome. In fractures of the upper third, owing
to the action of the ileo-paoas muscle, and of the lower
third, owing to the action of the gastrocnemius and
soleus muscles, it has been difficult, if not impossible,
to secure satisfactory results with former extension
methods.
Operative methods which aimed to hold the frag-
ments in position by the use of bone plates or grafts
have given many poor results, principally by reason of
failure to appreciate the necessity for lateral support
and extension after the plate or graft has been placed.
With the advent of the great war, it was found that
in the British armies, one out of every sixty wounded
had a fractured femur. With a mortality ranging
around 80 per cent, it can readily be seen that the
medical corps was faced with a stupendous problem.
Early in 1917 the Thomas splint was put into general
use as the routine method of fixation for transport,
with the result that the mortality was reduced to ap-
proximately 15%. The essential factors contributing
to this reduction were early application of the splint,
the hot air bath, hot drinks and morphine.
A method by which deformity, shortening, and stiff
knee joints could be eliminated, was urgently needed.
It was therefore decided to adopt skeletal extension by
means of the ice tong calipers, first proposed and used
by Ransohoff of Cincinnati, using the Thomas splint as
a support to the leg. The use of calipers in this coun-
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try and abroad had not met with much favor previ-
ously. It had been found impossible to prevent the
caliper points from deeply penetrating the femur, pro-
ducing at times necrosis and sepsis. To overcome
these objections the Besley caliper was modified by the
' addition of a thumbscrew and crossbar arrangement,
so as to have under control at all times the amount of
penetration of the point Then by adding a knee
• flexion splint it was possible to get early and continu-
ous mobilization of the knee joint, together with di-
rect traction on the lower fragment of the femur.
The results obtained by the use of the apparatus were
indeed striking and gratifying. Five to ten pounds of
weight sufficed to reduce all shortening in a few days.
At once it became an easy matter to dress and nurse
these cases.
It soon became evident that a special bed could be
used with great advantage. After some experimenting
the Pearson bed was evolved.
A discussion on the relative merits of skeletal trac-
tion and adhesive or glue extension is necessary to
show the great inefficiency of the latter. Extension by
adhesive plaster or the so-called "Bucks Extension,"
is familiar to all. While its use has been general and
often accomplishes much, there are a number of points
that militate against its use in fractured femurs. Long
continued application of adhesive plaster often irri-
tates the skin and many times it will slip despite all
precautions.
Now contrast this method with that of direct ex-
tension on the bone by means of the calipers. The
points of the calipers, engaged directly in the bone,
but not penetrating it, exert a pull in the direction of
the long axis of the bone itself. It is true the factor
of muscular contraction must be dealt with also, but
there is only the force of the group of muscles at-
tached to the lower fragment to be overcome. Then
again pull exerted in the proper plane tends to bring
about a perfect alignment of the fragments.
From the standpoint of the patient the calipers are
without discomfort or pain. The small incisions made
to engage the points in the bone will not give rise to
pain if properly placed. The small amount of weight
pulling on the calipers is in no small measure respon-
sible for the patient's freedom from distressing symp-
toms.
The results obtained in England in femur cases
treated by the Pearson method were so excellent that
a brief summary of them is worthy of mention. De-
formity was so seldom the outcome as to make it a
curiosity. Shortening was the exception rather than
the rule. Another noteworthy feature was the short-
ened period of disability. No former method ever re-
turned a patient with a fractured femur to work so
rapidly. While this important fact was very essential
during the war it is equally important that in civil
practice the surgeon should do his utmost to cure the
patient in as short a time as possible in order to avoid
an unnecessary economic loss. Formerly it was im-
possible to avoid more or less stiffness of the knee re-
gardless of what treatment was used in fractured
femurs. The normal range of movement in this joint
was almost always restored long before the patient
was discharged. Foot drop and stiff ankle also can be
obviated by Pearson's method.
There are certain essential features necessary in any
bed which is to be used in conjunction with the caliper
treatment. It is possible to improvise a fracture bed
at a moment's notice. However, the standard bed now
on the market modeled after Pearson's bed, adapts it-
self so readily to the caliper treatment that it is ad-
visable for hospitals to possess one or more of them.
These beds, when not used for fracture femurs, can
be instantly dismantled and at once become ordinary
serviceable hospital beds.
In order to satisfactorily place a patient in the cali-
per extension apparatus it is essential to have a frac-
ture board under the mattress to prevent sagging.
Having the patient at least thirty-six inches from the
floor facilitates treatment and nursing and it is de-
sirable that when an ordinary bed be used, it be raised
to this height. At times it is necessary to elevate the
foot or head of the bed. If the bed possesses tele-
scopic legs this can readily be accomplished. This
brings us to the upright and overhead bars which are
absolutely necessary when using caliper extension.
Probably the easiest way to accomplish this is to have
two pieces of one-inch pipe of lengths equal to the
height and length of the bed, respectively. Join these
at right angles by an elbow and erect by standing the
short ends on the floor about ten inches from each leg
at the foot of the bed. The long ends are then carried
to the centre of the top piece of the bed at its head.
These pipes are then made fast with bandages or rope.
This makes a V shaped support overhead, across
which can be fastened a piece of broom stick about
one yard long at a point directly above the ring of the
Thomas splint. If desired the support can be strength-
ened by fastening another broom stick from one pipe
to the other at the right angle turn. This completes
the apparatus necessary to the bed itself.
As regards the remainder of the apparatus it is only
required to have a Thomas splint, a knee flexion splint,
a foot piece, a hexagon of iron, calipers, rope (pref-
erably that used to support window weights) several
small pulleys, and a small canvas bag to carry the
weights.
In order to clearly convey to you the technic of
applying the apparatus the various steps necessary will
be outlined, tjpon receiving such a patient in the
hospital, he is at once taken to the operating room and,
preferably, a general anesthetic administered. When
the patient is completely anesthetized the clothing is
cut away, completely baring the lower extremities. A
Thomas splint with a large ring, padded with leather,
is then slipped over the leg and about three flannel
slings are carried from one bar to the other, and fas-
tened with safety pins. These support the thigh. A
knee flexion splint is then fastened to the Thomas
splint at points opposite the knee joint. Other flannel
slings are fastened to this splint, about three being
needed. These give support to the leg. The end of
the knee flexion splint is then tied to the end of the
Thomas splint temporarily, using about eighteen inches
of heavy cord, so that when the end of the Thomas
splint is raised from the operating table the lower ex-
tremity is supported entirely with the knee in about
thirty degrees flexion. An iron foot-piece is then
clamped to the end of the knee flexion splint and the
foot supported in its normal position by means either
of a piece of bandage slung across the foot piece or
by a broad strip of adhesive plaster carried from the
point of the heel over the sole to the top of the foot
piece. The whole apparatus is then allowed to lie flat
upon the table. The knee is then shaved and surgically
prepared for a distance of six inches above and below
it This operative field is then draped and the surgeon
prepares to apply the calipers. The technic as used by
Pearson is outlined in his monograph.
Some advocates of the method advise that the pa-
tient be kept partially under the influence of morphine
for the first two or three days following the placing
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PHILADELPHIA LARYNGOLOGICAL SOCIETY
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ot the apparatus in position. It induces quiet and rest
until he becomes accustomed to it. Frequent measure-
ments should be taken and recorded from the anterior
superior spine to the upper border of the patella and
compared with the sound side. Beginning with five or
six pounds, additional weight should be added tmtil the
measurement of the fractured side is ^ or i cm.
longer than the opposite side.
Efficient extension and counterextension can only be
obtained (i) if the lower end of the straight Thomas
splint be fixed against a rigid upright, and (2) if the
padded ring of the splint be held firmly against the
tuberosity of the ischium. The latter is of the greatest
importance and is accomplished by swinging the ring
of the splint clear of the mattress to an overhead sup-
port One should daily pass the hand between the ring
and the mattress to make sure that it swings free and
to determine the relation of ring to the tuberosity. The
propor degree of abduction must be maintained by see-
ing that the patient does not move to one or the other
side of the bed.
Axial rotation is controlled readily by the fixation
of the foot to the foot piece by a bandage. If it is
desired to rotate the lower fragment, it is readily done
by elevating the inner or outer rod of the splint either
by weight and pulley or permanent fixation. It is im-
portant that the hinge of the knee flexion splint be
kept at a point exactly opposite the knee joint If too
high or too low the lower fragment moves when
flexion is carried out, which is undesirable from sev-
eral standpoints.
Every five or six days the small wounds about the
entrance of the calipers are wiped clean with a small
swab saturated with cresol or lysol solution, and filled
with carbolized vaseline. A square of sterile gauze cut
half through is then placed over each caliper point
As soon as a satisfactory position of the fragments
has been attained, which should be in a week or ten
days, motion of the knee joint should be instituted and
continued daily. It should not be painful. If it is, the
apparatus is not properly placed.
Daily massage of the entire thigh and leg, except in
ipfected compotmd fractures, should be carried out
This is of the greatest value in preventing muscular
atrophy and in favoring early imion.
The patients are comfortable, which means much
when the duration of confinement to bed is considered.
Earlier union is obtained while the amount and dura-
tion of disability is diminished. Constant attention to
detail is essential for good results in this as in any
method. But it has been our experience that the
amount of attention and care required on the part of
the isurgeon with Pearson's method is markedly less
than in any other method. Nursing, too, is a much
simpler proposition, especially in compound fractures,
as all who have had to do with these patients will tes-
tify. Caliper extension is necessary for from six to
eight weeks as a rule. By this time the callus is suffi-
ciently firm so that extension is no longer required.
Upon removal of the splint it is advisable to cover the
thigh from knee to hip with a one-inch layer of cotton
and surround it with split wood faced with adhesive
and held with adhesive straps before permitting the
patient to be up and about with crutches. An ele-
vated sole is worn on the shoe of the sound side so
that the affected leg swings free. Weight bearing upon
the fractured leg should not be permitted for six
months from date of injury. The walking caliper
splint made from a Thomas splint is highly commended
by Pearson and others in lieu of crutches.
Nine cases are reported: The one outstanding fea-
ture is the lack of shortening, there being but one-
fourth of an inch in one case. There has been no in-
fection in the caliper wounds. Three cases were com-
pound. The maximum weight used were 13 pounds,
the minimum 7. The maximum age of patient is 54,
the minimum 12. The maximum of caliper days 88
(refracture), minimum caliper days 30. The maximum
bed days 115 (refracture), the minimum bed days 51.
Deformity: Slight anterior bowing in one case and
slight outward bowing in another.
Frederick B. Utiey, M.D., Reporter.
PHILADELPHIA LARYNGOLOGICAL
SOCIETY
"DEMONSTRATION OF TWO TONSIL CRYPT
EVACUATORS"
Henry S. Wieder
It is true that there are as many methods of remov-
ing tonsils as there are persons present in this room
but there are times when operation is counterindicated
on account of age and certain systematic diseases. I,
therefore, wish to present these two instruments
which are built in the manner of a comedo. These in-
struments have central openings which fit over the
tonsillar crypts. One of the instruments has a pillar
elevator which, when applied over the anterior pillar
and pushed forward and backward, the tonsil everts
and one could readily see pus in the crypts.
DISCUSSION
Dr. Ross H. Skillern: There is no question that
we have been overlooking this matter of looking at the
tonsils for a focal infection. I was in the clinic in
Rochester, Minn., and happened to say to one man
there : "Look at my tonsils and tell me what you think
of them." He looked in my throat and said my tonsils
were all right I came home and asked Dr. Ridpath
to look at them. He did and said there was a lot of
pus in them and he showed me twelve or fifteen drops
of pus. In a few days I' had my tonsils out. If such
a place as the Mayo Clinic will overlook this thing,
what are we doing here? There is only one way to
examine the tonsils and that is eversion. Both of
these instruments are extremely valuable.
Dr. George M. Coates: I would like to ask Dr.
Wieder: Do you put this crutch in back of the an-
terior pillar?
Dr. WiBdbr: Push on your pillar toward the cap-
sule of the tonsil.
Dr. George M. Coates : The pillar always should be
retracted and the tonsil crypts investigated. In this
way I can frequently bring out pus that I cannot find
in any other way. Thomas R. French uses a tonsil
transillimeter, which he has invented.
Dr. MacCuen Smith: Is this method that Dr.
Wieder speaks of sufficient for a fairly large number
of cases so that it will take the place of tonsillec-
tomies ?
Dr.- Wieoer : It will if you do it constantly in indi-
viduals of old age, etc., where you cannot operate. It
also demonstrates that they need the tonsils out.
Dr. Lewis Fisher : This method of squeezing ton-
sils appears to me as highly unsatisfactory. Many
cases, where tonsils are removed for focal infection,
are made a good deal worse for a week or two after
removal. During the operation the c6mpression I />
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THE PENNSYLVANIA MEDICAL JOURNAL
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serves to throw more toxin into the system. Why
should this method give trouble soon after opera-
tion? It is most unreasonable to try to squeeze ton-
sils without trying to do anjrthing for them. If they
do harm, they should come out; if not, they will
Dk. Sbth a. Brumm: I have seen many cases of
trouble in the tonsils. I use the technic that Dr.
Coates has spoken of. Often by driving a current of
air in the crypts it is improved. You can in this way
see if there is pus without doing any injury to the
crypts. • I am very much interested in the type of case
that I call a flare-up after tonsillectomy. Very often
in cases of chorea, if you do a tonsillectomy, the case
is made worse or is very much aggravated. Also in
cases of endocarditis. It is in these cases that an
autogenous vaccine should be employed. If we will
take an autogenous vaccine before tonsillectomy is
done, especially in cases of chorea, and prepare a vac-
cine from that case beforehand and after operation, it
will prove to be of great value.
Dr. Rau>h Butler: It is very interesting to see
how you get the different results. I have compressed
tonsils for quite a while on the anterior pillar with a
different instrument from Dr. Wieder's and have
never seen any flare-ups from it. Even after chorea
and endocarditis, I have seen cases where you have
inflammatory glands. I have seen one case where
there was pus in the glands and the surgeon refused
to operate. That man was very sick for two or three
weeks. It was opened but not dissected out.
Dr. W. L. Cariss: Transillumination is used in
New York Clinic. Maybe someone here knows some-
thing about it.
Dr. George M. Coates: Thomas R. French in 1916
developed his tonsillescope which some of you may
have seen demonstrated. The patient is in a dark
room, one or two small lights are put back of posterior
pillars. There is a chart of different colors from dark
pink to deep rose which, when compared with the
color of the tonsils, show whether the tonsils are in-
fected or not, and what percentage of tonsils is in-
fected. They say it is infallible. Diagnosis of small
collections of pus in these small nodules below the
tonsils is also made by French's method of transil-
lumination of the tonsils. Nobody has used it because
it takes about one or two years before you can recog-
nize the different colors. That discouraged most
of us.
Dr. MacCuen Smith : The article which Dr. Coates
has just spoken of is in reprints which have been sent
out. There are one or two different colors which
point out color schemes.
"REPORT AND PRESENTATION OF TWO
CASES OF BEZOLD'S MASTOIDITIS"
Dr. Sbth A. Brumm
In presenting these two cases to-night, it is not done
with the thought of the case but with the thought
of the variety of the case. The typical type of mastoid
is well understood, a type in which we have practically
no clinical manifestations of a middle ear involve-
ment Theoretically it is good, practically doubtful.
Dr. MacCuen Smith had a case.
Why do we have mastoids? They seem to be very
definitely anatomical factors. First, we generally
have a very much thickened outer plate, the relations
of the auditory canal to your lateral sinus and to the
antrum is abnormal. The ordinary type of mastoid
has a fairly large antrum, the perforation is through
that outer plate.
My first case had an otitis media, which seemed to
have apparently healed. He was allowed to go about
and return to work. Later he returned with an ab-
scess of the other ear. I treated it for five or six
days. He came into the office one day with very
distinct bulging and mastoid manifestations. The
other case was very much of that type. He was
treated by his family doctor for two or three weeks
as an ordinary case of otitis media. Then the mani-
fest swelling formed in this man's neck and opera-
tion was thought to be needed.
As regards treatment of these cases: To cite one
man in town who describes his operation — he makes
his incision from the mastoid tip down going well into
the sac and putting in a cigarette drain. We get
better results if we drain through the ordinary mas-
toid wound. Hydorite solution was used and dicho-
lorum-t solution also. Both men now have good
healing, and no hideous scars. This seems the most
common-sense way of treating these cases. The lateral
sinus was well in the posterior wall.
STAMMERING AND ITS CORRECTION
Mary Sum hers Steel
Philadelphia
The subject of defective speech covers a variety of
manifestations and corrective measures are now in-
creasingly occupying the attention of educators. The
general public seems to be awakening from the illusion
that if a child learns spontaneously to speak well he is
fortunate and if he fails to develop normal speech
there is nothing to be done to the realization of the
fact that correct habits of speech may be obtained by
training.
The speech defective was at one time at the mercy
of charlatans who are still guaranteeing so-called
"cures" for a given sum of money paid in advance.
Then came the interest of the medical profession,
aroused by Dr. G. Hudson Makuen, and now the sub-
ject is being taken up by schools, Girard College being
the first school in Philadelphia to provide for special
instruction for boys having defects of speech. The
time at -our disposal this evening limits us to the con-
sideration of but one form of defective speech,
namely, that of stammering or dyslalia. We shall not
dwell upon the causes and nature of dyslalia but note
for a brief time the problems existing in the conditioa
Mr. Leon Mons, of the Central High School of
Newark, N. J., in an article in The English Journal,
published by the University of Chicago Press, esti-
mates that two per cent, of all children stammer. In
Girard College, eight per cent, of the pupils have de-
fects of speech and about four per cent, of these
stammer. This large percentage is probably due to
the fact that it is a boys' school. The schools have
their problem. There are enough children with de-
fective speech in the schools to require attention for
many years to come and teachers should be trained
for this purpose. The new charter of Philadelphia
makes speech correction obligatory, but so far as I
know nothing definite has yet been started and the
schools are still sending children to the speech clinic
at the Medico-Chi Hospital, a section of the Uni-
versity of Pennsylvania Medical School. When this
work is started will the medical profession be re-
lieved of the speech problem? No; the medical pro-
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PHILADELPHIA LARYNGOLOGICAL SOCIETY
503
fession must do all in its power to prevent stanuner-
ing,
Here I wish to quote several acute examples : Eliza-
beth, of bright mentality and well developed physically
but with speech difficulty, was started in school this
term and her troubles have increased. She is unable
to utter a sound before the teacher and pupils.
Joseph, with speech hesitation, beg^n school in Sep-
tember, and was frightened by being called upon for
a reply. He could not speak. The teacher scolded
him, saying he was a naughty, stubborn little boy, who
would not reply when spoken to. The parents of
both children had been depending upon schools to
correct the defect In each case the little patient who
had an indefinite idea of voice production passed into
a psychic condition. They are both branded as stam-
merers whereas if they could have had speech train-
ing before entering school much suffering would have
been spared. It has been necessary to give Elizabeth
(a proud, sensitive child) her choice of leaving school
or being excused from all recitations in order to re-
lieve her of the srtuggle to speak which results in
failure and confirms her fears that she cannot speak.
She has chosen to be excused from reciting as the
lesser of the two evils. Joseph, in much the same
condition, was sent to the clinic from the public
school and Elizabeth was referred for private obser-
vation, to a neighbor whose little daughter had been
saved from Elizabeth's experience by early training.
These two cases have different social position but are
equally unprepared for school life. Their condition
emphasizes the importance of early training.
I have used for my title this evening the word
stammering, but I wish we could lose that word. The
words used most frequently to classify defects of
speech are stammer and tongue-tie. It seems to me
that the only way to eliminate the word stammering
is to educate all young children into coordinate speech.
The young child who fails to coordinate the mechan-
isms of speech does not realize this fact, but someone
says "he stammers." The word mystifies him and he
feels that he is being blamed for something over which
he has no control. He then becomes a stammerer.
He grows self-conscious, timid and very sensitive.
A small boy was recently presented for examination
and the following conversation resulted. "Have you
trouble with your speech?" "No." "Can you always
sound your voice?" "Oh, yes." "What is your trou-
ble?" "I stan»mer."
Training for speech is training for life and one of
the anomalies of the eduactional world is that speech,
the highest development within the possibilities of man,
has been neglected or left to chance. The most im-
portant years for the training of speech are the first
five years of life. Few if any children hesitate from
the very outset. Speech is an acquired faculty and
stammering is an acquired defect, the result of inco-
ordination of the mechanisms of speech. The child
generally begins to have trouble because he does not
know how to combine the art of ideation with that of
oral expression. His thoughts come rapidly and he
cannot arrange them in order. He usually possesses
initiative and grasps an idea quickly. He struggles to
utter a word after his mind has gone forward. If he
wishes to say "The boy has a book,' his mind is on
book and he fails to utter distinctly "The boy has."
His central and peripheral mechanisms fail to co-
ordinate.
Should the training be physical or psychic? The
answer is contained in two short sentences. "All
human achievement comes from bodily activity" and
"All bodily activity is caused, controlled and directed
by the mind." Speech is a "human achievement."
Faulty use of the peripheral mechanisms is respon-
sible for faulty kinesthetic memories which can only
be corrected by education of the peripheral mechan-
isms. Had Elizabeth been instructed in the coordina-
tions of speech before she understood that the train-
ing is necessary because she stammers our task would
be easier. She is now being taught active breath-
ing and voice production. Attempts are being made
to bring about coordination by means of reading from
a primer pronouncing each word distinctly and com-
posing stories of pictures in her own language, which
she learns to read in the manner of the primer, read-
ing after the sentences have been carefully written
out for her. After obstructions to normal breathing
have been removed, all young children showing the
slightest tendency to hesitate in speech should have
daily training in correct active breathing for voice
production, rhythmic vocal exercises and very dis-
tinct dictation of short colloquial sentences which the
child may repeat.
DISCUSSION
Dr. MacCuen Smith : Mrs. Steel has made a very
forceful and truthful statement to the effect that
speech is an acquired faculty. Before you undertake
to try to correct a defect of speech, it requires a very
close and hard study on your part I might also state
that inasmuch as speech is an acquired faculty, this
faculty could not be acquired unless the child had a
certain amount of intelligence. Normally the average
person learns to speak by imitation ; if he can hear he
can speak. The importance of the hearing in con-
nection with these cases is very great.
Long before Dr. Hudson Makuen took up the
subject of stammering, I had gone into the subject
myself. The reason was that when I was a boy of
nine or ten, my Grandfather MacCuen, who was a
judge in a fairly small community, used to tickle me
and I developed a stammering. My father, being a
physician, required that I read aloud from a half-hour
to an hour each day. I overcame almost wholly this
stammering, but even to-day there are certain words
that I find very difficult to pronounce. I am very
skilful, however, in substituting another word for the
one I cannot pronounce. I should like to ask Mrs.
Steel whether, in those children who have not the
opportunity of being taught, a selection for them to
read aloud to some person who is intelligent, would
be a good substitute. Mrs. Steel stated that the first
five years of a child's life are the most impressionable.
How early in that child's life can you start instruc-
tion? Perhaps you can start a little earlier with girls
than with boys.
Mrs. Steel: I spoke about the child reading and
pointing; that is a very important thing, and Dr.
Smith's father persisting in his reading kept his mind
working on language. In that way he learned to bring
out his words. I consider it a very important thing if
the child is taught to read properly, as many read
just as they are taught. Reading which is guided,
which is distinct and clear and allows the expression
and the idea and muscles of speech to come together
is certainly bringing about a coordination. I substitute
a repetition of sentences for a child who is very
young but no child is too young to begin speech train-
ing. Just as soon as the child has the slightest de-
fect of speech, start training. Girl babies talk -earlier
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THE PENNSYLVANIA MEDICAL JOURNAL
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than boy babies. Girls have the facility of speech
which enables them to keep time with the thought It
is more highly developed in girls than it is in boys.
Girls arrive by intuition and men reason things out.
Dr. Smith spoke about the child not hearing. There
is a difference between lip reading and teaching the
young child to speak. The young child who does not
hear, if trained in the use of language, develops lip
reading, is not taught it. Speech reading, as the
Kinzies call it, is the transference of the compfehen-
sion of language from the ear to the eye and is hard
for people to acquire. Lip reading is the transference
of the comprehension from the ear to the eye. People
are confused in the difference between the education
of the deaf child and the teaching of lip reading to
the adult.
NASAL PACKING IN SUBMUCOUS RESEC-
TION
Edw. W. Coixins, M.D.
Philadelphia
Nasal packing in submucous work is almost as im-
portant as the operation itself. Much good operative
work is spoiled by careless packing. The chief object
in the use of the Simpson splint seems to be the con-
trol of postoperative hemorrhage. I will endeavor
to show why this type of packing is harmful. After
using the Simpson splint myself in about aoo cases
and observing the condition of the nose in other cases
from which this and other types of tight packing was
removed I came to the following conclusions as to
their effect :
1. Pressure necrosis due to poor blood supply.
2. Edema of mucous membrane from congestion
and poor lympathic drainage.
3. Hematomae from poor drainage.
4. Infection in traumatised tissue due to infection
from nasal secretion and poor drainage.
1. Pressure Necrosis Due to Poor Blood Supply. —
The delicate layers of the mucous membrane when
packed with Simpson splints are held in a vise-like
grip and the blood supply is cut off almost as ef-
fectually as if a hemostat or ligature were on each
blood vessel, producing an area of anemia covering
the size of the splint and an engorgement of the sur-
rounding tissues due to fullness of the vessels. Con-
sequently if the membrane is torn or thin, the natural
process of healing cannot proceed and necrosis is the
result. This can be proven by packing lightly with
gauze, when large tears will heal and the large per-
forations which all of us dread will be avoided.
2. Edema of the Mucous Membrane Due to Conges-
tion and Poor Lympathic Drainage. — The pressure of
the tight nasal splint saturated with nasal secretion
exerts a pressure on the lateral wall of the nose as
well as on the septum, and this pressure sets up an
edema of the mucous membrane and effectually cuts
off drainage from the nasal cavity and sinuses. In
the advent of any sinusitis the infection is aggravated,
and a boggy nose and delayed resolution is the result.
3. Hematoma from Poor Drainage. — ^The cartilagi-
nous septum being removed and probably the descend-
ing plate of the ethmoid, with Simpson splints in place
the two mucous membranes will remain unsupported
above, and if the two membranes are not torn above,
there remains between them a closed pocket, which
may fill with blood from the denuded surface, with the
consequent organization of the clot and a thickened
septum above.
4. Infection of Traumatised Tissue Due to Reten-
tion of Nasal Secretion and Poor Drainage.— Wkh
Simpson splints are removed the nose is usually boggj
and full of mucous. With the tissues in this condi-
tion and also traumatised, an infection will occur very
easily both of the sinuses and septum, with the result
of a prolonged convalescence, which is distressing to
operator and patient.
Conclusions. — Packing with nasal splints probably
causes as many poor results as poor surgery.
Control of postoperative hemorrhage is usually not
necessary.
Packing lightly or moderately firm with gauze pack-
ing, enough to approximate the two layers of the
mucous membrane will insure better drainage, less
perforations, and quicker healing.
Bleeding helps wash out infection and usually stops
itself in two or three hours.
The method that seems to give best results after a
series of from two to three hundred cases is the foK
lowing :
After removing all cartilaginous and bony obstruc-
tion, a wooden tongue depressor is broken in half
laterally and one-half inserted in each nostril, the two
mucous membranes are approximated and pressed
firmly together with these wooden splints, then the
nose is again inspected after the removel of these
splints. Any torn membrance is replaced and pressed
into place. The nostrils are then packed with half-
inch gauze packing, packing the upper part fairly
firm and the lower part of the uose more loosely, just
enough so it will hold the two mucous membranes in
contact. All packing is removed in from twelve to
twenty-four hours.
This does not condemn the use of the Simpson
splint in cases of removal of a spur or ridge from the
septum. In this class of cases it has a most useful
field.
DISCUSSION
Dr. Ross H. SkillBRn: I have come to the con-
clusion that the use of the double splint should not be
resorted to. It is very disagreeable and agony to the
patient Packing is better. With the use of tincture
of benzoin, it comes out very readily and does not
cause the amount of traumatism.
Dr. Hbnry S. WiSDER : Dr. Collins has not told us
what he uses to prevent the packing from adhering.
I have come to the conclusion that Dr. Collins has. I
usually had a whole lot more hemorrhage the day I
took the packing out than the day I put it in, and
usually had to repack. I use bismuth subnitrate,
which will help to keep the secretions sweet and dry.
Here is a little scheme I learned in the matter of
packing: One night I was called to see a young lady
whom I had packed with gauze after operating, and
found about one-half yard of packing in the throat
I make a rule now to hold the gauze as I pack. Ap-
proximate the depth of your nose and push the gauze
up high, building layer on layer. I have seen Dr.
Walter Roberts use Simpson's tampon very effectually.
If you do not avoid hematoma, you will have just as
much obstruction after operation as you did before.
He cuts a splint in half and puts one-half of splint
on top, high up, and then the other portion of the
splint below. This does not cause much pressure, as
only a half splint is used.
Dr. MacCuen Smith : I have used bismuth nitrate
for twenty years. Gauze is already prepared, and the
bismuth is worked into the g^uze. I do not have
bleeding and it does not hurt the patient. We pre-
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PHILADELPHIA LARYNGOLOGICAL SOCIETY
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pare it at the hospital. You have to rub the bismuth
into the gauze. I always use the loop, too,
Dr. Henky a. Laesslb: When the packing has a
tendency to j)ull, draw it toward you. If it causes
undue pain and hemorrhage, take the end of the gauze
and give it a twist. Diminish the size of the gauze and
it will bleed gradually, and at the end, the hemorrhage
will almost cease.
Dr. Prank Embery: If you take a piece of J.ohnson
& Johnson gauze, which is flexible, and pack your nose
carefully with a piece of the gauze soaked in vaseline,
I find that it will not stick. Rubberized gauze is good
and comes out easily.
Dr. H. a. Schatz: I should like to ask what
method of packing is most desirable or recommended
in a case of sinus trouble where there is a diffuse dis-
charge of pus and where a submucous resection is
very necessary?
Dr. M. S. Ersnbr: In the last year or so in doing
my submucous resections I have made it a practice to
return three or four hours after the operation and
remove the gauze packing. I use the packing that Dr.
Collins has described. If the packing is removed three
or four hours later, the gauze won't be adherent, there
will be no hematoma and recovery is much more rapid.
Dr. George M. Coates : The ideal method would be
to do without packing altogether. I tried it but was
called to repack every time, so I gave it up. I use
the divided splint, putting one splint above the other.
The ordinary splint is entirely too thick and too nar-
row. The best thing is to put in a small amount of
gauze and put in something to keep it from sticking.
Bismuth is good, compound tincture of iodine, ben-
zoin and guaiac is also good. The principal thing is
to get enough packing to hold your two surfaces to-
gether without causing any pressure.
Dr. Margaret S. Butler: For a good many years,
I should think three or four years, we have used no
packing at the Woman's College Hospital. We some-
■ times take a piece of gauze about one inch in length
and three-quarters in width covered with sterile vase-
line. We have had no cases of hemorrhage. We very
often use two silver plates, which make very little
pressure. That has been more satisfactory, and we
have had no hemorrhage.
Dr. Collins (in closing) : Gauze packing is the
proper thing. Tight packing causes pressure and
sloughing. You can get tight packing of g^uze just
as well as with the Simpson splint. I have tried the
division of Simpson's splint but you cannot control it
as well as your gauze packing.
THE USE OF SUCTION IN OTOLARNGOLOGY
TECHNIQUE OF APPLICATION
Arthur J. Wagers, M.D.
Philadelphia
Among the various agencies employed in the local
treatment of suppurative inflammation involving the
ear and the nasal accessory sinuses, suction occupies
a high position in the scale of usefulness. Properly
applied, it provides a most eflicient means of obtaining
physical cleanliness of the. part being treated, and, in-
cidentally, it produces a local hyperemia, which, ac-
cording to Bier, is of benefit in promoting healthy re-
action in tissue exposed to the action of bacterial ir-
ritants.
Before taking up the details of application of suc-
tion, I wish to direct attention for a moment to the
mechanism employed for the production of negative
pressure. There are in general use three types of ap-
paratus : the suction pump operated by electricity,
the Brawley suction apparatus for attachment to a
water faucet, and the simplest form which consists
merely of a rubber bulb which, after being com-
pressed, produces suction by expansion.
Wherever current is available, the electrically op-
erated pump will be found efficient for all purposes,
the one objection to certain pumps on the market
being that they are not provided with a ready means
of regulating the pressure produced. The Brawley
water suction pump has the advantage of being simple
in construction, is light in weight, can be used wher-
ever there is running water, and the pressure produced
can be very easily regulated by controlling the amount
of water passing through the instrument. The rubber
bulb, of course, is ready for use at any time or place,
but its use is limited by reason of the light pressure
which expansion of the bulb produces.
Regardless of the type of negative pressure pump
employed, the complete apparatus consists essentially
of a rubber tube connecting the pump with any one of
a variety of applicator nozzles which it may be desir-
able to use. A bottle reservoir should be interposed
at some point between the nozzle and the pump. This
serves the double purpose of showing the total amount
and character of fluid removed and prevents this fluid
from entering the pump.
The applicator nozzle, from the practical point of
view, is the most important part of the mechanism.
Nozzles are made of metal, hard rubber, or glass. I
find glass preferable because one is able to determine
almost immediately after application, whether fluid
in any quantity is being withdrawn and its general
characteristics may be noted at the same time. Sharp
edges on all forms of nozzle are to be avoided and if
the nozzle is intended to fit tightly into any natural
opening, as for example the external auditory canal
or the nostril, it is advisable to protect the tip by
means of a band of rubber. These nozzles, as well
as the rubber connecting tube, are easily sterilized,
thus rendering the apparatus available for any type of
operation.
In the application of suction it must be remembered
that negative pressure may be so great as to cause the
patient extreme suffering. It is good practice to begin
with the lowest possible pulling force and let it be
gradually increased until desired results are obtained.
Applied in this way it is but seldom that a patient will
complain of discomfort. A vacuum pressure gauge
may be attached to the apparatus, but personally I do
not find this necessary.
I shall now consider in some detail the practical
application of suction in the treatment of certain ear,
nose, and throat conditions.
Given a case of acute suppurative otitis media, we
incise the membrane tympani to provide drainage from
the middle ear. A certain amount of the contained
fluid being under pressure flows into the external
auditory canal, but complete removal of fluid can only
be secured by applying suction. For this purpose a
round, rubber-protected nozzle is inserted closely into
the external auditory canal and the negative pressure
allowed to act very gently. Even the lowest possible
pressure may be painful if the operation is performed
under local anesthesia or none at all. I recently heard
a physician refer to this procedure in most uncompli-
mentary terms because he had seen a patient suffer
severely from this method of treatment and he there-
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fore condemned it most heartily. To avoid this diffi-
culty and for other obvious reasons it is better to
operate under general anesthesia. But even then it
must be remembered that too great pressure will fre-
quently produce a hematoma in the wall of the ex-
ternal auditory caiial. This is an undesirable occur-
rence as by its presence it not only tends to obstruct
natural drainage from the middle ear, but may itself
become infected before absorption takes place. Daily
removal, by suction, of the accumulated pus in the
middle ear should constitute a part of the routine
treatment of the condition.
Suction is quite as applicable in the treatment of
chronic otitis media as in the acute condition and the
technique is no different.
In the postoperative treatment of suppurating mas-
toids, suction may be employed to remove all pus from
the wound. For this purpose it is advisable to use a
nozzle of small calibre and long enough to reach all
parts of the wound. I find that an ordinary curved tip
medicine dropper answers the requirement exactly.
It is perhaps in connection with the diagnosis and
treatment of nasal accessory sinus disease that suction
finds its largest field of usefulness. At the same time
the difficulties of application in this region are greater
than those met with in treating conditions involving
the ear or throat. I mention suction as a diagnostic
aid because we sometimes examine a case in which all
the subjective symptoms indicate the presence of an
acute sinuitis, but inspection does not reveal the pres-
ence of pus in the naris. If there actually be pus in
one or more of the sinuses, suction, properly applied,
will bring it out into the nasal passage where 4t may be
seen, thus confirming at once what might, for a time
at least, remain a doubtful diagnosis.
Two general forms of nozzle have been devised for
use in the removal of fluid from the sinuses, the one
intended for direct introduction into the natural
outlet of the sinus to be treated; the other form
consisting of a nozzle which fits closely into the ves-
tibule of the naris and through this the negative pres-
sure acts indirectly upon all the sinuses in a manner to
be explained later.
The method of applying a nozzle tip directly to the
individual sinus has not been found practical in the
writer's experience, for the reason that the natural
openings of all the sinuses, except that of the sphe-
noid, are hidden beneath the middle turbinate and are
not easily reached except after removal of at least a
portion of this body, and unless this operation is indi-
cated for other reasons it would seem a needless sacri-
fice of tissue. The indirect method of applying suc-
tion to the sinuses is practicable and efficient, but for
its successful accomplishment we must take into con-
sideration certain points in the anatomical construc-
tion of the parts operated upon as well as the physical
laws involved.
In a recent discussion of this subject, the point was
brought out that a fluid lying in a cavity will not be
made to flow upward and out of an opening situated
above the fluid level when a vacuum has been pro-
duced in that cavity. The speaker failed to under-
stand, therefore, how suction could be used to empty
certain of the sinuses. When we consider that with
the exception of the frontal sinus, the natural outlet
of practically all of the sinuses is situated at a point
above the low level of the sinus, we realize that the
position taken was correct.
It is self evident that a fluid' flows more readily
from an opening in the bottom of its container than
from an opening in the side and particularly if dut
opening happens to be above the fluid level as can well
occur in the case of the maxillary sinus, for example.
It becomes evident, therefore, that to so incline the
head as to bring the outlet of the sinus being treated
to the lowest point, favors the removal of fluid when
suction is applied. In addition to this we must pro-
vide for two other conditions which are essential to
the success of the operation. The outlet from the
sinus must be sufficiently patulous to permit of the
passage of air and fluid. Direct application of a so-
lution of cocaine or adrenalin to the area about the
opening will insure this condition. It is further neces-
sary that the soft palate be elevated to close contact
with the postpharyngeal wall. After a few trials the
patient is able to do this voluntarily, but it is often
necessary to assist by some such simple act as swal-
lowing and when the position of the palate has been
attained, the patient is directed to hold it while suction
is acting. At the same time the suction nozzle is fitted
closely into the nostril of one side while the nostril
of the opposite side is tightly closed by the operator's
finger. As the negative pressure is applied, this is
what takes place: a certain amount of the air in the
nares and in the sinuses is suddenly withdrawn; that
is, a partial vacuum is formed. As the air leaves the
sinus a portion of the contained fluid is carried along
with it, and both air and fluid move in the direction
of the nozzle. But in a moment all movement of fluid
ceases though the vacuum be continued. If now the
operator release the unoccupied nostril there is a sud-
den and forceful inrush of air backward around the
septum and into the opposite nostril and its sinuses,
and the vacuum ceases to exist. We have the same
condition we began with. To continue the suction, we
simply close the free nostril again and the process is
repeated until further operation fails to bring away
fluid. The procedure is the same for all the sinuses,
bearing in mind the position of their respective out-
lets.
As the negative pressure often reaches the middle
ear by way of the eustachian tube, care must be exer-
cised that the pressure be not so great as to injure
that organ.
In the throat the use of suction is practically lim-
ited to its application to diseased tonsils and as a
means of removing blood and secretions from the
throat during throat or nose operations under general
anesthesia.
When tonsils are distinctly diseased the rational in-
dication is their removal. However, there are in-
stances in which owing to the age of the patient, or
because of conditions contraindicating the use of an
anesthetic, it is not advisable to operate ; and besides
there are the patients who refuse operation. Such
cases must be treated and here again suction is of
value as a means of cleaning out the pockets and
crypts which have been opened at the surface.
The employment of suction for the removal of
blood from the throat during operation has become
so nearly universal in all our large hospitals, and the
application is so simple, that there is little to be said
except to emphasize its value. When efficiently em-
ployed it provides a clean. field of operation and, by
preventing the aspiration of blood and germ-laden
secretions from the throat, undoubtedly serves to pre-
vent a certain number of so-called ether pneumonias
and the development of lung abscesses which has been
observed in certain instances following tonsillectomy
I do not wish to convey the impression that suction
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alone is a cure for suppurating sinuses or middle
ears, though one does see a certain number of these
cases which clear up in four or five days with prac-
tically no other treatment than suction. Neither can
it take the place of surgery when surgery is indicated,
but it is a principle of surgery that whenever and
wherever pus exists in the body it should be removed.
Suction thoroughly accomplishes this removal, and in
so doing carries away a multitude of bacteria and bac-
terial products from the area involved, and nature is
thereby greatly assisted in restoring the tissue to its
normal state.
DISCUSSION
Dr. Lewis Fisher: I was very glad to hear Dr.
Wagers speak of the values of suction as I am person-
ally a great convert to it. I use a small machine in
my office and find it very practicable. By use of the
foot switch I can graduate the speed of the machine.
In this way I can measure the amount of suction in
every case. It not only prevents injury to the patient
but also saves the machine. The question of suction
appealed to me on the face of it as so reasonable that
I tried it on some of the acute cases of otitis media.
It probably did more harm than good. In acute otitis
media is it better not to use suction. I think you
bruise the tissues too much and cause a lot of bleed-
ing. In the sinus cases I am a thorough advocate of
suction. I can never convince myself that patients
receive the full benefit of suction treatment by an oc-
casional visit at the office. When I see a case that will
be benefited by suction, I teach the patient the use of
that suction and have him use it twice a day and in
this way the patient gets the benefit of it. I found
this method particularly useful in cases of atrophic
rhinitis. In those cases the great object is to stimulate
the parts. In those cases wliere the patient can use a
suction pump that cannot be too powerful, and use it
several times a day, it will be much better. I fully
agree with Dr. Wagers that suction is a very valuable
thing.
Dr. M. S. Ersner : I believe that suction should not
be employed in acute otitis media. It is not the pus
that is in the middle ear that we are worried about,
but the pus in the eustachian tubes. It is true that
when suction is applied through the external auditory
canal the thick and slimy secretions are removed, and
has the advantage over the washing, but we must not
forget that we constantly reinfect the middle ear by
aspirating the pus from the eustachian tube. My pro-
cedure in treating acute otitis media is to shrink the
nasal mucous membrane and produce suction through
the nose. Dr. Wagers said it is not necessary to use a
gauge. He also spoke about three different methods
of suction employed. It would be interesting to know
how he uses these methods. Mastoid suction is pretty
difficult to carry out as you would have to bring the
suction apparatus to the patient's bed.
Dr. MacCuen Smith: I have to differ with Dr.
Fisher and Dr. Ersner about the use of suction in
acute otitis media. The little instrument that I de-
vised a good many years ago consists of a little curved
affair which fits in the ear, and has a little bulb and
a little reservoir to collect the fluid when it comes out.
I first saw the model of it in Germany. It is made
in this country. My custom is to incise the tympani
and use aspiration. It is not only efficient but very
frequently prevents mastoiditis.
Last summer when I was away one of my friends
was called in to see two children who were suffering
from acute otitis media. The family had nine chil-
dren. I had operated on almost all for acute otitis
media. Mother had become accustomed to seeing the
suction apparatus. It was not used in the last two
children and they had to be operated on for mas-
toiditis. The parents felt that if the suction apparatus
had been used it would have prevented the mastoid
disease. I feel that in those cases of otitis media
where we are making incision of membrana tympani
and put on the suction apparatus, it would certainly
prevent mastoid disease.
Dr. W. L. Cariss: I have used suction apparatus
in mastoid work. It keeps a dry field and aids very
much. Also in sinus work. In tonsillectomy you have
to be very much more careful. Dr. Wieder spoke of
dry space. The assistant might very readily cause
some traumatism.
Dr. M. S. Ersner: One thing that has not been
spoken about is saving the uvula with suction appara-
tus. I have saved many uvulas while students were
working on patients.
Dr. Ross H. Skiuern: Dr. Wagers spoke of fear
of using suction after tonsils have been removed. It
would seem that it might be a thing to be avoided. It
is a rule in our clinic that it should not be done. I
have not seen any hemorrhage following it. It is true
that theoretically the clots are all formed there in the
veins and in the arteries and that suction might very
readily pull them out.
Dr. H. a. Schatz: It is possible in my opinion to
corroborate the statement of Dr. MacCuen Smith. I
have used Dr. Smith's apparatus. The advantage is
that it allows gentle suction. Dr. Fisher's method is
far from gentle. Some can tolerate it and be benefited
and others cannot stand violence.
Dr. Herman Cohen : There is no question about it,
that suction is a helpful agent in maxillary sinusitis,
and in sphenoid sinusitis. Suction will draw out the
pus. In ethmoid and in frontal sinusitis, it is cer-
tainly helpful. I cannot see how it helps a great deal
in maxillary sinusitis. Washing out is the only thiiig
to do, I think. I have used Mr. MacCuen Smith's
new apparatus and find it very helpful in treatment
of otitis media. I do think it keeps away the tendency
of mastoid involvement.
Dr. MacCuen Smith : I have used suction of the
nasal accessory sinuses for a good many years. Even
if one set is involved I have used the glass tube spoken
of by Dr. Wagers in both. It does no harm and
benefits the patient after he uses it for a while. Every
fraction of a minute he should release its pressure
and then start over again, and in doing that you un-
questionably can evacuate these sinuses and even die
maxillary sinuses.
Dr. Ross H. Skillern : While I was in the service
we all had this suction apparatus sent down to camp.
I tried it. Ihad several cases of maxillary involve-
ment, so I put this syringe apparatus on and sucked
and sucked until I thought I had tried enough. It be-
came distasteful and then became painful. Then I
stopped. I then washed out the nose and about one
and a half ounces of pus came out. It shows that it
was not possible, at least as far as the maxillary
sinuses were concerned, to fully empty it by suction.
Dr. Wagers (in conclusion) : In this matter of
emptying the maxillary sinuses, I believe there are
some cases where you cannot empty the sinuses
through their natural outlet, especially if the fluid is
thick. In the majority of cases a plug of thick mu-
copus will come out when using suction. I should like
to relate a personal experience which I think illus-
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THE PENNSYLVANIA MEDICAL JOURNAL
April, 1921
trates the point that Dr. Cohen made. Some three. or
four years ago I suffered from severe pain in the
region of my left upper jaw. I thought at first the
teeth were involved. It occurred to me after su£Fering
intensely for more than twenty-four hours that it
might be my sinus. I applied suction, after shrinking
the tissues in nose, and almost immediately the secre-
tion in my sinus came out and pain was relieved. It
was a case of the natural ostium being plugged by
thickened pus.
Dr. Fisher spoke of treating these patients only
occasionally. I agree with him; it is of very little
value as far as the cure is concerned. It relieves at
the time but it should be done often if you want to
cure the patient — in fact from three to four times a
day. I have had patients use the apparatus at home.
It is a° simple instrument and the use of it can be
taught easily. Patients have often suflFered pain from
use of suction and are shy about using it again.
Dr. Ersner spoke of using suction after mastoid
operation. It can be used. In the treatment of acute
otitis media, my feeling is that these cases improve
much more rapidly by cleansing or by suction after
incision. If you have an ear that is discharging you
look in that ear and see the canal filled with pus. You
cleanse the ear, but you have not really cleansed it
thoroughly. The middle ear is involved when pus is
formed and that is the part of the ear you want to get
at. I do not know anything that is better than suction.
There is great danger of forcing this pus back in the
mastoid region and therefore producing acute mas-
toiditis. It is much better to have everything going
out and nothing going into the middle ear.
ABSTRACTS FROM STATE MEDICAL
JOURNALS
FRANK F. D. RECKORD, M.D.
Assistant Editor
THE TREATMENT OF BRONCHO-PNEUMONIA
IN INFANCY AND CHILDHOOD
By W. O. Colburn, M.D.
Lincoln, Nebraska
The treatment may be divided into three parts, and
in the order of their importance presented: (i) The
use of steam, plain or medicated. Steam has been
used for laryngitis and bronchitis, and is so men-
tioned in all the leading works of medicine for a cen-
tury back, and its use has in most instances been
suggested by means of the croup kettle, and to be
closely confined for a short time. I have been an
early advocate of steam, using it in the first year of
my practice, sixteen years ago, for broncho-pneumonia
cases, and I learned early that if a little is good, a
whole lot is better. The past four years, in my city
practice, I have found it very easy to administer the
steam night and day, and for several days if necessary.
The poorest homes already afford the necessary elec-
trical apparatus. In a few moments we make a tent
of part, or the entire bed, with sheets, leaving the en-
tire side of the bed open on the side under which the
steaming apparatus is working. I take the ordinary
electric flatiron, turn it upside down between a couple
of bricks set on edge, place a pan of water, holding a
ouart, on the iron, and open a window. All you need
to do is to replenish the water about every two hours.
I have had good results with steam alone, but believe
that my results are some better with the addition of
ten minims of creosote to each quart of water evapo-
rated. Creosote is highly recommended by Holt.
In the country, or where electricity is not available,
one may use a croup kettle, with an alcohol lamp, and
a smaller tent, and get very satisfactory results.
Steam will quickly quiet the most troublesome cough,
and within a few hours the labored quick breathing
returns almost to normal and the patient is comforta-
ble.
(2) Alkalinization of the patient. This paper will
permit of only a very brief discussion of this head.
All infections, mild or severe, but much more so when
severe, tend to bring about an acidosis. This is more
true in the child under four years of age. An acetone
odor can usually be detected on the breath of most of
these children, if they run the slightest temperature.
This is an early danger signal, and one that should be
recognized by the physician and treated at once. The
child may have been sick twenty-four hours or less,
and usually gives a history of not eating or drinking
up to norma! for the day previous, so that for forty-
eight hours, he has been deprived of his body fluids
to quite an extent, and all at a time when the demand
on these fluids has greatly increased. The physician
is very apt at this stage to give a drastic cathartic,
sacrificing more fluids, and precipitating an acidosis.
Cases presenting this danger signal do better in my
experience to withhold the physic, and begin at once
to supply fluids by mouth all you can, and if not suc-
cessful, then per rectum. I still cling to sodium-
bicarbonate ; plain water may be just as good. If you
feel that you must give a physic, then give the milk or
citrate of magnesia, and you will at least be admin-
istering; an alkali. In oUr pneumonias we make it a
rule to administer forty ounces of fluid daily, if not
successful by mouth, then proctoclysis is resorted to.
We administer enough sodium-bicarbonate to keep the
urin alkaline.
(3) Drugs: In beginning cases with few scattered
rales throughout the lungs we push belladonna to the
physiological limit, drying up the secretions, and
throwing the blood to the periphery. We do believe
that many times this has seemingly been a factor in
aborting pneumonias. I am not adverse to using it in
our severe cases, when the lungs are full of secretions.
I have never seen any bad results especially while the
patient is breathing steam.
Stimulants are rarely necessary in the pneumonia
case under five years of age, when using this form of
treatment. The use for stimulants increases as the
child approaches puberty, and takes on symptoms much
like the adult. — From the Nebraska State Medical
Journal, Norfolk, Nebraska, October, 1920.
A SIGN OF VALUE IN EARLY PHTHISIS
Seuc Simon, M.D.
St. Louis
For the past ten years the author has made it a
routine in examining chests for possible phthisis, to
pay particular attention to the heart, and especially to
the pulmonary second sound which, in the absence of
any organic right ventricular hypertrophy, is of in-
estimable value in that it is usually accentuated in
early phthisis.
He assumes that when an area of lung tissue be-
comes affected, the body's defenses, as in all inflamma-
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April, 1921
ABSTRACTS FROM STATE JOURNALS
509
tions, meet the situation by pouring into and around
that area an increased amount of blood, producing a
congestion.
This area of congestion is not demonstrable by phys-
ical signs of percussion or auscultation but, effecting
as it must an impediment to the lesser circulation, the
right ventricle attempts to overcome the obstruction
by the utilization of its reserve energy. This results
in an accentuation of the pulmonary second sound.
Furthermore, it has been definitely shown that in
proven tuberculosis, with bacilli in the sputum, this
sign still persists even though percussion of the right
heart, roentgen-ray plates and fluoroscopy fail to show
any right ventricular hypertrophy. — From the Journal
of the Missouri State Medical Association, January,
IC121.
GOITER PRESSURE OR INTRATHORACIC
GROWTH
By Frank H. Laiiev, M.D.
Professor of Surgery, Tufts College Medical School
Under the treatment of hyperthyroidism he speaks
only of surgery, as he is convinced that it offers by
far the most rapid and complete means of influencing
the course of this disease.
Certain conclusions that he has reached after having
personally operated on over four hundred thyroid
cases are : His surgical procedure is to ligate the poles
in those serious or doubtful cases too ill to endure the
complete operation, and then send the patient home for
a period of eight weeks, having them report for x-ray
treatment every three weeks during this interval. At
the end of eight weeks the basal metabolism has usual-
ly dropped ; there has been a gain in weight and such
improvement in general condition that the complete
operation may be undertaken with safety. In certain
cases it does not seem wise to submit the patient to
ligation of both poles, and in those cases one pole is
rapidly ligated, and after an interval of a week or two
—during which short time the patient makes a re-
markable gain— the other pole is tied, and the patient
sent home for eight weeks. Following the stay at
home of eight weeks and of x-ray treatment, the pa-
tient again returns to the hospital for a period of
observation and for basal metabolism estimation, and
if her improvement warrants it as demonstrated by
drop in metaboKsm, gain in weight, and diminution of
symptoms, the final operation of partial thyroidectomy
is done. We feel very sure that this two stage pro-
cedure materially increases the margin of safety in
those cases. If he feels that they will probably stand
the operation, either in the case of pole ligation or of
partial thyroidectomy, but that there is some doubt,
he takes them to the operating room, prepared for
operation, gives them gas-oxygen, and if doubt still
exists, sends them back to bed, notes the degree of re-
action from this procedure and is governed by this
reaction in his decision. Again, if after pole ligation,
x-ray and the eight weeks' stay at home, he feels that
the ligated case may still not endure the complete
operation of partial thyroidectomy, but will stand fur-
ther ligation, he ligates the inferior thyroid arteries
as they run along the inner borders of the scaleni
antici.
He feels that after eight weeks there is a tendency
for basal metabolism to rise again and that partial
thyroidectomy or further ligation should not be de-
ferred much beyond that point.
In the procedure of partial thyroidectomy we have
also been convinced that nothing short of the removal
of a considerable portion of the gland (3/4 to 4/5)
accomplishes the purpose desired.
At the risk of being misunderstood, he states that he
believes that thyroid surgery belongs in the hands of
men experienced in, dealing constantly with, and
equipped to handle such cases. It is the type of sur-
gery which should be tmder the control of the surgeon
before and after operation, first, because study is nec-
essary for proper decision as to the course to pursi«*.
and, second, because postoperative care plays a con-
siderable part in the percentage of recoveries. These
statements appear perhaps rather extreme, but are
borne out by our mortality (2 7/10%) and that of
other thyroid clinics, as compared with the much
higher mortality of thyroid cases handled without an
organized equipment for their study and cure. — From
the Journal of the Maine Medical Association, Decem-
ber, 1920.
THE DISPLACED UTERUS
By J. F. Gallagher, M.D., F.A.C.S.
Assistant Professor of Gxoecology, Vanderbilt School of Medi-
cine, Nashville
The operative procedures for the correction of
retroflexion, retroversion and retrocession have been
directed mainly to shortening of the round ligament
and, to a much lesser extent, the shortening of the
uterosacral ligaments. The operations for shortening
of the round ligaments may be grouped tmder the fol-
lowing six heads, according to the avenue of attack:
(i) Inguinal, (2) vaginal, (3) intra-abdominal fold-
ing, (4) fixation to the anterior surface of the uterus,
(5) fixation to the posterior surface of the uterus,
(6) fixation to the anterior abdominal wall. From a
collective review by Chalafant (S. G. O., November,
1916, Vol. 23, p. 433) the author tabulated seventy dif-
ferent types of operations on the round ligament alone.
Obviously it would be futile to attempt to discuss
them. The fundamental principle to be observed to
make for the success of any operation on the round
ligament would be the utilization of a design that ulti-
mately depends on connective tissue rather than muscle
for support. Nowhere in the body is muscle called
upon for continuous action, and no exception should
be made here. The success of round ligament shorten-
ing is perhaps due to the fusion of apposed peritoneal
layers rather than the shortening of the muscle proper
of the ligament.
The problem of the cure of'descensus, prolapse and
procidentia immediately brings to our consideration
whether the patient is in the child-bearing period and,
if so, whether that function shall be preserved or not.
The types of operations which offer the highest per-
centage of cures necessarily contemplate the steriliza-
tion of the patient either by the very nature of the
operation itself (e. g. vaginal hysterectomy with im-
brication of the broad ligaments, or supravaginal
hysterectomy with suture of the cervical stump to the
abdominal wall) ; or the operation may have such dire
results on the mother should pregnancy supervene that
sterilization is desirable (e. g., the Schauta interposi-
tion operation). Rarely will operations on the liga-
ments proper of the uterus effect a cure in prolapse or
procidentia. Happily, most of these conditions occur
after the menopause, and we are not concerned with
the preservation of the child-bearing function. — From
the Journal of the Tennessee State Medical Associa-
tion, Nashville, Tenn., October, 1920.
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THE PENNSYLVANIA MEDICAL JOURNAL
April, 1921
THE PENNSYLVANIA
Medical Journal
Published monthly under the supervision of the Publication
Committee of the Trustees of the Medical Society of the State
of Pennsylvania.
Editor
FREDERICK L VAN SICKLE, M.D Harrisburg
Aialitent Editor
FRANK F. D. RECKORD Harrisburg
Aaaociato Edltori
Joseph McFaklamd, M.D Philadelphia
Geokce E. Ppahlu, M.D Philadelphia
LAwmCHCE LiTcunXLD, H.D., Pittsburgh
Gkokge C. Johnston, M.D., Pittsburgh
J. Stewart Rodhan, M.D Philadelphia
John B. McAlistkx, M.D Harrisburg
Bernard J. Myers, Eso Lancaster
PnbUoatton Oommlttee
Ira G. Shoehaker, M.D., Chairman Reading
Theodore B. ArrEL, M.D Lancaster
Frank C. Hammond, M.D Philadelphia
All communications relative to exchanges, books for review,
manuscripts, news, advertising and subscriptions are to be ad-
dressed to Frederick L. Van Sickle, M.D., Editor, 3ia N.
Third St., Harrisburg, Pa.
The Societ)[ does not hold itself responsible for opinions ex*
pressed in original papers, discussions, communications or ad-
vertisements.
Subscription Price — 13.00 per year, in advance.
April, 1921
EDITORIALS
A NATIONAL DEPARTMENT OF
PUBLIC HEALTH
The platform of the Republican party adopted
June, 1920, had a plank which read as follows:
"The public health activities of the Federal
government are scattered through numerous
departments and bureaus, resulting in ineffi-
ciency, duplication and extravagance. We ad-
vocate a greater centralization of the Federal
functions and in addition urge the better co-
ordination of the work of the Federal, state
and local health agencies."
Is it a coincidence or does the passage by the
National House of Representatives, December
14, 1920, by a unanimous vote, of the Senate
Joint Resolution No. 191, mean that this plank is
to be enacted into law and placed on the statute
books ?
The resolution creates a Joint Committee on
Reorganization to consist of three senators and
three members of the house whose duty it is to
make a survey of the administration services of
the Federal government; to secure facts perti-
nent to overlapping or duplication which may
exist in present departments.
An investigation will show an extremely un-
fortunate situation, with reference to public
health departments. An official survey recently
made, showed that there were thirty-four inde-
pendent government organizations carrying on
some kind of work directly relating to public
health. These organizations instead of being
closely correlated, according to a recent state-
ment in the Journal of the American Medical
Association, are scattered throughout the differ-
ent departments. In the Treasury Department
are the U. S. Public Health Service and the War
Risk Insurance Bureau. The Children's Bureau
is in the Department of Labor. The Division of
School Hygiene and Physical Education, the In-
dian Medical Service and the Government Hos-
pital for the Insane are under the Department of
the Interior. The Department of Agriculture
has Bureaus of Chemistry, Animal Industry,
Entomology and Biology, all performing some
health functions. In the Department of Com-
merce, the Bureau of Census conducts the Divi-
sion of Vital Statistics. The War and Navy De-
partments each have their own medical service.
The list could be extended largely but this will
suffice to point the moral and adorn the tale.
The need of organizing and correlating these
numerous agencies is evident. The hope has
been frequently expressed that out of the discus-
sion and investigation that will result shall come
a well planned and coordinated Federal health
organization. It is only by unity of action and
complete knowledge of the plans of each division
or bureau or department that constructive war-
fare against the enemies of health, public or local,
can be secured.
There has been much talk and discussion for
many years about establishing a Department of
Public Health with its chief a member of the
President's cabinet. Surely the time is ripe for
such a movement. It is a consummation de-
voutly to be wished. C. R. P.
THE CAPPERS-FESS BILI^NATIONAL
At a public hearing before the Committee on
Education in the House of Representatives,
Washington, D. C, January 12, 1921, the medi-
cal profession was the scapegoat in many base-
less charges and groundless fears expressed by
the opponents of the bill under discussion ; i. e.,
the Cappers-Fess Bill, to provide for "the pro-
motion of physical education in the United States
through cooperation with the states in the prepa-
ration and payment of supervisors and teachers
of physical education, including medical examin-
ers and school nurses ; to appropriate money and
regulate its expenditure; and for other pur-
poses." Section 2 of the bill reads as follows:
"The facilities for securing these ends shall be
understood to include a comprehensive course of
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April, 1921
EDITORIALS
511
physical training activities ; a periodical physical
examination; correction of postural and other
remediable defects ; health supervision of schools
and school children ; practical instruction in the
care of the body and in the principles of health ;
hygienic school life; sanitary school buildings,
playgrounds, and athletic fields and equipment
thereof; and such other means as may be con-
ducive to these purposes."
(i) The American Optometric Association
opposed the bill because "it has a tendency to
give to the medical practitioner, and by the medi-
cal practitioner I mean the allopathic school of
medicine, a control that is almost absolute over
the examination of public school children."
(2) The National Association of Osteopathic
Physicians oppose because a million people of the
nation partial to the osteopathic method of treat-
ment "would resent any attempt to interfere
with the parents' right of choice of the kind of
treatment which the children should have when
the defects are discovered by the Federal or state
inspector under such a bill as this."
(3) The Public School Protective League op-
posed because "we believe that this bill as it is
at present framed is more in the interest of medi-
cal control — more in the interest of compulsory
medicine than it is of physical education."
(4) The Indiana Society for Medical Free-
dom opposed because "millions of intelligent,
law-abiding American citizens have adopted and
have been using for years and years drugless
methods of healing, and the provisions of this
bill, with its companion bills, would establish a
medical monarchy, the equal of which I have
never heard of or read about, even in ancient
history."
(5) The First Church of Christian Scientists
of Boston and its branches and members through-
out the country opposed because "you find the
insidious propaganda emanating from what they
call the little political ring of the American Medi-
cal Association to make every effort and every
endeavor to inject in some way connected with
the public welfare of the citizens of the United
States, a proposition whereby State medicine or
compulsory medication shall be imposed upon the
people of this country" ; and because ''many par-
ents send their children to private schools in
Massachusetts rather than subject them to the
medical surveillance of the public schools. It is
a very common thing. I think such a bill as this
would directly tend to drive pupils from the
public schools to private schools to escape the
medical surveillance which the bill contemplates" ;
also, because "the most far-reaching, as well as
the most recent evidence obtainable, is found in
connection with our national army, where medi-
cal inspection and treatment were compulsory
and where the men frequently were called upon
to listen to so-called "health" talks by medical
officers. The control of the soldiers was so com-
plete that the medical authorities could do almost
anything with them" ; and because "there was an
average of one physician to every 1 16 men of the
total strength of the army, and what was the
result? The more complete medical control be-
came in the army the larger the death rate. The
death rate of American troops has increased
from 4.5 in 1910 to 6.3 in 1917"; and lastly,
because "to develop a mentality in which no un-
clean thought shall enter, in which disease and
fear have no place, is the surest way to a normal,
robust, physical development, and an overflow-
ing fullness of health and abundance of life. On
this basis we object to the frequent or infrequent
physical examination leading necessarily to diag-
nosis, which all too frequently implants the
thought of disease in the mind of the child."
(6) The American Medical Liberty League
opposed because while "the American flag float-
ing over school buildings in this country and
many other places in the country, and also to
know that there are a great many medical liberty
leagues in almost every state of the Union, that
the people have to combine themselves to fight
against a despotic school of "medicine. My fa-
ther, who was "J"] years of age, now is under the
stones at Arlington. He went through the Civil
War and was not inoculated with anything, and
disease was rampant in camps, yet he lived a long
and useful life. My brother, four years younger
than I, went into the American Army, where
medical liberty was not free, although he was
fighting for democracy. Religious liberty was
free, and he could go anywhere, to hear a Catho-
lic priest or a Christian Scientist, or any school
of any one of the different denominations of his
own religion ; but he was not free to select his
own school of medicine. Had he been, he would
not have had all that forced upon him. He was
inoculated against typhoid, and very soon was
dead of septic endocarditis of the heart ; and now
lies by my father, a man who was "jj, and he
only 38 years old. I wanted to give you another
sample of what the American Medical Associa-
tion does."
Mr. Dallinger : "You think that the American
Medical Association killed him?"
Mr. Bradford: "I mean the allopathic phy-
sicians of the country, who are formed into a
trust. They gave them their allopathic treat-
ment, their preventive serum inoculation, gave
them vaccine to prevent typhoid, smallpox vac-
cines to prevent smallpox, and when the "flu"
came along it killed ten times as manr ofjhese^l
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THE PENNSYLVANIA MEDICAL JOURNAL
Aprii., 1921
selected men who had been selected by physi-
cians and had been treated by them, to prevent
disease, ten times as many as of the rejected ones.
That is the way that worked. It seems to me
that what we need in this country is medical edu-
cation. I have studied thoroughly the systems of
education. Twenty-five years ago I rejected
allopathy, and that is the reason I am here to-
day."
The Chairman: "It might be of interest to
you to know that the American Medical Asso-
ciation has not backed this bill."
Speaking in favor of the bill. Dr. C. Ward
Crampton, Dean of the Normal School of Physi-
cal Education at Battle Creek, Michigan, said :
"Objections have been raised by previous speak-
ers to the bill because of its alleged possible at-
tachment to some medical system or cult. Noth-
ing could be further from the case. Far from
being attached to medicine, it is attached to
health. It concerns itself with the prevention of
disease by the establishment through right habits
of living, and primarily by physical exercise in
all of its forms, which produce a condition of
abounding vitality, which in turn prohibits the
thought of medicine and disease. It is because
physical exercise is such an efficient health meas-
ure that other health measures have become nat-
urally and probably attached to it.
"Physical education is, primarily, games, ath-
letics, gymnastics, dancing ; secondarily, instruc-
tion in hygiene, physical examinations, health
clubs, hygiene inspection, social games, dancing,
community and recreation center activities ; lastly,
the discovery of noncontagious and contagious
medical defects and school nursing.
"In present practice in state laws now on the
statute books and in this proposed legislation this
order of emphasis is preserved. It is not the
purpose of this law drastically to impose upon
the school children of the United States the ne-
cessity of having their tonsils and adenoids re-
moved. If this were the case, I would be un-
alterably opposed to it. The health and vitality
of the men, women, and children of the United
States is of national and not merely local con-
cern. If the children in the schools of any one
state of the Union were to remain with their suc-
ceeding generations within the bounds of that
state and never by production, consumption, or
commerce of any kind to affect the people of
neighboring states, and never to join with the
neighboring Americans in fighting for a com-
mon cause, then and only then would it be right
and proper for the United States Government to
withhold its counsel, inspiration, and effective
support to the public schools of that state."
The underlying motive in the various expres-
sions of opposition to the organized medical pro-
fession as expressed above is selfishness, and in
most instances the alarm expressed is based on
ignorance. The unwarranted attack by the Chris-
tian Scientists upon the results of preventive
medicine in our army during the World War is
worthy of a specific refutation.
Without attempting to discuss the suggestion
of Federal interference in the affairs of the sev-
eral states of ther Union, we do believe that the
unselfish interests of the organized medical pro-
fesssion should be protected against the attacks
of ignorance and greed. We believe that prop-
erly authorized committees of the American
Medical Association should develop new lines of
defense, as well as augment the older methods
against the cheap but all too common public ex-
pression of the existence of "a medical trust."
W. F. D.
MEDICAL LIBRARIES
By virtue of their association, medical editors
naturally are the official representatives of medi-
cal literature. Medical literature is useless with-
out public medical libraries. Medical libraries
have not shown the progress one would expect.
There should be medical libraries in every center
of medical activity. Such new libraries, as well
as already established libraries, should have
placed on the shelves only worthy literature, in
order that the libraries shall become of progres-
sively increasing value to the profession, and
through the profession to the world.
The various counties could place a medical
library in the county seat which may be the head-
quarters of the county medical society. All hos-
pitals should have a library for the use of the
visiting staff and the internes.
The Philadelphia County Medical Society has
placed certain medical works and journals in sev-
eral of the free libraries of the city, in order that
the physicians living in the various sections of
the city may have easy access to the latest medi-
cal literature.
Every medical editor knows from daily expe-
rience how the practitioner of the country and
village is handicapped by his lack of reference
books. Books may be obtained by gifts from
physicians retiring from practice; from the
libraries of deceased physicians; from publish-
ers; from the lists of duplicates and triplicates
in public libraries ; from the departments of ex-
change and review of medical journals; from
auction sales; from medical societies, domestic
and foreign, by the presentation of their trans-
actions and publications.
A public library in every community would
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April, 1921
EDITORIALS
513
stimulate the independent and intellectual life of
the profession more than any other conceivable
institution. F. C. H.
MEDICAL PAPERS AND HOW TO
WRITE THEM
About this time of the year there are many of
the profession who are planning to write papers
upon medical subjects to read before the Medical
Society of the State of Pennsylvania, as well as
other state societies, and f rorti the experience of
every editor of a medical journal, papers often
come in improperly prepared and requiring edit-
ing to a rather extensive degree. Much of the
fault is due to lack of conception on the part of
the writer as to the system which should be fol-
lowed in the preparation of papers.
No doubt every writer has a style of his own
and yet there must be some system in order that
papers shall appear in proper shape when put in
print. This subject has been called to the atten-
tion of the profession many times in different
ways and we submit this topic after reading an
article by Dr. E. Gustav Zinke of Cincinnati,
Ohio, which appeared in the March issue of the
Ohio State Medical Journal. For the benefit of
those who will take the time to read this editorial
we submit the suggestions made by Dr. Zinke;
"The ability to speak well and to write attrac-
tively is a gift. It is a talent, however, that may
be much improved by painstaking practice in
speaking and writing. It is well known that
some of our most successful practitioners and
skillful operators are poor speakers and not very
good writers, while there are others who possess
the talent of expressing themselves well, but who,
although they are well educated, are frequently
most indifferent as to how they speak and write.
"A paper carefully and attractively written is
more likely to be read by the average reader than
one carelessly prepared and couched in poor Eng-
lish. Thus it happens that a paper of great in-
terest and pr2ictical value is frequently disre-
garded by the reader solely because its compo-
sition is faulty, its language imperfect and unin-
viting. To secure the attention of the medical
profession for the perusal of our transactions
they should be, as nearly as possible, free from
criticism, at least from a literary point of view.
"As secretary of the American Association of
Obstetricians, Gynecologists and Abdominal Sur-
geons, it is my duty to edit every paper presented
at each session before it is given to the editor of
the journal. A well-written paper does not, as a
rule, require more than an hour or two of edi-
torial scrutiny. A paper upon which little or no
• care has been expended, however, not infre-
quently requires from twelve to fourteen con-
secutive hours of the most intensive effort on my
part to make it fit for presentation to the editor
and printer. Occasionally I have been obliged to
spend every leisure hour at my disposal for one
whole week upon one manuscript.
"I am sorry to state that the majority of the
papers presented at every annual meeting show
sometimes an extreme lack of care in their
makeup, not only in the use of imperfect Eng-
lish, but also in the disposal and consideration of
the subjects with which they deal. A paper writ-
ten just the day before it is to be read is never a
good paper; I care not how able and well-
trained its author may be from a scientific and
literary standpoint.
"To write a good paper you must first select
the subject you desire to present for discussion ;
the next step is to examine the literature of the
matter to be treated, then to compare the expe-
riences and studies of others with your own.
This done, make your dispositions and write out
in detail what you have to say on each of them ;
lastly, draw your conclusions.
"After the manuscript is completed, put it
aside for a week or two, but continue to think of
the subject, making a note now and then of what
you would like to add or omit. At the end of
this period, read the manuscript a second time,
and you will be surprised at the many changes,
additions, omissions, and transpositions you will
find it necessary to make. You may even marvel
how it was possible for you to write as poorly
as you did.
"Again the paper, in its improved form, is
locked away for another rereading at the end of
a week or two; and, when you read it for the
third time, you will find words, phrases, and sen-
tences that may be changed to advantage to make
the subject matter clearer, the organization more
compact, the diction more forceful and pointed.
"The next and final reading should be devoted
to 'polishing' the paper. Remove every super-
fluous word, phrase, and sentence. See that your
adjectives are properly selected and correctly
shaded, and that your language is pure, simple,
effective and inoffensive to those who may dis-
agree with you.
"After you have thus labored to do your best
with the manuscript, submit it for careful peru-
sal to one who is a master (or nearly so) of the
English language, and ask him, or her, to point
out further defects and shortcomings, especially
with reference to syntax, punctuation, para-
graphing, and diction.
"A paper thus prepared will be at once an
honor to you and a credit to the association.
Every fellow should have the ambition, and con-
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514
THE PENNSYLVANIA MEDICAL JOURNAL
April, 1921
sider it his duty, to raise the standard of our ef-
forts and to place the association upon the highest
plane of efficiency, and thus increase its useful-
ness to the greatest possible extent."
We trust this subject may be seriously consid-
ered by those who contemplate writing papers
for the Pennsylvania Medical Journal.
THE VOLSTEAD ACT RULINGS
When prohibition of alcohol as a beverage was
first seriously considered and finally adopted,
few conceived the conditions which have since
arisen in the application of the Volstead Act and
the state prohibition enactments. It was hoped
that some definite, sane method would be adopted
in relation to the dispensing and sale of intoxi-
cating liquors for medical purposes without plac-
ing the burden and responsibility entirely on the
profession of medicine and pharmacists and
druggists of the country.
More and more, however, it seems the design
of certain movements originating in various ways
and eminating from various sources, to place this
burden upon the two professions which happen
to deal with sickness in the home, namely, the
physician and the druggist. The recent ruling
of former U. S. Attorney General A. Mitchell
Palmer, in the closing days of his term, that beer
and light wines might be dispensed under the
same regulations as had previously been promul-
gated in the case of stronger intoxicants, was in
the first place a dastardly method of shifting the
answer to the appeal made by certain classes of
people in the country for the privilege of using
light wines and beer. This program would turn
every doctor's office into a potential "speak-easy"
and the only salvation from such serious conse-
quences is the realization of the morale and
honor which we know exists in the minds of the
medical men of this and every other state. Yet
we cannot minimize the dangers which come
from pressure upon those who are not so deter-
mined to live right in the profession and will
hide behind the word "tonic" in over-dispensing
alcohol in any form.
In the beginning this very thing which has hap-
pened was feared by many of us as the serious
outcome which would eventually affect the pro-
fession. The result of this will be a belittling of
the medical and drug professions when they are
obliged to become the legalized dispensers of
alcoholic beverages. Some of us may be thin-
skinned and resent the slaps which the public
press gives us, especially when we read such items
as the following : "After a while they (the doc-
tors) will be divided into these classes— doctors.
near doctors, dear doctors and beer doctors."
When viewed in the light of the honor and tra-
dition which have followed the steps of the medi-
cal profession since its beginning, can you not
conceive how humiliating are such flings as the
above ?
Are we in a new era which will eventually
place the medical fraternity in the position of
barkeeper? Will we have the same honor and
distinction as was accorded the saloonkeeper in
years gone by?
There must be some strong, determined atti-
tude taken by the profession in this matter, be-
cause one or two physicians in a county or com-
munity can so disgrace the rest of the profession
in that community, and bring such discredit to
the body, as will for years to come bring distrust
and dishonor upon the entire profession.
This is indeed a very serious condition that
should not be passed over lightly as one of the
things which is a joke, for it has a distinct in-
fluence upon the future of the practice of medi-
cine in this country.
PREPARATIONS FOR OUR ANNUAL
MEETING
It is not too early to bring to the notice of the
members of our Society what has been and is
being done toward the preparation of the pro-
gram and activities connected with the 1921 ses-
sion of the Medical Society of the State of Penn-
sylvania which will be held in the Bellevue-
Stratford Hotel, Philadelphia, October 3d to 6th,
inclusive.
The notice of the preliminary meeting of the
Committee on Scientific Work was given in jm
earlier edition of the Journal, and a call for
volunteer papers appeared in the March issue of
the Journal. The committee is active in its en-
deavor to prepare a live, scientific program for
the autumn session and the request for volunteer
papers should be acknowledged by a prompt re-
sponse from those who should write and present
them before some section.
Few of our members, except those who have
previously served on this committee, realize the
immense amount of effort necessary to be put
into operation in order to develop a well rounded
program for such a meeting as has in the past
been presented at each annual session. In every
one of the sixty-three component county socie-
ties there are men who, in their work, develop a
sufficient amount of material which should be
brought before some section of our society and
published in the Pennsylvania Medical Jour-
nal during the succeeding year for the benefit of
scientific medicine.
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April, 1921
EDITORIALS
515
Arrangements have been completed and cir-
cular letters issued to prospective exhibitors, for
the commercial exhibit. This year we anticipate
a much larger attendance than any of the past
sessions and are striving to induce a larger num-
ber of business houses to reserve space in the
commercial exhibit, thereby not only increasing
the revenue from which our aimual session ex-
pense is derived, but also presenti'ng a full line
of exhibitors whose products are used or rec-
ommended, by the profession. To this end the
assistance of the members in counties where
manufacturers and dealers reside or have their
plants, is solicited by the management and wc are
anxious that personal solicitation bring us ap-
plicants for space from those whom we do not
have upon our list. There are many such in this
state whom we do not know and whose addresses
we have no means of obtaining. Yet these firms
would be equally as interested in an exhibit were
the matter brought to their attention.
The second floor of the Bellevue-Stratford
Hotel will furnish ample space, not only for the
scientific meetings, but for our commercial ex-
hibit, and we wish to announce -the fact that
seventy-eight booths will be constructed and ar-
ranged for exhibitors.
We trust that the members will keep in mind
the fact that they have a duty to perform equal
to that of the officers and committees in assist-
ing in every manner possible to make the 1921
session both profitable and interesting.
SOCRATES REDUX-
THE LEGALIZATION OF MEDICAL
PRACTICE
"Well, I judge that it is about time for us to
set our legal machinery in motion again." So-
crates struck a match as though to light his pipe,
but paused without touching it, evidently waiting
for the effect of his words.
As there was no response, he continued, "1
understand that the Chiropractors are going to
introduce a bill to provide them with a board of
medical examiners of their own, and legalize
their system of practice."
"That would be pernicious ; we must nip it in
the bud. These irregular sects are getting more
and more bold. A Board of Medical Examiners
in every state, a Homeopathic Board in many
states, an Osteopathic Board in a good many
states, and now a Chiropractic Board — the next
thing will be nothing less than a Board of
Naphr^wths."
"We differ a little in our view of the subject ;
I look upon it as a good thing."
"Good Lord, man, how can it be a good
thing?" We were shocked and for the moment
began to doubt the sagacity of our good friend
and frequent visitor. What could he be driv-
ing at ?
"Well, in my judgment, the sooner it comes
the better it will be. As things go at present, the
tendency is to license everybody that wants to
practice, and as the Chiropractors, the Nephra-
paths, the Medical- Electricians, the Christian
Scientists and the Criminal Abortionists have no
way of getting a license at present, the sooner
one is provided, the better. When they are all
registered and licensed, we will know who they
are, and will put them in competition with one
another, as well as with us."
We remarked that this was doubtless some
pleasantry, as no medical man in his senses could
possibly entertain such a thought.
"Pleasantry, no, indeed, I never was more in
earnest in my Hfe. I remember when there were
no such thing as State Boards of Medical Ex-
aminers, and all that was necessary if one wanted
to practice medicine was the possession and regis-
tration of a diploma. It cost one dollar, and was
easy to accomplish. If one had not the diploma,
he bought one, and then registered it, and went
ahead. One estimable lady of my acquaintance
asked me whether she could not practice upon a
diploma that had belonged to her deceased fa-
ther. She willingly showed it to me, and I was
struck with her originality, for it proved to be
one given, not by a medical college, but by a pri-
vate individual, and asserted that the possessor,
having taken a six weeks' course of instruction,
was competent to practice Medical Electricity.
I asked her how it could apply to her, and she
replied that it was a diploma, and the possession
of it ought to confer the right to practice. But
I said, 'It was not granted to you, but to your
father; you did not take the course of instruc-
tion it represents, how could it apply to you?'
To which she replied that she had frequently seen
her father give the treatments, and they were
quite simple. Understand that this lady was in
other respects, in no way different from most of
those you meet every day.
"But that is the most ridiculous thing we ever
heard."
"It isn't the most ridiculous thing / ever
heard. It reflects popular opinion and knowl-
edge of medical subjects. One has a diploma,
and therefore ought to be permitted to practice.
These various sects — I hate to dignify them with
the name of sects — consist of groups of individ-
uals who confer diplomas, and in the eyes of per-r^(jTp
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516
THE PENNSYLVANIA MEDICAL JOURNAL
April, 1921
haps a majority of our fellow countrymen are
therefore entitled to practice. This is a free
country."
"But let us lay <iside jesting; what are you
driving at ? You certainly do not think that such
a bill to license Chiropractors ought to be
passed ?"
"Why not ? We license Osteopaths."
"For that let us bow our heads with shame.
We did what we could to prevent it, but politics
got it through."
"Yes, and politics may get this through. Is it
equitable that the Osteopaths be permitted to
qualify and the Chiropractors not? Are the
former any better or more learned than the lat-
ter?"
"No, but having lost out in the one case, we
must take greater precautions this time, and not
let such a bill get through."
"Well, when the State Board of Medical Ex-
aminers was first established, I was delighted, for
I thought I saw in it a defense of the public
against incompetent and irregular practitioners,
but in my judgment it has largely failed."
"How can you say such a thing ?" In a quar-
ter of a century it has greatly raised the standard
of the medical profession, immensely improved
and uniformized the medical colleges, standard-
ized hospitals, and put the whole practice of
medicine upon a new and improved basis."
"Has it? It has certainly made it harder for
an intelligent and well educated man to get into
practice through the regular legal system, which
it was not intended to do, but what has it done to
prevent the irregulars from practicing, which
was what it was intended to do? As I walk
along the streets I see more signs than I can
count with Osteopath, Chiropractor, Nephrapath,
Herb Doctor, and I don't know what all, on
them."
"But we are gradually weeding them out."
"Not at all. We are giving them their special
privileges, and licensing them. In my judgment
we ought to follow a diflFerent plan."
"What is it?"
"License them all."
"It is inconceivable."
"You don't quite follow me. Here is the plan
in a nutshell. If any one wants to treat the sick
and call himself a doctor, let us welcome him.
Let us say to him, here is the door to medical
practice ; it stands wide open to everybody. All
that you have to do is to show that you have a
reasonable acquaintance with Anatomy, Physi-
ology and Pathology to know how the body of a
man is made, how it works, and what can get
the matter with it, and enough knowledge of
Diagnosis to know what is the matter with it,
and enough Chemistry and Pharmacology to pre-
vent you from involuntary manslaughter. This
is what every doctor must know, and without it
no one can avoid being dangerous. If you know
these things, we don't care what system of prac-
tice you prefer, or how you will treat your pa-
tients. We ask no more of you than we require
of ourselves, and with your especial sect we do
not concern ourselves. Any university will fur-
nish you with the information; you may enter
the regular classes in these subjects, and study
them as we do. After you have finished your
medical course, you can do as you please. Do
you get me ? The idea is one board of examiners.
Let all who want to practice be able to pass it.
Have its examinations searching in the funda-
mental things, but do not ask about the matters
appertaining to sects. Say to the legfislators, 'We
don't care what these men call themselves, or
what or how they practice ; we don't know that
we are the only ones in the right. But this we
do know: an ignorant man is apt to be a dan-
gerous one, and what we want to do for the pub-
lic is to defend it from the dangerously ignorant
who would masquerade as a doctor when in real-
ity he is only an ass or a knave.' As you permit
the laws to be framed at the present time, you
are making it more and more difficult for your
sons who are and want to be honest and capable
men and good physicians, and more and more
easy for the charlatan and humbug whose only
desire is to prey upon the public."
"But you said license these men a while ago."
"Exactly. The faster we license them, the sooner
we must have new laws, or raise their standards
until uniform with our awn. If the Osteopaths,
who are now legalized, and claim to have col-
leges, will advance their entrance requirements
to conform with ours, and give courses equal to
ours, wherein will be the curse of Osteopathy?
Any one of our own graduates is free, without
criticism, to carry on treatment by massage if he
wants to. A really educated osteopath, if such a
thing is thinkable, with the knowledge of the ar-
rangement of the vertebral column, that follows
real study of anatomy, will be very much
ashamed to hear one of his fellows tell a patient
that 'the rejison his child has diphtheria is be-
cause one of his cervical vertebrae has slipped
out of place.' That kind of piffle will disappear
with the proper education of Osteopaths. One
more thought : the Osteopath himself when prop-
erly educated would be as fully entitled to treat
disease with 'the use of drugs or knife' as any-
body else. Wouldn't that be an asset ? I believe
it would be greatly appreciated, too."
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The Medical Society of the State of Pennsylvania
OFFICERS' DEPARTMENT
WALTER F. DONALDSON, M.D.
Secretary
8014 Jenkins Arcade Btdg., Pittsburgh, Pa.
AMERICAN MEDICAL ASSOCIATION
1921 MEETING
We quote from the March number of The
Medical Program of the Washington County
Medical Society sentiments expressed by Presi-
dent Charles L. Harsha of that society regarding
the annual meeting, June 6-10, 1921 :
"The American Medical Association meets in
Boston, June 6-10. It may be a trifle early to call
attention to this fact, but those of you who have
attended the meetings for the past few years
know the difficulty of securing suitable hotel
reservations, unless you get your call in early.
The coming meeting promises to be one of the
best yet held, and there have been some mighty
good ones. Do not get the idea that these meet-
ings are for "specialists." The general practi-
tioner is the one who gets the most good from
them. One of the great dangers that besets the
average physician is that of getting into a "rut"
— of being satisfied with himself, his practice, his
results.
"There may be men who never attend county,
state or national meetings — who never spend a
week or two in the clinics of our larger hos-
pitals, and yet are able to avoid this "rut" — there
may be. The large majority of us need frequent,
or at least occasional inspiration. Attendance at
our county, state or national meetings stimulates
us to better work. We read more interestedly;
we study our cases more thoroughly; we take
greater joy in our work.
"If you have never attended a national meet-
ing in Boston, get the habit ; it is easy to get and
a mighty good one to hold on to. The man who
goes to Boston will have just as much income
upon which to pay tax next year as he would had
he remained at home, and he will have the added
satisfaction of deducting the expense of his trip
from his tax and income."
RAILROAD RATES TO BOSTON AND
PHILADELPHIA
Upon presentation of proper identification
certificate, signed by Secretary Alex. R. Craig,
M.D., 535 N. Dearborn St., Chicago, 111., Penn-
sylvania members will receive a reduction of
twenty-five per cent, of the round trip rate from
any point in Pennsylvania to New York City.
Fiill fares from New York to Boston and return
to New York will be in force.
Regarding reduced rates to the meeting of our
own Society in Philadelphia, October 3 to 6,
1921, we quote the following from letter received
from C. M. Burt, Chairman, Trunk Line Asso-
ciation : "No special fares are being granted for
any meetings whatever held in the State of Penn-
sylvania from points therein since September i,
1920. We regret therefore that railroads will
not be able to grant any concession for your
meeting at Philadelphia, October next."
MEDICAL DEFENSE
are immune from suit for
read the following corre-
If you think you
alleged malpractice,
spondence :
March 9, 192 1.
Edward Martin, M.D.,
Commissioner of Health,
Harrisburg, Pennsylvania.
Dear Doctor Martin:
One of our members residing in Erie County
is threatened with a suit for alleged malpractice,
the alleged malpractice occurring under the fol-
lowing circumstances : The physician in question
was called to attend a child three years of age, ill
for three days with "whooping cough" ( ?) He
found the child cyanotic, delirious with a laryn-
geal stridor, temperature 103, pulse 140. The
physician diagnosed laryngeal diphtheria, in-
jected immediately 80,000 units of antitoxin,
then took culture of throat. Twelve hours later -
child was rational, temperature and pulse consid-
erably lower, color much improved, breathing
not labored but noisy. Three hours later, physi-
cian was notified that child was much worse. He
responded, and found the child was very cya-
notic. In a short time the attending physician
was joined by another physician who made a fu-
tile attempt at intubation. The child died about
I p. m. Suit is threatened on grounds that an
overdose of diphtheria antitoxin was given. The
throat culture proved positive for the Klebs-
Loeffler.
The application for defense in this case has
been approved by the Board of Censors, by
Trustee and Councilor Mitchell of Warren, by.
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518
THE PENNSYLVANIA MEDICAL JOURNAL
April, 1921
the Secretary, and will no doubt be approved by
President Jump. I believe we would all appre-
ciate an expression from you representing the
Department, of the treatment received by this
unfortunate child at the hands of the applicant
for our medical defense. A prompt reply will
greatly oblige us. Very truly yours,
(Signed) Walter F. Donaldson, Sec'y.
March lo, 1921.
Dr. Walter F. Donaldson,
Secretary, State_ Medical Society,
8014 Jenkins Arcade,
Pittsburgh, Pa.
Dear Doctor Donaldson:
Concerning the treatment bearing on the case
which you outline, the physician who treated it
should be commended for his promptness and
efficiency. The giving of 80,000 units of anti-
toxin was in complete accordance with modern
life-saving practice.
As to the question of overdose, there was a
child in York who was given 700,000 units. The
child recovered. There is no evidence at hand to
indicate that these large doses produce any but a
beneficial effect.
It is to be hoped that this case may come to
trial, and that the triumphant vindication of the
physician may prove an object lesson to those of
our profession who lose these cases because of a
failure to appreciate the life-saving value of full
doses of antitoxin given promptly.
The Department will gladly testify as to 'its
approval of the action of the doctor in this case.
Believe me. Faithfully yours,
(Signed) Edward Martin,
Commissioner of Health.
Are you fully protected against such suits?
You are if your 1921 dues to your county medi-
cal society have been paid.
scientious secretary will devote further effort and
energy to restoring to good standing the small
proportion of members delinquent in payment
of 1921 dues.
GOOD SECRETARIES
The proportion of good secretaries in our com-
ponent societies has been on the increase for a
number of years and this year a result of their
combined efforts is manifest in the large increase
in the number of state per capita tax payments
received by the State Secretary to date. The
exact figures for March 17, 1920 and 1921, re-
spectively, are 2,384 and 3,389. This is an in-
crease of 42% and would indicate that by April
1st, more than 90% of our 1920 membership will
be in good standing for 1921.
The functional activities of the good county
society secretary, however, are never permitted
to relax. Each succeeding month brings its re-
sponsibilities. In the month of April, the con-
CHANGES IN MEMBERSHIP OF COUXTY
SOCIETIES
The following changes have been reported to March
15th:
Allegheny: New Members — Glenn H. Davison,
Westinghouse Bldg. ; J. Edwin Purdy, Mercy Hos-
pital; Thomas T. Sheppard, 1015 Hiland Bldg.; David
L. Rees, Jenkins Arcade; Brown Fulton, 610 Hiland
Bldg. ; Max A. Blumer, 1631 Denniston Ave. ; Russell
H. -King, 1742 Brighton Road (N. S.) ; Edward Rec-
tenwald, 2600 Brownsville Road, Pittsburgh; E. S.
Henry, iioo State St., Coraopolis; Geo. F. McDonald,
207 Peoples Bank Bldg., Tarentum; Henry B. Barn-
hart, 704 Broadway, McKees Rocks; Paul B. Steele,
12 Lawson Ave., Grafton. Reinstated Member — Albert
T. Smith, Hunter Bldg., Turtle Greek.
Beavek: New Member — Ernest J. Aten, Ambridge.
Berks: New Members — Frank B. Gryczka, 148 S.
9th St.; Harold Hirshland, 1019 Penn St., Reading;
Donald G. Moyer, Wyomisstng.
Blair: New Members — R. O. Gettemy, 310 Fourth
St., Altoona; Caleb G. McNaul, Juniata. Transfer —
Roy Deck of Lancaster to Lancaster County.
Clarion : Resigned — Harvey B. Summerville,
Rimersburg.
Crawford: Death — George W. Ellison (Cleveland
Pulte Med. Coll. '99), of Townville, January 21.
Dauphin: Netv Members — ^John H. Krieder, 1410
Derry St.: J. E. Rhoads, 402 N. Second St., Harris-
burg. Reinstated Member — Valentine Hummel Fager,
410 N. Second St., Harrisburg.
Delaware: New Member — Jane R. Bondart, 817
Edgmont Ave., Chester. Transfers — Robert T. Deve-
reau of Swarthmore from Philadelphia County; Wal-
ter A. Blair, of Upland, from Huntingdon County.
Erie: New Member— John H. E. Fust, 138 W.
Ninth St., Erie. Transfer — William W. Richardson,
Commerce Bldg., Erie, from Mercer County.
Fayette: Death — Peter A. Larkin (Medico-Chirurg.
Coll., Philadelphia, '00), of Uniontown, Feb. 14. from
lobar pneumonia, aged 56.
Jefferson : Reinstated Members — W. A. Hill, Reyn-
oldsville; J. C. Stauffer, Rossiter (Ind. Co.).
Lackawanna: Reinstated Members — Albert A.
Novak, Throop ; Louis H. Gibbs, 217 S. Main St.,
Scranton.
Lancaster: New Member — Milton U. Cerhart
(honorary member), 43 S. Prince St., Lancaster. Re-
moval— Charles E Helm from Bart to Quarryville.
Lehich: Reinstated Members — H. E. Guth, Ore-
field : Mark Young, 728 N. Seventh St., Allentown ;
J. Edwin S. Minner, Egypt.
Luzerne: New Member — J. F. Dolphin, Miners
Bank Bldg., Wilkes-Barre. Reinstated Member-
Richard Bunce, Miners Milts.
McKean : New Member — Francis DeCaria, Brad-
ford.
Montour: Netv Member— 'Enoch H. Adams, Geis-
singer Hospital, Danville.
Montgomery : New Member — Philip J. Lukens,
Ambler. Transfer — George A. Kerling, Pennsburg,
from Lackawanna County. Resigned — Henry F.
Slifer, North Wales.
Philadelphia : Netv Members — ^James H. Paul,
2222 S. Fifteenth St.: Thomas Wolden Phillips, 144
N. Sixtieth St.; William J. Enders, Home for Con-
sumptives, Chestnut Hill : Warren S. Reese. I<B9
Chestnut St.; Raymond A. Tomassene, 6368 Drexel
Road. Overbrook; Hugh McC. Miller, iftv Spruce
St. ; Carmine Carlucci, 819 Christian St. ; Charles .A.
Barron, 6327 Torresdale Ave.; Clarence E Apple.
1509 Sixty-eighth Ave., Oak Lane; Howard Frederick
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April, 1921
OFFICERS' DEPARTMENT
519
Heinkel, 107 E. Lefaigh Ave. ; Walter J. Freeman, 1832
Spruce St; William Walsh Lermann, Northeast cor.
Sixteenth and Spruce Sts. ; Melissa E. Thompson-
Coppin, 1913 Bainbridge St; Raul (y Cordova) Ber-
nett 3813 Spruce St; Oscar James Mullen, 1750 N.
Park Ave.; David Reiter, 4025 Girard Ave. (trans,
from Allegheny Co.) ; Charles S. Aitken, 140 N.
Broad St. ; Henry S. Weig le, 1014 S. Fifty-eighth St
(trans, from Lycoming Co.). Deaths — William M.
Welch (Univ. of Penna. '59), of Philadelphia, Feb. 8,
aged 83; Hugh P. MacAniff ( Medico-Chirurg. Coll.,
Philadelphia, 97), of Philadelphia, aged 51.
Schuylkill: Reinstated Members — Ella J. Rynkie-
wicz, Shenandoah ; A. W. Fisher, Gordon.
Somerset: Death — Albert M. Lichty (Univ. of
Penna. '86), of Elk Lick, Feb. 17, from cerebral hemor-
rhage, aged 62.
Washington : New Member — Samuel W. Huston,
Denbo. Reinstated Member — Walter J. Shidler, Hous-
ton.
Westmoreland :
Donegal.
New Member — Domer S. Newill,
PAYMENT OF PER CAPITA ASSESSMENT
The following payment of per capita assessment has
been received since February 15th. Figures in the first
column indicate county society numbers; second col-
umn, state society numbers:
Feb. 15 Elk 18-21
Clinton 12-14
Columbia 32-34
Frankfin 17-19
Beaver 30-34
Dauphin 81-89
Montgomery 92-108
16 Somerset 18
Bedford 1-3
Franklin ao-25
Mercer 54
Butler 6-11
Lycoming 56-67
Juniata 8
Erie 57-63
Cambria 25-52
Bradford 28-35
Allegheny 477-582
Mercer 55-5^
Venango 39-41
Delaware 66-67
Venango 36-38
Lackawanna 33-52
Mercer 57
Northampton 71-89
McKean 15-24
Clinton 15-16
Montour 13-14
Schuylkill 1-41,66
Wyoming 11
Clarion 27-28
Somerset 19-20
Greene 19-21
Bucks 51-64
Cumberland 20
Monroe 17
Union 13
Erie 64-69
Mercer 58
Somerset 21
Allegheny 335, 377.378,
414, 415. 4J0. 417. 427.
';83-<oo, 603-609, 611-
637, 639. 640
Mar. I Adams 14, 19-22
Montour 15-16
Wayne 17
Lackawanna 53-67
17
18
19
23
24
25
26
28
2048-2051
2052-2054
2055-2057
2058-2060
2061-2065
2066-2074
2075-2091
2092
2093-2095
2096-2101
2102
2103-2108
2109-2120
21 21
2122-2128
2129-21 56
21 57-2164
2165-2270
2271-2272
2273-2275
2276-2272
2278-2280
2281-2300
2301
2302-2320
2321-2330
2331-2332
2333-2334
2335-2376
2377
2378-2379
2380-2381
2382-2384
2385-2398
2399
2400-2406
2407
2408-2413
2414
2415
2416-2477
2478-2482
2483-2484
2485
2486-2500
$20.00
1500
1500
1500
25.00
4500
85.00
5.00
15-00
30.00
5.00
30.00
60.00
500
3500
140.00
40.00
530.00
10.00
15-00
10.00
15-00
100.00
5.00
95-00
50.00
10.00
10.00
210.00
5 00
10.00
10.00
1500
70.00
5.00
35 00
500
30.00
5.00
5.00
310.00
2500
10.00
5.00
75 00
Center
Union
Wayne
Juniata
Greene
Berks
Warren
16-19
IS
18
9
22
82-111
2-14
Northumberland 42-45
Jefferson
Westmoreland
Franklin
Huntingdon
Northampton
Blair
Mercer
Erie
Montgomery
Greene
Snyder
Elk
Wayne
Delaware
Somerset
Mifflin
Union
Clarion
Lycoming
Lawrence
Lancaster
Wayne
Huntington
1-27
66-83
26-29
13-24
90-96
29-53
59
70-92
109-119
23
22-26
19-22
68-70
22
21-22
16
29-30
68-80
1, 3-19. 21-39
i-«i
23
25-30
Lackawanna 68-83, 85-104
10
II
12
Dauphin
Venango
Clinton
Franklin
Butler
Westmoreland
McKean
Columbia
Cumberland
Monroe
Cumberland
Delaware
Berks
Mercer
Delaware
90-113
42
17-18
30
12-17
84-113
25-29
35-37
21-29
8-9
30
71-76
112-121
60r^7
77
2501-2504
2505
2506
2507
2508
2509-2538
2539-2551
255^2555
2556-2582
2583-2600
2601-2604
2605-2616
2617-2623
2624-2648
2649
2650-2672
2673-2683
2684
2685
2686-2690
2691-2694
2695-2697
2698
2699-2700
2701
2702-2703
2704-2716
2717-2753
2754-2834
2835
2836-2841
2842-2877
2878-2901
2902
2903-2904
2905
2906-2911
2912-294T
2942-2946
2947-2949
2950-2958
2959-2960
2961
2962-2967
2968-2977
2978-2985
2986
20.00
5-00
5-00
500
5-00
150.00
65.00
20.00
13500
90.00
20.00
60.00
35 00
125.00
S-OO
115.00
55-00
5-00
5.00
25.00
20.00
15-00
5-00
10.00
5.00
10.00
65.00
185.00
405.00
5.00
30.00
180.00
120.00
5-00
10.00
5.00
30.00
150.00
25.00
1500
45-00
10.00
S.oo
30.00
50.00
40.00
5.00
FREDERICK L. VAN SICKLE, M.D.
Executive Secretary
212 North Third St., Harrisburg, Pa.
MEDICAL AND PUBLIC HEALTH
LEGISLATION
Legislative Bulletin No. 2 was issued on
March 4, 1921, and contained the following list
of bills introduced into the House of Represen-
tatives and Senate up to that time. These bulle-
tins were circulated through the Committee on
Public Policy and Legislation of each county
Medical Society and we simply wish to refresh
the minds of the profession upon bills which are
passing and as to their progress.
Senate Bill No. 29 — An act to protect the peo-
ple against adulterated and impure butter and
which has now passed the Senate and will prob-
ably be concurred in by the House of Represen-
tatives.
Senate Bill No. 37 — Also in the interest of
public health in relation to contamination of food
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520
THE PENNSYLVANIA MEDICAL JOURNAL
April, 1921
dispensed to the public. This bill is in the same
position as the preceding one.
Senate Bill No. 197 — A supplement to amend
an act regarding the manufacture of oleomar-
garine. This supplement to the act has passed
the Senate and is in the House. It will no doubt
be promptly reported from the Committee of the
Judiciary General and pass the House.
Senate Bill No. 207 — Regarding the handling,
storing and serving of food in hotels, restaurants
and dining cars, as to cleanliness, etc., has passed
the Senate and is in the Committee of Public
Health and Sanitation of the House which will,
without doubt, promptly report it.
Senate Bill No. 309 — A bill to amend the
optometry law regarding soldiers who were un-
able to complete examinations prior to the war
and to aid in revoking, or suspending, licenses
and to prevent peddling by unreliable and irregu-
lar pseudo-optometrists. This bill has been re-
ported out and slightly amended and will prob-
ably be sent along in the Senate and through the
House.
House Bill No. 73 — Was for the purpose of
omitting the crffice of coroner from those to be
elected in counties of this state. This bill was
placed in the hands of the Committee on Coun-
ties and Townships and has not yet been acted
upon by the House.
House Bill No. 135 — An act to amend the
quarantine act introduced by the Department of
Health ; has passed second reading, been recom-
mitted for amendment to the Committee on Pub-
lic Health and Sanitation, March ist. This will
be promptly done and the amended bill will be
brought out for final passage.
House Bill No. 400 — An act prohibiting ad-
vertisements of cures or medicines relating to
venereal diseases and certain sexual disorders
and prescribing the penalties. This bill has
passed second reading in the House of Represen-
tatives.
House Bill No. 425 — Referring to the trade of
papering and paperhanging is still in the Com-
mittee on Public Health and Sanitation.
House Bill No. 449 — An act to amend an act
for the protection of the public health by regu-
lating the possession, control, dealing in, giving
away, etc., of certain drugs and keeping records
thereof. This bill has passed second reading in
the House.
House Bill No. 450 — Relating to caustic acid
and alkali preparations for household use. This
bill has passed the House and has been referred
to the Committee on Public Health and Sanita-
tion of the Senate which, no doubt, will promptly
bring it out and the bill will be passed by the
Senate and become a law.
House Bill No. 497 — ^An act to prevent the
manufacture and sale of condensed milk made by
the introduction of foreign fats. This bill was
in the hands of the Committee on Agriculture;
passed second reading ; was referred back to the
committee for a hearing which was held on
March 2d. This bill was promptly reported out
and passed by the House, and we trust it will
have the support of the Senate and become a law.
House Bill No. 524 — This bill was introduced
for the purpose of amending the medical practice
act in regard to reciprocity, etc., and will be
promptly reported by the House Committee on
Public Health and Sanitation and will be pushed
forward on the calendar.
House Bill No. 549 — An act to amend the
anatomical act so that it will be possible for the
Anatomical Board to secure sufficient material
for the purpose of teaching anatomy in the medi-
cal schools of the state. This bill has been re-
ferred to the Committee on Public Health and
Sanitation and was brought out and passed by
the House. We trust it will have the support of
the Senate for the reason that the 1919 amend-
ment to this act has prevented the medical schools
from receiving sufficient material.
House Bill No. 559 — ^An act to protect paint-
ers by prohibiting the use of the spraying ma-
chine for painting. This bill has had a bearing
and we doubt whether it will receive the support
of the House.
Since Medical Legislative Conference Bulle-
tins No. I and No. 2 have been printed and dis-
tributed, several other acts have been introduced
into the Senate and House of Representatives
which refer to public health and medical affairs.
Senate Bill No. 212 — ^An act to amend an act
to provide for the immediate registration of all
births and deaths throughout the commonwealth
of Pennsylvania by means of certificates of births
and deaths and burial or removal permits. This
was the bill passed in 1915 to enable the Depart-
ment of Health tb collect statistics and permits
the department to be more explicit in their blanks
for return.
Senate Bill No. 385 — Provides for the protec-
tion of the public health by requiring clean sani-
tary establishments to be provided for bottling
nonalcoholic drinks, including clean sanitary in-
gredients, bottles, receptacles and utensils in the
manufacturing of nonalcoholic drinks. This bill
has passed the Senate and is now in the Commit-
tee on Public Health and Sanitation of the
House.
Senate Bill No. 507 — An act to provide for the
disposition of all drugs which are introduced in
the evidence of any trial for the legal possession
and sale of the same, to provide that such drugs
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April, 1921
OFFICERS' DEPARTMENT
521
shall be Confiscated by the district attorney of the
county in which the trial takes place and author-
izing the delivery of such drugs to the State De-
partment of Health, or to any other legally con-
stituted health board of any county of this com-
monwealth as in his discretion he may deem fit.
House Bill No. 664 — An act to regulate the
practice of pharmacy in the sale of poisons and
drugs and providing for the purchase of samples
of drugs fpr determining the quality, strength
and purity of same. As amended has passed the
House.
House Bill No. 665 — Pertains to the same as
No. 664 and is for the purpose of requiring per-
mits to conduct pharmacies, providing for the
revocation thereof and prescribing penalties.
Both of these acts while not relating to the
medical profession yet have a particular bearing
upon the practice of medicine.
House Bill No. 937 — An act to amend an act
for the protection of the public health by provid-
ing that persons conducting hotels, restaurants,
dining cars, etc., shall not employ help suffering
from tracoma, active tuberculosis of the lungs,
syphilis, gonorrohea, open external cancer, bar-
ber's itch or the carrier's of typhoid fever and
providing other regulations. 'This bill is in the
hands of the Committee on Public Health and
Sanitation of the House.
The three bills of the Senate which refer to
laws bearing upon foods have passed the Senate
and are now in the House for final action.
House Bill No. 785 — ^An act to authorize the
Department of Health to purchase radium to be
used for the cure of disease and making appro-
priation therefor. This bill is in the hands of the
Committee on Appropriations.
By the time that this number of the Journal
is in the hands of the readers no doubt many
changes will have taken place in these bills during
their passage and we are only endeavoring to
present the various legislative acts for the infor-
mation of the readers of the Pennsylvania
Medical Journal.
IN MEMORIAM— RESOLUTIONS ON THE
DEATH OF JAMES B. McAVOY, M.D.
Whereas, God in His Almighty wisdom has re-
moved from our midst, Doctor James B. McAvoy, and
Whereas, He was an esteemed, beloved and re-
spected member of the Northampton County Medical
Society, and
Whereas, He steadfastly ministered unto the wants
and needs of others, mindful yet uncomplaining of a
daily loss in his own strength and vitality, be it there-
fore
Resolved, That we, tlie members of the Northamp-
ton County Medical Society of the State of Pennsyl-
vania, desire to record our deep sense of loss in his
untimely death, and also wish to express our apprecia-
tion of his professional attainments, his unfailing pa-
triotism and his sterling character as a medical man;
and be it further
Resolved, That our sympathy be extended to his be-
reaved family, and a copy of this resolution be spread
upon the minutes of our society, and also sent to his
family. Committee,
Dr. T. J. BuTtER,
Dr. D. K. Santee,
Dr. £. D. Schnabeu
NOTICE
Call for Volunteer Papers — ^Philadel-
phia Session
The Committee on Scientific Work at its
first meeting at Harrisburg, February 2,
1 92 1, decided to call for a total of eleven
volunteer papers for the Philadelphia Ses-
sion of the State Society, October 3 to 6,
1921.
(i) The subject and a brief outline of
all papers must be furnished the committee
before May i, 1921.
(2) The time limit for the reading of
each paper is ten minutes.
(3) An author wishing stereopticon or
projectoscope for the illustration of his
paper must ask for same when submitting
title and outline of paper.
(4) Titles of papers are to be sent di-
rect to section officers or the Chairman of
Committee on Scientific Work.
(5) The Committee reserves the right
to decline any paper not deemed of suffi-
cient merit for the sessions.
Thomas G. Simonton, M.D.,
Chairman.
RECIPROCITY
By Adsie Reads
There once was a doctor who wanted to buy
Some special particular office supply.
He looked through the ads in this month's P. M. J.
But could not find mentioned there, to his dismay.
The article wanted, in all of the pages.
Said he "That darned Editor don't earn his wages I
I'll admit it's the first time I've e'er read an ad
But I don't see how that would affect ii, by jad I"
Now this is the moral of my little tale :
If forsooth you're not anxious to part with your kale,
Read the ads every month and patronize too
The man who is willing to patronize you.
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County Medical Societies
REPORTERS OF COUNTY SOCIETIES:
Adams — Henry Stewart, M.D., Gettysburg.
Allegheny — Lester Hollander, M.D., Pittsburgh.
Armstsonc — Jay B. F. Wyant, M.D., Kittanning.
Beavek— Fred B. Wilson, M.D., Beaver.
Bedford — N. A. Timmins, M.D., Bedford.
Berks — Clara Shetter-Keiser, M.D., Reading.
Blair — James S. Taylor, M.D., Altoona.
Bradford — C. L. Stevens, M.D., Athens.
Bucks — Anthony F. Myers, M.D., Blooming Glen.
Butler — L. Leo Doane, M.D., Butler.
Caubria — John W. Bancroft, M.D., Johnstown.
Carbon — Jacob A. Trexler, M.D., Lehighton.
Center — James L. Seibert, M.D., Bellefonte.
Chester— Henry Pleasants, Jr., M.D., West Chester.
Clarion — Sylvester J. Lackey, M.D., Clarion.
Clearfield — -J. Hayes Woolridge, M.D., Clearfield.
Clinton — R. B. Watson, M.D., Lock Haven.
Columbia — Luther B. Kline. M.D., Catawissa.
Crawford — Cornelius C. LafFer, M.D., Meadville.
Cumberland — Calvin R. Rickenbaugh, M.D., Carlisle.
Dauphin— F. F. D. Reckord, M.D., Harrisburg.
Delaware — George B. Sickel, M.D., Chester.
Elk — Samuel G. Logan, M.D., Ridgway.
Erie— Fred E. Ross, M.D., Erie.
Fayette — George H. Hess, M.D.. Uniontown.
Franklin — John J. CofFman. M.D.. Scotland.
Greene — Thomas B. Hill. M.D., Waynesburg.
Huntingdon — John M. Keichline, Jr., M.D., Petersburg.
Indiana — Frederick W. St. Clair, M.t)., Indiana.
Jefferson — W. J. Hill. M.D., Reynoldsville.
Juniata — Benjamin H. Ritter, M.D.. McCoysville.
r,ACKAWANNA — Harry W. Albertson, M.D., Scranton.
Lancasthx — Walter D. Blankenibip, 1(.D., Laacuter.
Lawremci — William A. Womer. M.O., New Castle.
Lebanon— John C. Bucher, M.D., Lebanon.
LsuiGH — Frederck R. Bausch M.D., Allentown.
Luzerne — Walter L. Lynn, M.D., Wilkea-Barre.
Lycoming — Wesley F. Kuskle, M.D., Williamsport.
McKXAN— Fred Wade Paton, M.D., Bradford.
MZRCut — M. Edith MacBride, M.D., Sharon.
Mifflin — O. M. Weaver, M.D., Lewistown.
Monroe — Charles S. Flagler, M.D., Stroudsburg.
Montgomery — Benjamin F. Hublejr, M.D., Norristowii.
Montour — John H. Sandel, M.D., Danville.
NoRTHAUFTON — W. Gilbert Tillman, M.D., Easton.
Northuuberlahd — Charles H. Swenk, M.D., SunbuT-
Perry — Maurice I. Stein, M.D., New Bloomfield.
PuiLADELPHiA^John J. Repp, M.D., Philadelphia.
Potter — Robert B. Knight, M.D., Coudersport.
Schuylkill — George O. O. Santee, M.D., Cressona.
Snyotr— Percy E. Whiffen, M.D., McClare.
Somerset — H. Clay McKinley, M.D., Meyersdale.
Sullivan — Martin E. Herrmann, M.D., Dushore.
Susquehanna — H. D. Washburn, M.D., Susquehanna.
Tioga — John H. Doane, M.D., Mansfield.
Union— Oliver W. H. Glover, M.D., Laurelton.
Venango — John F. Davis, M.D., Oil City.
Warren— M. V. Ball, M.D., Warren.
Washington — Homer P. Prowitt, M.D., Washington.
Wayne— Edward O. Ban^f, M.D., South Canaan.
Westmoreland — J. F. Trimble, M.D., Greensburg.
Wyoming — Herbert L. McKown. M.D., Tunkhannoclc
York— Gibson Smith, M.D., York.
April, 1921
COUNTY SOCIETY REPORTS
ADAMS— MARCH
The March meeting of the Adams County Medical
Society was attended by sixteen members.
The principle topic of discussion was the concluding
arrangements for the formal opening of the Annie M.
Warner County Hospital, in this place.
The initial assignments for staff duty were an-
nounced. Medical service — Drs. Hartman, Crouse, T.
C. Miller and Lindaman ; surgical service — Drs. Dick-
son, Crist and Rice; x-ray service — Dr. Dalbey; lab-
oratory service — Dr. Stewart ; pediatrics — Drs. Crouse
and Elgin ; obstetrical — Drs. Hartman and Gettier ;
eye, ear, nose and throat — Drs. Seaks, Dalbey and
Woomer; anesthesia — Drs. Wolff and E. A. Miller.
These appointments will remain in effect from March
15th until June isth.
The bulletins of the Medical Legislative Conference
were presented to the society and the following letter
of endorsement was sent to each representative to the
general assembly from Adams County:
"I am directed by the society to advise you that it
endorses the recommendations of the Medical Legis-
lative Conference on proposed legislation relative to
health matters, and requests that you vote in accord-
ance with those recommendations."
Henry Stewart, Secretary.
ALLEGHENY— MARCH
The regular monthly scientific meeting of the Alle-
gheny County Medical Society held on March 15, 1921,
8 : 30 p. m., at the Pittsburgh Free Dispensary Build-
ing, 43 Fernando Street, Pittsburgh, Pa.
The president, Dr. <^arey J. Vaux, in the chair. At-
tendance: 194.
Dr. F. H. Rimer spoke on "The Diagnosis and Treat-
ment of Scarlet Fever," and emphasized the differen-
tial diagnosis between the angina of scarlet fever,
follicular tonsillitis and diphtheria. He thought that
cervical adenitis, suppurative, rarely complicates any
other disease outside of scarlet fever. The following
order of frequency of complications were noted at the
Municipal Hospital of Pittsburgh, Pa.: Cervical ade-
nitis, otitis media, nephritis, endocarditis, arthritis.
As an intercurrent disease in scarlet fever, diphtheria
is very frequent; this may be elicited by cultures.
Treatment is along symptomatic lines and 3,000 units
of diphtheria antitoxin is given to each case of scarlet
fever. He advocates the removal of tonsils and ade-
noids following scarlet fever.
"The Use of Radium in Benign Uterine Hemor-
rhages and Fibroids" was- taken up by Dr. Curtis S.
Foster. Emphasis made on the indications for the ap-
plication of this very valuable adjunct to surgery. In
the twelve cases treated by him uniformly good results
were obtained. Leucorrhea may and usually does fol-
low this procedure, but will disappear in a shorter or
longer period of time, dependent on length of ex-
posure. The discussion by Dr. R. E. Brenneman and
Dr. K. I. Sanes were along the same line.
Dr. S. H. Adams took up the "Presentation of a
Case of Pupura Hemorrhagica with Extensive Slough-
ing of Skin — Recovery," and after a short r6sum6 of
our present knowledge of the disease, he presented the
following case. An 18-year-old married American
woman seven months pregnant, 24 hours after devel-
oping a very sore throat and arthrtis, showed large
symmetrical areas of pupura on arms and forearms,
several spots on face and over large surface of both
limbs. A gangrene ensued, which was surgically re-
moved, and after the disease subsided skin grafted,
with a very good result. Lantern slides and the pres-
entation of the patient concluded this interesting case.
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April, 1921
COUNTY MEDICAL SOCIETIES
523
In the discussion Dr. Joseph Stybr related a case of
"Pupura Fulminans" which he observed in a nursing
babe, after her mother had taken considerable amount
of liquor. This case died within 24 hours. Dr. G. W.
Stimson reported a case of "deaf mutism" after an at-
tack of pupura hemorrhagica.
In a very instructive paper, combined with a large
number of lantern slides Dr. K. I. Sanes took up the
"Obstruction of Ureter." The importance of pyelo-
grams and their study would materially cut down mis-
diagnosis which so frequently occur. Constrictions,
obstructions (stones), developmental defects (scolio-
sis) were amply demonstrated. The time limit was
extended to Dr. Sanes to finish the presentation. Drs.
E. J. McCague, H. R. Decker and Theodore Baker
discussed the paper.
In a contribution pleasingly humorous and infinitely
valuable Dr. B. M. Dickinson took up the question of
"The Surgical Tonsil." As the centrum of focal in-
fection it should always be carefully examined. He
suggests the following steps in examination of a tonsil :
1st, Examine cervical glands ; 2d, Dentition and gums ;
3d, Color of midpharynx, if this normal tonsil is not
diseased; 4th, Mucosa of pillars; 5th, Examine for
presence of adhesions of tonsil to pillars ; 6th, By ro-
tating the tonsil on its perpendicular axis with a re-
tractor contents of follicles should be expressed and
examined.
Dr. E. J. McCague contributed a paper on "Cystitis,
an indication of kidney disease," in which he empha-
sized the fact that cystitis per se is a rare disease and
that symptoms referrable to the bladder such as pain-
ful and frequent micturition, if not caused by some dis-
turbance in the genital apparatus, may mean the pres-
ence of destructive process in the kidney. He reports
two cases of this type, where in searching for the
cause of the bladder symptoms tuberculosis kidney was
found. The termination of the two cases was different ;
while one was apparently cured by the removal of the
offending kidney, the other case after a longer period
of considerably better health broke down and is at
present in the last stages of genital tuberculosis. In
the discussion Dr. W. W. G. McLachlan and Dr. K. I."
Sanes agreed with the previous speaker.
"Exhibition of a Traction Splint for the Humerus,"
by Dr. I. K. King, a simple but very ingenious appa-
ratus, which should find quite a number of users.
Dr. Theodore Diller spoke on a bill to be introduced
shortly at Harrisburg for the establishment of a "State
Commission on Mental Health," to replace the Lunacy
Commission. Lester Hollanoeb, Reporter,
Allegheny County Medical Society.
CHESTER— MARCH
The regular monthly meeting of the Chester County
Medical Society was held at the Chester County Hos-
pital on Tuesday, March 15th, with President Smith
in the chair. The attendance at this meeting was un-
usually large, and as the program was particularly in-
teresting, the occasion was highly successful. It is to
be hoped that all of the subsequent meetings will be as
well attended.
In the course of the regular order of business the
secretary read a letter of invitation to the members
of the society to attend a meeting to be held at the
Bellevue Stratford Hotel, Philadelphia, in the interest
of certain public health measures. Dr. Charles D.
Deitrich, of Parkersford, was unanimously elected to
membership in the society. Dr. Brush, of Phcenix-
ville, was granted a transfer from membership in the
Chester County Medical Society to membership in the
Montgomery County Medical Society. The committee
on Public Policy and Legislation reported having com-
municated with the county representatives in the State
Legislature relative to opposition to several bills which
are at present under discussion. The representatives
agreed to give these bills their careful consideration
and vote upon them as seemed best in their own judg-
ment
Dr. S. W. D. Ludlum, of Philadelphia, addressed the
society on the subject of The Internal Secretions. He
stated that the consensus of opinion of those who had
studied the role of the internal secretions in relation
to disease conditions of the human body is that there
is still a great deal to be learned. Nervous diseases
are no longer considered to be separate entities, but
due more often to changes in bodily metabolism
brought about by visceral disorders, and improper
functioning of the endocrine glands.
The most important of the endocrine glands may be
classified according to their effects on bodily functions,
and symptoms which their over- or under-activity may
produce as follows:
Pituitary, Thyroid, Adrenals.
Affecting the sympathetic nerve by stimulation.
Symptoms — High blood pressure, increased peristal-
sis, rapid pulse, dry skin.
Thymus, Pcmcreas, Gonals (Sex).
Affecting the Vagus Nerve by stimulation.
Symptoms — Low blood pressure, increased peristal-
sis, slow pulse, moist skin.
Dr. Ludlum stated that it was essential to study the
case to the fullest extent before instituting specific
organotherapy. Often the most important part of pre-
liminary treatment is the elimination of any auto-
toxemia which may be present. The colon is particu-
larly likely to be the offending organ and it is essential
to cleanse the colon by saline irrigations until sandlike
material is removed.
Dr. Ludlum stated further that one of the reasons
for the failure of organotherapy in psychoses which
are definitely attributable to deranged endocrine secre-
tion is that the extracts are given when a patient is not
in the proper condition to gain the benefit from them.
For instance; it is not uncommon to find a patient
with an extremely low blood pressure in whom the
administration of ovarian extract is indicated, yet the
administration of this extract may produce symptoms
of dementia. If on the other hand the patient is
treated by administration of supra-renal extract until
the blood pressure is normal, or nearly so, the results
when ovarian extract is given will be strikingly satis-
factory. Another plan of organotherapy is the admin-
istration of thyroid extract in i/io gr. doses in
addition to the specific extract. The thyroid extract
tends to activate the other extract.
In many cases the failure of organotherapy may be
caused by a concomitant acidosis which is unrecog-
nized. To obtain the best results, the system must be
neutralized by bicarbonate of soda before the extract
is administered. Oral administration of the animal
extracts is as satisfactory as the hypodermic adminis-
tration and is less painful to the patient.
Dr. B. H. Warren, of West Chester, read an inter-
esting paper on the subject of Effects of Pollution of
Streams on the Health of Individuals and Animals.
Dr. Warren was for a long time dairy and food com-
missioner of the state and acted in an advisory capacity
in public health work in Philadelphia. He has long
been known throughout the state as a naturalist ^nd
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THE PENNSYLVANIA MEDICAL JOURNAL
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sportsman. In his talk he emphasized the growing im-
portance of more careful supervision of the larger
streams in the commonwealth. He stated that there
were many instances where the pollution of the streams
and rivers had caused enormous destruction of fish,
one large hatchery of trout at Allentown being com-
pletely wiped out of existence. In some instances
horses and cattle had been killed by drinking polluted
water, and he further emphasized the danger of stream
pollution by reading a letter from Prof. C. B. Cochran
in which the writer stated that there was distinct evi-
dence that the milk of cattle was greatly affected, and
even made dangerous by polluted drinking water. He
stated that the most important step taken towards the
prevention of stream pollution had come not so much
through the efforts of physicians and public health of-
ficials but through the efforts of the locomotive and
boiler manufacturers because it had been found that
polluted water has a very corrosive, action upon the
metal in the boilers.
He called attention to the fact that the Brandywine
River had formerly been full of fish, and had been a
well known rendezvous for sportsmen, but of recent
years the discharge from the paper mills has killed
practically all of the game fish, and rendered the'
stream dangerous for any drinking purposes.
He recommended the passage of laws making com-
pulsory the establishment of filtration plants at all
mills where the discharge of waste water. would be
likely to pollute the streams.
Henry Pleasants, Jr., Reporter.
DAUPHIN— MARCH
At the March meeting of the Dauphin County Medi-
cal Society held in the Harrisburg Academy of Medi-
cine, with Dr. C. R. Phillips, President presiding, Mr.
S. S. Riddle, Chief of the Bureau of Rehabilitation, of
the Pennsylvania State Department of Labor and In-
dustry, gave a most interesting and instructive illus-
trated lecture on "The Experience of the Common-
wealth of Pennsylvania in Administering a Rehabilita-
tion Program for Victims of Industrial Accidents."
Mr. Riddle said in abstract :
Experience of the Commonwealth of Pennsylvania
IN Administering a Rehabiutation Program
FOR Victims of Industrial Accidents
The Commonwealth of Pennsylvania established a
Bureau of Rehabilitation in the Department of Labor
and Industry by Act of Assembly July i8, 1919.
That legislation virtually supplemented the Work-
men's Compensation Act in Pennsylvania and an ap-
propriation of $100,000 to conduct the rehabilitation
work during a two-year fiscal period, was to be ex-
pended for administration of the bureau ; for payment
of whole or part cost for artificial appliances for
physically handicapped persons unable to pay for such
appliances needed for return to the industries; for
maintenance, including living and school costs of
physically handicapped persons, not in excess of $15
per week, during a period of training, in preparation
for suitable employment.
Persons eligible to the benefits of the act are defined
as "any resident of the Commonwealth of Pennsylva-
nia whose capacity to earn a living is in any way de-
stroyed or impaired through industrial accident occur-
ring in the commonwealth." The act applies to per-
sons injured prior to its enactment and applies also to
persons injured in agricultural accidents.
The Pennsylvania Bureau of Rehabilitation operates
with field adjusters from a central office at Harrisburg
and six branch offices located in centers of high indus-
trial accident hazard and centers of transportation fa-
cilities.
To March i, 1921, the Pennsylvania Bureau of Re-
habilitation had offered its services to 1400 persons
reported as disabled in sixty-three of the sixty-seven
counties of the state. Nine hundred and six of the
persons to whom the services of the bureau were of-
fered registered with the bureau and traveling ad-
justers have called on almost all of the registrants,
carrying the services of the bureau directly to their
homes.
Eight hundred and eighty-three of the registrants
are men, and 23 are women ; 24 are Negroes, and 179
cannot read or write English.
One hundred and forty-three of the registrants are
under' 21 years of age; 242 are between 21 and 30;
204 are between 31 and 40; 153 are between 41 and
50, and 164 are over 50 years of age. Consideration
of those figures shows that the majority of registrants
are over 30 years of age.
Five hundred and twelve of the registrants are na-
tive Pennsylvanians ; 76 were born in the United
States outside of Pennsylvania, and 318 were bom in
foreign countries. Disabilities of registrants include
386 hands, 179 arms, 98 feet, 267 legs, 14 one-eye cases,
and 35 totally blind. Eighty-five of the victims are
afflicted by other disability than loss of use of parts.
The bureau has been of definite benefit to 405 regis-
trants having 635 dependents. Two hundred and
twenty-six of those registrants have been aided by the
bureau to obtain artificial appliances necessary for re-
turn to employment. One hundred have been entered
in training and 87 of the 100 have received weekly
maintenance payments from the bureau during training
courses. The remaining number have been placed in
suitable employment at tasks for which very short
periods of training were required. The types of train-
ing courses in which registrants of the bureau have
been entered include telegraphy; wireless telegraphy;
motor mechanics; preparatory course for mechanical
engineering; traffic managemnt; salesmanship; elec-
'trical wiring and armature winding; commercial
courses of various kinds, including cost analysis and
accounting; Braille reading and writing, piano tuning
and carpet weaving for the blind ; mechanical drawing
and machine design ; teacher training course in a state
normal school; jewelry manufacture; watchmaking
and other skilled occupations.
The activities of the Bureau of Rehabilitation are
not medical or surgical. The bureau takes charge of
a man after physicians and surgeons have restored
him to his highest possible physical efficiency. Co-
operation of physicians and surgeons with the Bureau
of Rehabilitation is, however, absolutely essential if
the bureau is to be successful. In many cases infor-
mation must be obtained from physicians, surgeons,
and hospitals regarding the physical condition of a dis-
abled worker, who desires to enter employment or a
training course. Later developments may be establish-
ment of clinics by physicians and surgeons at various
points in Pennsylvania to consider methods of func-
tional restoration and general physical rehabilitation of
disabled industrial workers. The great war centered
attention upon the absolute necessity of reclaiming for
useful effort disabled men. It is a natural sequence
that this would be extended to include the thousands of
workers disabled annually through industrial accidents
in Pennsylvania. The cooperation of physicians and
surgeons in this work is earnestly sought.
Frank F. D. Reckord, M.D., Reporter.
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COUNTY MEDICAL SOCIETIES
525
ELK— MARCH
The regular meeting held on the tenth with a little
more than a quorum present. Those in attendance
were Drs. Smith, Wamick and McCabe from Johnson-
burg, and Wilson from St. Marys. Routine matters
were disposed of.
'Dr. Flynn reported a case of strangulation of the
entire small bowel on March 2d, caused by a small
band extending across the root oC the messentery.
The band was severed, abdomen closed, and death ex-
pected, but at present the patient is doing nicely
(March 17th).
Dr. Logan talked on blood transfusion, quoting
freely from Sappington, Pemberton, Ashby and Unger.
The Ridgway Medical Society meets to-night (17th)
at which Dr. Shaw will discuss hand disinfection.
The hospital is filled to capacity.
S. G. Logan, Reporter.
MERCER— MARCH
The regular meeting of the Mercer County Medical
Society was held at Buhl Hospital, Sharon, Pa., March
10, 1921.
A surgical clinic was held at 10 : 00 a. m. Forty
members and one guest; Col. James Duffy, of the State
Department of Health, were present. At i : 00 o'clock
a bounteous luncheon was served by Miss Gumming,
superintendent of the hospital, in the elegant dining
room of the Kimberley Memorial Home for Nurses
which was beautifully decorated with jonquils and
smilax. Music was furnished by Prof. Reese and his
Sharon High School orchestra, the members joining
in the singing of several songs.
After lunch, we moved into the living room and held
an interesting business meeting with President O'Brien
in the chair. Many important topics were discussed
and Col. Duffy gave an excellent tsdk. One application
for membership was read.
The society voted Miss Gumming, Col. Duffy and
Prof. Reese a rising vote of thanks. Adjourned to
meet second Thursday of May at the Sharon Country
Club, Sharon, Pa.
Edith MacBmdb, M.D., Reporter.
NORTHAMPTON— MARCH
The monthly meeting of the Medical Society of
Northampton County was held at the Easton Hospital
on Friday, March 18th, with a good representation of
the physicians of the county in attendance.
Dr. E. M. Green gave an interesting talk on "Some
Thoughts on Nephritis," showing a case of post-
diphtheretic paralysis having a marked kidney involve-
ment A second paper on "The Pathological Findings
in Nephritis following Fevers" was presented by Dr.
Ralph Fisher. The last paper was accompanied by
lantern slides.
Luncheon was served in the nurses' home following
the meeting.
The next meeting will be held the third Friday of
April; the place of the meeting still to be decided.
Arrangements are being made to hold a cancer meet-
ing in May at a date to be decided by the committee.
W. GiLBBRT TiuMAN, Reporter.
PHILADELPHIA— FEBRUARY
The president, Dr. George Morris Piersol, in the
chair.
After the transaction of routine business the follow-
ing papers were read :
THE SERUM TREATMENT OF PNEUMONIA
SSBOTHERApy IN Pneumonia : Its Cunical Aspects
— Dr. Truman G. Schnabel, Philadelphia : The use of
antipneumococcus serum dates back to the Klemperer
Brothers in 1891 although it was five ytars before this
that Fraenkel had noted the possibility of producing in
animals a protective immunity against lethal doses o£
a pneumococcus culture. In 1896 Weissbecker re-
ported favorably on the use of convalescent serum in
lobar pneumonia. It was Neufeld and Handel who
first reported work "which made it quite evident that
pneumococci were capable of being grouped into sev-
eral different types from the immunological point ot
view. In 1910 with the opening of the Rockefeller
Institute, Dochez and others took one of Neufeld's
cultures and began what has been one of the most
noteworthy pieces of research accomplished in this
country. As a result of their efforts it now seems quite
certain, after about a decade, that serum of a horse
immunized against the original Neufeld pneumococcus
is of some value in the treatment of a pneumonia due
to the same type organism. This pneumonia is type I
lobar pneumonia and this diplococcus we now know as
type I pneumococcus. This serum, when properly
used in appropriate cases, quickly frees the blood
stream of the infective organisms and arrests the
spread of the pulmonary lesion. It furthermore
ameliorates the subjective and objective symptoms and
has almost certainly lowered the mortality rate for this
class of cases. After the intravenous use of this
serum, as may occur after the parenteral injection of
any foreign protein, there may follow one or more of
three reactions: anaphylactic shock, the thermal reac-
tion or the serum disease.
The rational treatment of acute lobar pneumonia
should now include early sputum typing together with
the determination of the patient's protein sensitiveness.
If the infective organism is the type I pneumococcus,
the type I serum should be used in sufficient dosage
at the earliest opportunity and at eight hour intervals
until the critical phenomena occur. If the facilities
for typing are not available or if the infective organ-
ism is not type I, there seems to be no sufficiently con-
trolled scientific or clinical evidence, that any other
univalent or polyvalent serum should be used. The
Pennsylvania State Laboratories are prepared to type
sputa for physicians in any part of Pennsylvania. It
has not been possible to create in animal sera satisfac-
tory curative antibodies against pneumococcus lobar
pneumonia consequent upon type II, type III, or type
IV infections. There are in the literature some ex-
ceedingly favorable reports on the use of other sera
than the type I variety and careful observers have
felt that often the results after their use have been:
most striking. If a serum does no good therapeutical-
ly, we are not certain that the so-called parenteral,
protein reactions are without harm. The use of other
sera in lobar pneumonia as well as in broncho-pneu-
monia and the post-influenzal pneumonias has been,
favorably reported upon in the literature, and those
who have employed them are often impressed by the
good results obtained. Plain horse serum, the chicken
serum of Kyes, and convalescent, or post critical,,
serum all have their enthusiastic supporters and excel-
lent mortality rates. The pneumonias are, however,
well known for their unrivaled variability. Their pic-
tures change with the seasons, with the age incidence
and with the infective type of organism. Their clinical
course, duration and mortality are dependent upon a
multitude of factors. To properly control a laboratory-
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526
THE PENNSYLVANIA MEDICAL JOURNAL
April, 1921
experiment is oftentimes a difficult problem, but to
properly control a clinical experiment is many, many
times more difficult. As the difficulty of experimental
control increases, so must the caution with which in-
terpretations are placed upon clinical results increase.
Notes ON TH8 Bactbriologv and Sebum Treatment
OF Pneumonia — Dr. H. L. Brockman, Philadelphia:
It was a common observation during the influenza
pandemic that streptococcic pneumonia gained unusual
prevalence while pneumonia caused by recognized
"type pneumococci" was relatively less common than
had formerly been the case. Among the influenzal
pneumonia cases, gn'een producing streptococci (in-
cluding pneumococci) were found in larger numbers
than any other organism. Later in the pandemic
hemolytic streptococci became relatively more numer-
ous. Fifty-six cases occurring at the University Hos-
pital between October 2, 1919, and March 30, 1920,
have been tabulated; 24 were diagnosed as broncho-
pneumonia and 32 as lobar. Blood cultures were taken
in 44 of the cases and were positive in seven instances.
Six proved to be pneumococci which corresponded in
types to those found in the sputum. Hemolytic strep-
tococcus was found in one blood culture. The mor-
tality rate among those giving positive blood cultures
was practically the same as those in which the cultures
were negative. Judging by this series of 56 cases, the
impression to be obtained is that during the period
1919-1920 there continued to be prevalent to an unusual
degree pneumonias caused by organisms other than
the well recognized fixed types. It is recognized that
in given cases of well developed type I lobar pneu-
monia, serum for type I pneumonia has a distinct
value, the mortality, under good conditions, having
been reduced by its use from 30 per cent, or higher to
10.5 per cent. For pneumonia caused by the other
recognized types of pneumococcus, as well as by heter-
ogeneous type. IV and by other organisms, it is not
practical to prepare and give effective sera. There
are instances, however, in which serum, withdrawn
from patients just convalescent from pneumonia of
these types may be given with very apparent advantage
to patients in the midst of attacks of the same type.
Dr. Stengel, in the February number of the Afedical
Climes of North America, cites instances of this kind
drawn from his experience with a series of lobar
pneumonia cases prior to our entrance into the war,
and with a 1918-1919 series of influenzal pneumonia.
He considers the facts that after a pneumonia crisis
the cardiac action is so rapidly restored, the pulse
rate diminished, and normal respirations resumed
without discoverable change in the degree of consoli-
dation or in the other physical signs, as indicating that
the embarrassment of these functions is toxic in origin
rather than mechanical. We have not yet reached a
definite knowledge regarding the formation of anti-
bodies in lobar pneumonia but we do recognize at least
a transient immunity following recovery. This is
probably at its height just after the crisis. It is for
this reason that the serum is obtained as soon after
the crisis as is possible. The treatment has probably
not been employed to a sufficient extent, especially with
due care being given to typing of the pneumonia cases,
to be able to forecast the real extent of its value. Ex-,
perience thus far fully justifies its employment wher-
ever practicable. The general plan at the University
Hospital for handling cases of pneumonia is as fol-
lows: On admission .5 c. c. of horse serum are
injected into the skin. If the patient is sensitive, reac-
tion will probably appear before typing has been done
and other preparations made for giving sera, in event
the case is one in which this form of treatment is in-
dicated. This preliminary injection of horse serum
also helps to desensitize the patient Assuming that it
is a type in which serum treatment is indicated, and
the patient shows no sensitization, 75 to 100 c c of
appropriate serum are given intravenously, by gravity,
allowing it to enter the vein slowly over a period of
15 minutes to one-half hour. This dose is repeated
every six or eight hours until favorable results are
established, the average total dose being about 250 c. c
If the patient is sensitive, as shown by the skin test,
small frequently repeated doses should be given first,
or IS c c. given slowly, about 15 minutes and the pa-
tient observed for reaction. If no reaction (tachy-
cardia, restlessness, suffusion of eyes, dyspnea, or
urticaria) occurs the remainder of the serum may be
given more rapidly. Great care should be taken with
known asthmatics.
Dr. Herbert Fox, Philadelphia: There seems no
question about the value of type I serum. As to the
advisability of using convalescent serum from other
types for other forms of pneumonia it is open to ques-
tion as to whether we are at present in a position to
say that this is a generally applicable procedure. It
has been established in several ways that it might be
undertaken under properly controlled conditions. All
those who have used post critical convalescent in-
fluenzal serum in influenzal pneumonia have small
doubt that the chances of recovery of those influenzal
pneumonias is increased by the use of the serum. That
the same is true of lobar pneumonia of types II, III
and IV one cannot say quite so definitely, but surely we
see after the introduction of the use of convalescent
influenzal serum, a very different outlook of the indi-
vidual's recovery than before it is used. The serum
of type I, horse or preserved serum of immune cases,
should be warmed before introduced into the body
and by all means should be diluted.
Dr. Edward H. Goodman, Philadelphia: The domi-
nating type of pneumonia in the Presbyterian Hospital
has been type IV. In type I there was no question
that the mortality was decreased, the patient was bet-
ter, the blood stream soon rendered sterile and all
symptoms improved. The thing of importance is lab-
oratory cooperation to determine the proper type.
There is no reason why a type should not be returned
within 12 hours in a hospital. It is wrong in any case
to use polyvalent serum.
Dr. John A. Murphy, Swarthmore: Properly con-
trolled and treated cases in type II and particularly
in type III showed some benefit and that had been
found in cases where the dose had been considerably
higher than the ordinary 50 to 75 or 100 c. c. doses.
Dr. Frank M. Huntoon, Philadelphia : We can pro-
duce antibodies from type I both in human beings and
in horses. There is no evidence up to this time to
justify us in using type II serum, but how can evi-
dence be obtained if we do not try it on cases? That
such types can be influenced by antibodies has been
shown by experimental work. They are not using
serums, but antibodies derived from serums.
John J. Repp, Reporter.
WARREN— FEBRUARY
The first meeting of the season 1921 occurred Feb-
ruary 2ist, at the residence of the new president. Dr.
Roy Young, and twenty members were present
Dr. Young outlined briefly what he thought the work
of the society should be for the coming year. He
urged the members to attend every meeting; to send
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April, 1921
STATE NEWS ITEMS
527
out bills monthly; to weed out the dead beats; to
take an active part in welfare work and support it.
It was decided to send a delegate to the conference
on Health Insurance to be held in Philadelphia in
March and Dr. Mitchell of the Board of Trustees was
elected to that position.
The paper of the meeting was given by Dr. C. J.
Frantz and it was a resume of his experience in the
treatment of appendicitis without operation. Dr.
Frantz reported one hundred cases without death and
treated medically chiefly by rest and proper diet and
care. These cases did not have recurrences and their
symptoms were relieved as efficiently as if they had
had an operation. He argued that the operation does
not always cure or relieve the symptoms that many
seek an operation for; that the pains and so-called
adhesions for which operations arc often recommended
are frequently not benefited, and even with suppura-
tion he has seen the pus discharged through the bowel
and the patient go on to recovery.
The surgeons side was discussed by Drs. Clancy,
Stewart, Condit and Robertson. It was their opinion
that the acute cases requiring operation were often
hard to distinguish from those who might recover
without operation. The blood count, temperature, etc.,
may lead astray. The operation in some of these ap-
parently mild cases often discloses serious conditions
which, if left to themselves, would terminate fatally.
In order to save the 25 per cent, from recurrences,
and possible death, it is best to operate on the 100 per
cent. Dr. Robertson pointed out the advantage of an
operation when all conditions are favorable rather
than under circumstances when time becomes an im-
portant element. The mortality at the hospital in the
past few years has been less than three per cent, for
all cases operated upon.
Dr. Clancy reported sixty-three operations without
a death.
The meeting was very instructive. Deaths from ap-
pendicitis seem to be three times as frequent in cities
as they are in the rural districts although there is but
a slight difference in the general death rate.
The members were then furnished by Dr. Young
and his wife with a very fine supper. M. V. Ball.
STATE NEWS ITEMS
YORK— FEBRUARY
The York County Medical Society met in regular
session, February 3d, in the parlor of the Colonial
Hotel. During the absence of Dr. L. S. Weaver, Dr.
L. M. Hartman was chosen by the society to preside.
Dr. Tom A. Williams, of Washington, held the
scientific prc^ram and chose for his talk, "The Ground
Work of Psychotherapy." Dr. Williams emphasized
at much length, the importance of careful examination
of the neurasthenic, of diagnosis before stating treat-
ment. Many so-called neurasthenics have an evident
physical cause, including endocrine disturbances, for
their condition ; in such cases psychotherapy is of no
value. Dr. Williams referred to psychasthenic cases
having a true psychopathology as cause for the condi-
tion ; he briefly sketched the line of treatment for such
cases, psychotherapy, psychanalysis, it's field and limi-
tation were discussed. The entire talk throughout was
emphastzed by citation of case records of Dr. Wil-
liams. At the close of the paper numerous questions
were answered by Dr. Williams.
Following in the regular order of business, Dr. H.
W. Kohler, of Red Lion, and Dr. W. J. Shenberger, of
Windsor, were elected to membership.
Between fifty and sixty members were present at
the meeting. Gibson Smith, Reporter.
DEATHS.
The Philadelphia County Medical Bulletin re-
ports the death of Dr. Samuel R. Skillern on Feb-
ruary 17th.
Dr. Wallace H. Dale, of Houtzdale, Clearfield
County, died March 11, 1921. Dr. Dale was born in
1861, was a graduate of the College of Physicians and
Surgeons, Baltimore, Md., 189S, and a Fellow of the
American Medical Association.
Dr. H. D. Rentchler, 80 years old, died at Ring-
town early in March. He was a member of the board
of education for twenty-eight years ; president of the
First National Bank of Ringtown; prominent Mason
and Odd Fellow, and a former coroner of Schuylkill
County.
Ete. A. M. Lichty, of Elk Lick, Pa., had a cerebral
hemorrhage on February 17th, and died on the 27th,
without having regained consciousness. He was buried
in the Odd Fellows' Cemetery at Salisbury on March
3d — the most largely attended funeral at Salisbury in
many years. The very targe attendance shows the
esteem in which he was held. He had been a member
of the Somerset County Medical Society since 1^9.
Dr. Morris B. Oberholtzer, of Boyertown, formerly
of Souderton, died at a Reading hospital from diabetic
complications, February 12th, aged 45 years. He had
been afflicted for several years. Dr. Oberholtzer grad-
uated at the Medico-Chirurgical College, 1898. He
was located in Souderton for a number of years and
was well known in the upper end of this county. He
was one of the original_ members of the North Penn
Clinical Society. His widow, a son and daughter sur-
vive.
Evan J. Groom, M.D., Bucks County's oldest phy-
sician and a_ resident of Bristol for sixty years, died
suddenly while conversing with friends at his home on
Sunday, February 20th, following an illness of two
years, aged 87 years. His activity covered a period of
63 years, and, it is said, that he attended 3,300 births. He
graduated from the Jefferson Medical College in 1856;
the first four years he practiced in Attleboro, now
Langhome. He moved to Bristol in 1863 and resided
in the same house all this time. For many years he
was a member of the county medical society but with-
drew several years ago.
Dr. George W. Ellison, died Friday, January 21,
1921, at his home in Townville, Pa., after an illness of
more than a year, with pulmonary tuberculosis. He
was born June 17, i860, in Richmond Township, Craw-
ford County. Graduated from the Cleveland Home-
opathic Medical College in 1899 and located in Town-
ville in 1900. He was a member in good standing of the
Crawford County Medical Society. He stood well as
a citizen and physician in the community where he
lived and took a lar^e part in the activities of his
neighborhood. He will be greatly missed by friends-
and patrons.
Daniel Baugh, president of Daniel Baugh & Sons
Company, manufacturers _ of chemical fertilizers,
founder of the Baugh Institute of Anatomy of Jeffer-
son Medical CoIlegCj -died February 27th in the Break-
ers, Palm Beach, Fla. He was 84 years old. Mrs.
Baugh was with her husband when he died. Despite
his varied activities, Mr. Baugh devoted a large part
of his time to philanthropic enterprises and civic af-
fairs. Among the many institutions with which he
was identified were the Jefferson Medical College, the
Howard Hospital and Rush Hospital, as a member of
their boards of managers.
Dr. Alpheus B. Fitch, aged about 70 years, for al-
most half a century a practicing physician at Factory-
ville, died at the family home at that place February
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528
THE PENNSYLVANIA MEDICAL JOURNAL
Aprii,, 1921
24th of pneumonia. His widow and two children,
Mrs. Roy Chase, of Factoryville, and Allan Fitchj of
Camden, N. J., survive. Dr. Fitch was born in Falls
Township, near Mill City. He was a mere boy, when
his father, Allan Fitch, was thrown from a flighty
horse and killed. The boy later attended Bucknell
University, graduated and attended a medical school.
He located in Factoryville and made it his home for
the remainder of his life.
Dr. (jEorge W. Allyn, physician and Civil War
veteran, died February 26th at his home in Pittsburgh.
Dr. AHyn was born November 28, 1845, in Plymouth,
Mich. He graduated from the University of Michigan
in the scientific and medical departments. When the
Civil War began he enlisted in the navy and was as-
signed to the lower Mississippi squadron, where he re-
mained until the war closed. E>r. Allyn came to
Pittsburgh in 1878, taught natural science in the public
schools for six years, practicing medicine at the same
time. In 1884 he began his specialty of eye and ear
work and continued this practice until 1917. He. was
president and secretary of the Academy of Science
and Art, Carnegie Institute of Technology, a member
of the Allegheny Medical Society, the State Medical
Society, the Ontological Society and Post No. 259, G.
.\. R. He leaves his widow and a brother. Dr. H. S.
Allyn, of Brazil.
Eh(. Jesse H. Hughes, aged 56, one of the best
known medical practitioners in Wyoming Valley and
the founder of Nanticoke State Hospital died at his
home in Nanticoke, March 12th. Pneumonia, with
which he was afflicted for six days, caused his death.
Dr. Hughes was born at Orangeville, Columbia
County, in April, 1865, and when one year of age his
parents moved to Hazleton, where he lived until he
completed his medical course, when he came to Wilkes-
Barre. After a short period of practice in this city he
removed to Nanticoke. ■ When the compensation laws
went into effect he was named chief surgeon of the
Wyoming Division for the Susquehanna Collieries
Company, in which capacity he served at the time of
his death. He was a graduate of Hazleton High
School and earned his degree from the City College
of New York.
He was a member of the Wilkes-Barre Franklin
Club and of Nanticoke Aerie of Eagles.
He is survived by his widow and one daughter. Miss
Jessica, and two brothers. Dr. W. E. Hughes, of Ash-
ley, and Edward Hughes, of Hazleton.
ITEMS
Dr. Samuel Z. Shope, formerly of Harrisburg, has
assumed the practice of the late Dr. Samuel D. Risley,
Philadelphia.
Dr. L. D. Sargbant, of Claysville, attended the re-
cent meeting of the American Congress of Internal
Medicine at Baltimore, Md.
Dr. John J. Gilbride, Philadelphia, delivered an ad-
dress on the Surgery of the Stomach before the York
County Medical Society on March 3d.
Dr. J. B. F. WvANT, Kittanning, enjoyed a trip to
New York and Washington the early part of March.
Dr. J. B. McAusTER and family spent a week in
Atlantic City during March.
Dr. James Koshland, of Marklesburg, Huntingdon
County, will specialize in eye, ear, nose and throat
work in Huntingdon.
The marriage of Dr. John M. Skirpan and Miss
Emma Dorothy Hudock, both of Plymouth, was sol-
emnized January 12th at Plymouth.
Dr. Cameron Shultz and wipe, of Danville, who
have been spending several weeks at Miami, Florida,
returned home on March ist. The doctor is County
Medical Director of Montour and Columbia Counties.
Eht. C. T. Dddd, of Claysville, is now on a trip to
Arkansas and Oklahoma.
Dr. and Mrs. R. K. Rewalt, of Williamsport, have
recently returned from a three weeks' visit to Cuba.
Mrs. G. D. Drick, wife of Dr. Drick, has been seri-
ously ill for the past month but is now reported as
considerably improved.
Dr. and Mrs. B. Milton Gareinkle and their chil-
dren, of Harisburg, spent several weeks at the sea-
shore during February and March.
Dr. S. S. Watson, of Moosic, Lackawanna Co., was
called to New York state, February 28th, on account
of the death of his brother-in-law.
Dr. H. C. Kinzer, secretary of Lancaster County
Society, has been seriously ill with diphtheria. A
speedy recovery is the wish of the Journal.
Dr. Peter Swank, who had temporarily located at
Luthersburg, Clearfield County, Pa., has returned to
Salisbury to relieve the urgent need of a physician at
that place.
Dr. and Mrs. Edward Cronauer, of Ashley, Lu-
zerne Co., and Miss Genevieve Gunning, of Gallitzin,
were guests at the home of Dr. and Mrs. A. F. Akers,
Harrisburg.
John J. Sweeney, M.D., of Doylestown, has been
appointed by the Federal Bureau of Pensions as ex-
amining surgeon for Bucks County. Dr. Sweeney was
a major in the Reserve Medical Corps during the
World War and served abroad.
LEwrsTowN drinkers of beer and wine will get no
comfort from the Federal, ruling that physicians may
prescribe those beverages. All but two of Lewistown's
sixteen doctors stated on March 17th that they do not
intend to prescribe beer and wine for patients, and
several of them declared they will not apply for per-
mits.
Announcement has been made of the appointment
of Dr. Oscar Klotz, professor of Pathology in the
University of Pittsburgh Medical School, as repre-
sentative of the International Health Board of the
Rockefeller Foundation for medical research work
and education in Sao Paulo, Brazil, serving as direc-
tor of a pathologic institute.
Dr. William C. Miller, chief of the division of
public health education. State Department of Health,
has initiated a correspondence course of instruction
for health officials in every county throughout the
state. The curriculum will consist of lessons in hy-
giene and the practical application of the state health
laws. The course which is required of all health of-
ficials, is open to nurses, welfare workers and workers
in allied fields.
The Kernels of Wheat. — The busy physician can-
not read everything that comes to his desk. The
varied assortment of pamphlets, circulars and other
printed matter that comprise a considerable portion of
his daily mail often receives but scant consideration
unless there be some conspicuous feature in it to fix
his attention. But even chaff may contain kernels of
wheat — a_ thought suggested by the receipt of an at-
tractive little pamphlet just issued by Parke, Davis &
Co., bearing the superscription "Adrenalin in Medi-
cine." Here is something which even the busy practi-
tioner can read with pleasure and profit. It sets forth
in the briefest possible manner all that is known re-
specting the properties and therapeutic uses of Adre-
nalin.
We suggest that our readers send tor a. copy of the
booklet. A descriptive announcement will be found jn
the advertising section, and Parke, Davis & Co. will
cheerfully honor all requests for the booklet from
medical men.
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Aprii,, 1921
STATE NEWS ITEMS
529
On Thursday, March 3, 1921, a joint meeting of
the New York Obstetrical Society and the Obstetrical
Society of Philadelphia took place in Philadelphia.
Clinics were held during the day in the various hos-
pitals. The meeting in the evening was held at the
Hotel Adelplio, where dinner was served. After the
dinner the visitors were requested to discuss the opera-
tions, technic, etc., they had seen during the day. Fol-
lowing this a paper was read by Dr. John O. Polok, of
Brooklyn, based on a study of 307 cases of ectopic
gestation.
Becinning Makch i8th, under the management of
the staff of Mercy Hospital, Philadelphia, Pa., Dr.
John J. Gilbride, surgeon to the hospital, will give
special clinics at the hospital every Friday at 2 : 30
p. m.
March 18, ig2i — Ileus; varieties, symptoms, diag-
nosis and treatment.
March 25, 1921 — Cancer of breast; causes and sites
of recurrence.
April I, 1921 — The role of the lymphatics in malig-
nant diseases of the abdominal vicera, course of ves-
sels and location of glands.
April 8, 1921 — The external secretion of the Pan-
creas (into the gut) and its bearing on the surgery of
the pancreas.
April 15, 1921 — ^The selection of cases and choice of
operation in gastric and duodenal ulcer.
But for the timely arrival of Dr. Bruce Lichty, Mr.
and Mrs. William Housel and their two children
would probably have burned to death in the flames
which destroyed their home at Meyersdale on Febru-
ary 27th.
The doctor had been summoned shortly after mid-
night to see a sick boy at the home of George W.
Smith, and, returning home, found the Housel house
in flames with the members of the family at an up-
stairs window, their escape cut off. I>octor Lichty
caught the two-year-old child which was tossed to him,
and when the one aged five years landed in his arms
he was knocked down.
He caught Mrs. Housel in the same way, both going
down. By this time, Jack Crowe arrived, and he auo
Doctor Lichty braced themselves to receive the impact
of the body of Mr. Housel. Nobody was injured.
The Housel family lost everything.
Honorable Cufford B. Connblley, Commissioner,
Department of Labor and Industry, Commonwealth of
Pennsylvania, Harrisburg, Pa., in an interview given
out February 28th announces that on Tuesday, March
ist, the Bureau of Employment in his department will
open on the second floor at the N. W. corner of 18th
and Chestnut Streets, Philadelphia, Pa., a state em-
ployment office exclusively for women. This office is
established primarily and exclusively for the placement
of factory and shop workers, clerks, stenographers,
institutional employees, office executives, technical and
professional women. It will give especial attention to
securing employment for women who are graduates of
city high schools, of colleges, and of universities.
This office will be in charge of Miss Rebecca W.
Ball, superintendent, assisted by Miss Leona Teeter,
who will devote her time and attention to calling upon
employers of women in Philadelphia and in investigat-
ing the working conditions of women in the Philadel-
phia district.
On Thursday evening, March 11, 1921, the drug-
gists of (icrmantown and Chestnut Hill, Philadelphia,
acted as hosts to the physicians living in the district.
.About one hundred were present. Dinner was served
at one of the caf^s in the community. The object was
to assemble the physicians and druggists of that sec-
tion, to afford an opportunity to become better ac-
quainted, and to discuss problems of interest to both
professions. The meeting was unique and considered
by all present to have been very successful. Such a
gathering is recommended for other sections.
The following addresses were made: Dr. Wilmer
Krusen, "The Relation of the Physician to the Phy-
sician" ; Mr. Charles H. La Wall, 'The Relation of the
Druggist to the Druggist"; Dr. Frank C. Hammond,
"The Relation of the Physician to the EKniggist," and
Dr. John R. Minehart, "The Relation of the Druggist
to the Physician."
This was a wonderful affair; the problems covered
in the addresses were complete in all details. The
pros and cons of both sides were covered and there
was not anything left to be unsaid.
In a series of appointments announced recently.
Colonel Edward Martin, State Commissioner of
Health, has named Dr. A. Miltonberger as chief of the
maternity center at Johnstown; Dr. L. E. McKee as
chief of the genito-urinary clinic at Altoona, and Dr.
Lewis H. Seaton, chief of the same clinic at Cham-
bersburg. Medical inspectors of schools named in-
clude: Dr. William Nix, Pocopson and East Marlboro
Townships, and Dr. T. L. Moore, West Marlboro and
New Garden Townships, Chester County. Dr. John L.
Good was named for New Cumberland, Upper and
Lower Allen, Cumberland County.
Health officers appointed include: Dr. M. R. Derk
for Piatt, Porter, Watson, Bastress, Nippenose and
Limestone Townships, Lycoming County; W. E. Mil-
ler for Connellsville, Bullskin and Upper Tyrone
Townships, Fayette County; Chance W. Hillegass for
Juniata and Napier Townships, Bedford County ; J.
H. Edwards, Allen and East Pike Run Townships,
Washington County; R. A. Snyder, Nicholson Town-
ship, Wyoming County.
Registrars named include: Philip T. Raub, Dallas-
and vicinity, Luzerne County; Edward M. Strickler,
York County; Hampton J. Leech Yeadon, Delaware
County; W. O. Rojahn, Dallastown, York County,
and Charles A. Jones, Youngsville and vicinity, War-
ren County.
S. Heilman, M.D., Sharon, Mercer County, holds
the distinguished record of fifty years in the medical
service.
I>r. Heilman was born in Armstrong County on June
10, 1847. When a youth he attended Tolleston Insti-
tute, Tolleston, Ind., graduating in a civil and mining
engineering course. After a short term at this profes-
sion, he decided he preferred medicine and began in
1868 to read with E>r. J. C. McMunn, of Cochran's
Mills, near his home, later taking his course at Jeffer-
son.
In 1886-87 he spent some time abroad taking a post-
graduate course in surgery and attending clinics in
Berlin, Vienna and London. He was surgeon for the
Erie and New York Central lines in this district for
35 years, resigning these positions a year ago.
In the course of his busy life he found time to de-
vote to National Guard affairs and he was prominently
identified with the old Fifteenth Regiment, from 1874
to 1898, holding the rank of Major and Surgeon. _ Dur-
ing the Spanish-American War he was chief divisional
surgeon, with the rank of Lieutenant-Colonel and was
recommended by Governor Hastings for promotion,
which was approved by President McKinley.
Dr. Heilman was one of the founders of the Pro-
tected Home Circle, which was orgfanized on .\ugust
6, 1886. He has held the office of Supreme Medical
Examiner since the inception of the organization.
Only one other of the founders is living. Past Supreme
President P. D. Stratton, now of .Akron, Ohio.
Eh". Heilman's wife, who was Miss Isabelle McKee,
of Cochran's Mills, died two years ago. Of the three
children born to them, one survives. Dr. Ralph Salem
Heilman, who has been practicing in Sharon ever since
leaving college in 1907.
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53d
THE PENNSYLVANIA MEDICAL JOURNAL
April, 1921
BOOKS RECEIVED
Diagnostic and Therapeutic Technic, a manual of
practical procedures employed in diagnosis and treat-
ment, by Albert S. Morrow, A.B., M.D., F.A.C.S.,
Late Lieut-Colonel, M.C., ,U. S. A.; Attending Sur-
geon to the City Hospital, and to St. Bartholomew's
Hospital ; Consulting Surgeon to the Nassau Hospital,
Mineola, L. L Third Edition, entirely reset, Octavo of
894 pages, with 892 illustrations, mostly original.
Philadelphia and London: W. B. Saunders Company,
1921. Cloth, $8.00 net
Surgery, Its Principues and Practice, by various
authors. Edited by William Williams Keen, M.D.,
LL.D., Emeritus Professor of the Principles of Sur-
gery and of Clinical Surgery, Jefferson Medical Col-
lege, Philadelphia. Volume VII, with 359 illustrations,
17 of them in colors. Philadelphia and London: W.
B. Saunders Company, 1921.
Heart Affections, Their Recognition and Treat-
ment, by S. Calvin Smith, M.D., Instructor in Medi-
cine, University of Pennsylvania Graduate School of
Medicine ; Visiting Physician to the Philadelphia Gen-
eral Hospital; Visiting Physician for the Study of
Cardiovascular Affections, Philadelphia Hospital for
Contagious Diseases ; formerly Instructor in Medicine,
Jefferson Medical College; formerly Special Cardio-
vascular Examiner, United States Army. Cloth, 440
pages, illustrated. Philadelphia, F. A. Davis Company,
1920. Price, $5.50 net
BOOK REVIEW
THE BASIS OF PSYCHIATRY. ( Psychobiological
Medicine). By Albert C. Buckley, M.D., Medical
Superintendent of Friends Hospital, Frankford.
Price, $7.00. Pp. 427. J. P. Lippincott, Philadelphia.
The text is divided into two parts. The first part
(212 pages) contains chapters on historical data, bi-
ology, psychology, etiology, classification and symp-
tomatology. _ The second part (207 pages) is devoted
to a discussion of the different psychoses. A glossary
of 223 terms used in the text is appended.
The author has seen fit to break away from the
mediaeval ideas of psychiatry so prevalent to-day and
has placed the subject where it belongs — as a subdivi-
sion of biology and treats it from that point of view.
After four pages of introductory and historical ma-
terial, the subject of biological phenomena is discussed
in a most interesting and instructive manner. The
chapters on Mental I>eveIopment and Psychological
Processes are fascinating and far superior to similar
chapters in any American textbook. This is true also
of the chapters on Etiological Factors and Exciting
Causes. The classification of mental diseases is that
adopted by the American Medico-Psychological Asso-
ciation. .At the end of each chapter is found a number
of good references.
The chapter on technic of laboratory examinations
is not at all in keeping with the superior quality of
the rest of the book and should not have been included.
It is poorly written and contains many errors. Xo de-
scription of the needle used for spinal puncture is
given except to say that it should be longer than that
used for collecting blood. The statement that "the
needle should enter the intrathecal space before meet-
ing with any obstruction" makes one wonder whether
it is supposed to meet with an obstruction after it has
entered. The technic for the Wassermann reaction is
very incomplete. Xo directions are given for prepar-
ing antigen ; final dilutions are stated as "about 4
c. c"; no control tube for natural antisheep ambo-
ceptor is mentioned and the leeway between the anti-
genic and anticomplementary doses is too small — only
two doses. The definition of an antigen would lead
one to believe that only substances capable of exciting
the formation of hemolytic amboceptors can act as
pntierens. The technic for determining the CO com-
bining power of plasma is also incomp'ete. Precau-
tions to be observed in collecting the blood, the use of
antifoam mixture and corrections for temperature and
barometric pressure are not even mentioned. The
method for determining urinary acidity was abandoned
years ago by most workers and the addition of potas-
sium oxalate to the urine before titration is now the
accepted procedure.
The illustrations on pages 261 and 262 are very poor-
ly printed. The "area of softening" shown_ on page
405 could hardly be found except by one familiar with
the pathology of the brain. Figure 77 is so lacking in
contrast as to be of doubtful value.
The high quality of the text is certainly worthy of
being printed on better paper than the publishers saw
fit to use. Only two typographical errors were found
in the whole book.
The book is by far the best text on psychiatry that
we have in English. Paul G. Weston.
WANTED
Physician, male preferred, for Assistant Superin-
tendent at State Sanatorium for tuberculosis, Wallum
Lake, R. I. Institution well equipped for the care
and treatment of all stages of tuberculosis. Fine
X-Ray plant, staff discussions of all cases. Initial
salary, $2,000 with maintenance of self and family.
Increases for one who makes good. Applicant should
have had some tuberculosis experience. State age,
height, weight, health, preliminary education, medical
school, date of graduation, number in family, experi-
ence and references in first letter. — Dr. H. L. Barnes,
Wallum Lake, R. I.
Wanted.— Doctor for good country practice. No
capital required. Act quickly. Dr. James Koshland,
Marklesburg (James Creek P. O.) Huntingdon
County, Pa.
Wanted. — To purchase a general practice in Penn-
sylvania. Address Dept. 501, c|o Pennsylvania Med-
ical Journal.
INDEX TO ADVERTISERS
Aloe, A. 8., Company x
Arch Control Company, Tbe zi
Armour £ Company 4th cover
B. B. Culture L,aboratory i
Bauer & Black v
Brady, Geo. W., & Company xvii
Brown, D. V xl
Burn Brae xir
Crest View xv
Deutsch. Max, The Gravid Shoe xvl
Devltfs Camp xv
Pelck Brothers Company Ix
Goodell, J. E., Liaboratory vl
Horllck's Malted Milk Co xvl
Hynson. Westeott and Dunning xvll
Jacobl, Edward, Prescription Blanks xll
JeRerson Medical College xlll
Kenwood Sanitarium xlv
Langner L,aboratory, The Iv
Mcintosh Battery and Optical Co ix
McKennan Pharmacy 4th cover
Maltble Chemical Co vlll
Manhattan Bye Salve Co., Ix
Massey Hospital, Tbe xii
Mayo Foundation, The xll
Mead. Johnson & Co., vlll
Medical Protective Co II
Mercer Sanitarium xlv
Metz, H. A., Laboratories, Inc x
Moore's Hospital xv
Mutual Pharmacal Company, Inc Ix
Parke. Davis & Company Ill
Physicians' and Surgeons' Adjusting Association vl
Pomeroy Company xvl
Radium Company of Colorado Ix
Radium Laboratory xvl
Saunders, W. B., Company 1st cover
Schering & Glatx, Inc., Iv
Storm, Katherlne L., M.D x
Sunnyrest Sanitarium xlv
Taylor Instrument Company ■. xvll
I'niversltv of Pennsylvania xlii
University of Pittsburgh xll
Victor X-Ray Corporation vll
Woman's Medical College of Pennsylvania xlll
Zemmer Company, The ^. . ■'•>*-^-< .^^ I .^11
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Owned, Controlled and Published by the Medical Society of the State of Pennsylvania
Issued monthly under the supervision of the Publication Committee
VOLDIIK XXIV
NuusKx 8
212 North Third St., Harrisburg, Pa., May, 1921
sobscxiption :
$3.00 Per Ykaii
ORIGINAL ARTICLES
IS THE PRACTICE OF MEDICINE
WORTH WHILE?*
EVAN O'NEILL KANE, M.D.
KANE, PA.
The question under consideration is answered
with the supposition that the practice of medi-
cine is to be conducted somewhat along the same
lines as it has been in the past, where the doctor
still retains the right to his own initiative, being
an independent man, and where his patient is still
permitted to employ whom, how and when he
pleases. It is here assumed that a man may still
practice general surgery and add, if time and
strength permit, obstetrics ; that the family phy-
sician has not become extinct ; that the practice
of medicine is not yet under state control with
a host of salaried officials who automatically
perform their duties with the unfeeling and me-
chanical regularity of a departmental clerk —
that deplorable condition in which there shall be
a single specialty for every doctor and the pa-
tient is taken cognizance of only in sections, his
feelings and wishes being ignored.
To briefly enumerate advantages strikingly
those of medical practice it may be safely stated
that an energetic man can always make a good
living by it; that this livelihood may be fair to
begin with and grow with increasing years;
that not alone does a wide-awake practitioner
profit directly by his practice, but fortunes are
accumulated in many side lines afforded through
the opportunities for investment which a man
with many friends and moving everywhere se-
cures ; that our profession is not only fitted for
bright men, the stupidest, if a good enough stu-
dent to graduate, being able to gain a fortune,
even honors, by simply sticking to his job, look-
ing pompous and not talking too much ; that no
location is overcrowded for him who is patient,
climate and environment, therefore, being
chosen at will if time and means permit ; that a
life of travel and adventure is most safely and
suitably conducted by the physician if a single
man (the military surgeon is peculiarly happily
'Read before the general meeting of the Medical Society of
the State of Fennajrlvania, Pittsburgh Session, October 6, 1920.
placed; his danger is exaggerated) ; that good
health and a long life are possible to those who
practice what they teach, yet if shortened by
over-activity, is it not better to "wear out than
rust out?"; that sociologic research and scien-
tific investigation of every description are com-
patible with continuing in active medical prac-
tice, by sleeping less and working harder, and
all varieties of philanthropic effort are fitted for
physicians, many a one having thus died nobly
a martyr to the cause of humanity (it was worth
while!); that social standing, the respect and
praise of the people, influence in political life
and a name in history are the reward of those
physicians who diligently search after such
things (he may have all that is possible to hu-
manity).
The veteran medical practitioner who has
studied and practiced medicine for a working
lifetime, if asked whether the practice of medi-
cine is worth while, replies emphatically that it
is. Yet he does not always speak encouragingly,
perhaps, for he recalls the years of unremitting
toil, the hardships endured and the thankless
treatment often received for his self-sacrifice.
He realizes that for all his devotion to his call-
ing he has neither become a millionaire nor
achieved world fame. His careworn visage, too,
proves that he has taxed his physical endurance
to the limit. Operating infections have crippled
him, contagious diseases contracted while visit-
ing the sick and exposure to rough weather have
told upon his constitution Loss of sleep and
anxiety make him look prematurely old.
But still in spite of hardship, self-denial and
perhaps straightened circumstances but few
physicians "putting their hand to the plough look
back." They much prefer to die in harness.
Those who are persuaded or forced to retire,
regret having done so. Few are contented even
to take a vacation as other men do. They are
restive and impatient until back again at work.
The lure of medicine is a something indescrib-
ably attractive. There is a charm in his voca-
tion which raises the medical man above others
and holds him there through the inspiration it
creates. Abused, censured, criticized, ridiculed,
feared, worshiped, loved and respected^ always
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532
THE PENNSYLVANIA MEDICAL JOURNAL
May, 1921
talked about, his position is peculiarly captivat-
ing. To the physician are revealed the truths of
the here and maybe the hereafter. He knows
family secrets ; they cannot be hidden from him.
He sees men and women as they really are, not
as they are supposed to be. His counsels are
heeded for he, best, can advise. He may have
jealous enemies but his warm friends outnum-
ber them.
The physician usually starts his professional
career on a practical business basis. He does
not necessarily set out with any exalted ideas' of
service to humanity, despite his Hypochratic
oath. It is his intention to make a handsome
living. He expects to be well paid for his serv-
ices. Though not altogether disappointed, he is
not rewarded as he should be; he sometimes
gets only enough out of it to support his wife
and himself comfortably and raise his children
respectably. Could he adhere to strictly mer-
cantile principals he would, in time, grow fairly
rich — ^and a few do. But in spite of himself, he
insensibly becomes charitable. Constant ap-
peals for help, the daily contemplation of suffer-
ing which he alone can alleviate and the realiza-
tion that upon him depend the lives of many
changes the nature of the business-like medical
man and ere long he is doing much of his work
regardless of cash returns. If to gain a profita-
ble living were all that was worth while in medi-
cine, the honest practice of it would prove dis-
appointing, but money is not everything.
From the viewpoint of the public, the unde-
niable fact that the world cannot exist without
doctors should render it fully aware that it is
worth while to encourage them. The industrial
surgeon, the hospital surgeon, the country sur-
geon, physicians in general practice and those who
specialize, research workers and public health
medical officials and last but not least, the ob-
stetrician who saves two lives at once — all these
are essential to the public welfare. They lit-
erally keep the community alive.
Though evidently the practice of medicine is
worth while, yet with the tedious preparaticwi
now necessary to enter upon a medical career,
with the increased demands made upon the phy-
sician to render free services to the poor and
his small remuneration, it is a somewhat dis-
couraging business in the present "get rich
quick" days. As a result, the public may find
itself without the protection it now receives
from the medical profession unless it treats the
doctor with greater consideration. Expressions
of gratitude alone are a poor recompense for
life service. Society should be made to realize
that if it is to live, it must pay liberally for its
existence. The doctor should demand and he
will receive the consideration he deserves. It is
up to him ! Quackery and every phase of hum-
bug doctoring should be discountenanced. The
false standards of the various "pathies" and
all medical cults, whether conducted ill^ally or
with such pseudo-scientific pretense as secures
legislative protection, must be vigorously op-
posed. At the same time honesty on the part of
the regular medical profession should be scru-
pulously maintained together with so high a
standard of efficiency as would, by contrast, re-
quire no argument to prove its superiority over
spurious practice.
In conclusion : should a young aspirant ques-
tion "Is it worth my while to enter upon a
medical career?" answer "Yes, if the doctor is
to remain a free agent, if he is prepared to lead
a strenuous life, if he has an indomitable will
and a strong constitution, an unflinching deter-
mination to stick to his task and, still better, if
he is inspired by a noble singleness of purpose,
having formed a high ideal — in such a case he
will make the practice of medicine worth while
for himself and for the world.
DISCUSSION
Db. Jambs Johnston (Bradford) : This is not a
question so much as it is an opportunity. To practice
medicine is to live the life of a physician, and of all
men the physician is closest to all that is real and all
that is vital, closest to the living, closest to the coming
and the going of humanity. What is it to live, unless
it is to manifest the forces of the world in ourselves
and to witness the manifestation of these same forces
in our neighbor? What is it unless to grow and to
watch the processes of growth?
True, our work is with the pathologies of mankind,
yet it is also true that our work brings us closer to the
physiology of existence. We know our neighbors as
no other men know them. Ours is the work of the
world that possesses in itself the greatest interest.
Then, too, it is the work that is most appreciated.
The progress of humanity is most largely in our
hands. It is to us, for the most part, that men turn for
knowledge as to how they shall live and how they shall
grow. The idea of a sound mind in a sound t>ody is
fixed and forms a working basis of common knowl-
edge for those with whom we associate in 1921. Our
forefathers had these words but they did not have the
sure knowledge of the fact as our running mates of
to-day have it, or still more as our children have it.
They look to us for guidance.
Then, most of all, our work helps us, more than any
other work could possibly help us, to grow. We know
that we are here to grow and we know it so well and
so surely that we do not for an instant forget it Life
and the world we live in has fewer secrets for die
physician. More is revealed to him in the course of
his daily study and labor. A physician may say, "I
believe in God, Creator of heaven and earth," and to
him that is a clearer belief because he, more than any
other man, has some faint understanding of how that
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May, 1921
END RESULTS IN NERVE INJURY— BABCOCK
533
was done and why. His daily grind brings him to a
close-up observation of God's work. He knows how it
is possible to live so as to at the end enjoy intellectual
light full of love, love of true good full of joy.
He may be happy in realizing this for himself and
for all whom he may reach and to whom he may teach
the worth-whileness of life and of growth and the
value of the fight against death and disease, that we
may go at it again and again — an unending fight as
also an unending growth.
Dr. Spencer M. Free (DuBois) : As to this paper,
"Is the Practice of Medicine Worth While?" the an-
swer is yes or no. If your ideas in life are money,
ease, fame, the praise of your fellowmen; if you
want to have a good time, if you want to be in so-
ciety, if you want to marry a woman and make her
happy instead of uncomfortable and miserable — keep
out of medicine. If you want to live the ideal life,
if you have that in your soul which fixes your eyes
upon the stars, if you have in mind the great Man of
Nazareth than Whom no greater has lived in the his-
tory of the world, Who caught the inspiration of the
Golden Rule, Who placed service above self, )Yho gave
up His job and wandered through all of that country
teaching His ideals, Who said to His disciples, "If you
would be the greatest of all be servant of all," if you
have these ideals and do not care for the accumulation
of money, do not mind missing meals frequently, do
not care what people say about you, then the practice
of medicine is worth while. If you want a home you
cannot have it without some real woman. If you can
find such a woman, present the matter fairly and
squarely to her, tell her what she will have to endure
at your hands, that she must go through life without
the silks, satins and furs of other women, that she
must do without social life and the many things that
are attractive to her. If she is then willing to stand
with you and be a helpmeet, marry her. There is no
man on earth who stands so close to Almighty God as
the honest doctor who has the inspiration of souls to
heal as well as bodies to heal. Ours is a double office.
People lie to everybody but to the doctor, and some-
times to him. But we get nearer to the truth, we
know more about the skeletons in closets and about
the inner history of the man, woman and child in a
family. We ought to know; it is the secret of our
heart and that gives us powec
I have not time to discuss the entire paper of Dr.
Kane, because it has in it so many good things. Just
this one thing: If in addition to all the labor, self-
sacrifice, self-denial, loss of fame and everything of
that kind, you are still willing to take the abuse that
comes to you and yours then the practice of medicine
is worth while. Will you be abused? Undoubtedly.
You all know it. You will be misrepresented and lied
about and, like the Great Physician of Nazareth, after
you have done your best you will be crucified. But
it is worth while. Wouldn't you rather to-day be the
Man of Nazareth than all the Alexanders, Csesars, and
Napoleons? In the history of the world where are
they now compared to Jesus of Nazareth, the Great
Physician who went about doing good without a home
— indeed without a place to lay his head and without
a meal arranged for in advance? If these are your
ideals, to serve constantly to the best of your ability,
to sacrifice everything — sometimes even your health
and life— if you have before you the opportunity to be
of some good in this world and to make the world a
little better, a little more fit for others, then what mat-
ters everything else?
END RESULTS IN 608 CASES OF
PERIPHERAL NERVE INJURY*!
W. WAYNE BABCOCK, M.D., and JOHN O.
BOWER, M.D.
PBU,ADEI.PHIA
Two years have now elapsed since the first
of between three and four thousand soldiers
with injuries to peripheral nerves returned to
our shores. Nearly all have since been system-
atically studied and treated in a few designated
army hospitals especially equipped for work in
neuro-surgery. We may now determine to some
degree at least the efficacy of the various treat-
ments used, and may begin to formulate the
conclusions that should most carefully be crys-
tallized out of the multitude of observations that
have been made and that are yet to be made.
Our conclusions are based almost entirely on
secondary operations performed from four to
eighteen months after the original injury in con-
trast with a series of patients treated by non-
operative measures. While primary operations
upon injured nerves were carried out by the
American Expeditionary Forces abroad, the
number of sutures was relatively not large and
the wounded returned either without their clin-
ical records or with records so incomplete that
the evidence of primary nerve suture was often
disclosed at the reoperation in this cotmtry.
From the cases observed, it is our impression
that conditions in the zone of military activities
usually were not favorable for the successful
primary suture of nerves. The patients re-
turned with nerve injuries complicated by asso-
ciated injury or infection of bone, by extensive
loss of soft tissue, by atrophy, fibrosis and dense
adhesions of muscles and tendons, by fibrous or
bony ankylosis of joints, or by healed or un-
healed woimds with cicatricial deformity, and
at times by deep foci of infection from embedded
foreign bodies. Some of the patients had all of
these complications associated with their pe-
ripheral palsy. In these cases, an operation
upon the nerve alone, no matter how perfect,
could not be expected to return motion to an-
kylosed joints, or contraction to muscles, ad-
herent, wasted and almost completely trans-
formed into fibro-connective tissue. If we can
show that surgery is effective in the treatment
of these old and very complicated nerve injuries
of war, we shall have amply proved its efficiency
for the simpler nerve injuries of civil practice.
At the time these patients were returned,
many of the reports from abroad discouraged
operations for wotmded nerves. Certain of the
'Read before the general meeting of the Medical Society of
the State of Pennsylvania. Pittsbureb Session, October S, 1920.
tProm U. S. General Hospital No. 6, Ft. McPberson, Ga. —
Col. T. S. Bratton, Commanding.
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534
THE PENNSYLVANIA MEDICAL JOURNAL
May, 1921
French surgeons eyen considered the suture of
divided nerves a mistake and almost certain to
result in harm or failure. These reports preju-
diced American surgeons and in some of our
army hospitals pride was taken in the small per-
centage of patients with nerve injuries brought
to operation. It was said that not over 25 per
cent, of the patients required operation, and we
found ourselves criticized and gently admon-
ished for having early operated on 65 per cent,
of our patients. Time has not only proved the
safety and value of surgical intervention, but
has shown that we were not sufficiently radical,
for a niunber of the soldiers, after months of
useless delay, have finally come to operation,
while not less than twenty, from our undue con-
servatism at the early operation, have required
reoperation.
The operations were preceded and followed
by a series of elaborate examinations and tests
in which the work of the neuro-surgeon and
ward surgeon was amplified and counter-
checked by other departments of the hospital.
The neurological examinations, including the
electrical tests, were for the most part made by
Major Irving J. Spear, a Baltimore neurologist,
who gave his entire time to this work ; the elec-
trical treatments, passive movements and mas-
sage were given by especially trained aides
under the direction of Major H. C. Westervelt,
of Pittsburgh ; and the orthopedic treatment as
regards special splints, braces and the Uke were
supplied by Captain John C. Wilson and Captain
Steele, of the Orthopedic Department. Charts
showing the areas of tactile, . pain, and deep
pressure loss were plotted by Miss Marjorie
Brown, Mrs. Bower, Mrs. Babcock, Miss
Hawkins and others. Arrangements were made
to examine each patient at least once monthly,
and it is difficult to appreciate the thousands of
tedious examinations made and the enormous
number of treatments given. To the splendid
cooperative work of many persons, and not to
the operations alone, is any success of this work
to be attributed. Indeed the only patient for
whom a nerve suture has seemed valueless had
as a result of months without splinting and mas-
sage such an advanced wasting and fibrous de-
generation of his muscles that no contractile ele-
ment remained to be stimulated.
Our indication for operation was a persistent
total or partial interruption, or a serious irrita-
tive lesion in a nerve, as shown by repeated ex-
aminations usually over a period of two or three
months. The mild or improving cases were re-
ferred for massage and electro-therapy; the
more severe cases explored, neurolized or her-
saged, and only when there was evidence of
complete division of a large area of the nerve
was a suture carried out. Each operation in-
cluded the excision of the old scar, the liberation
of adherent muscles and tendons and their re-
pair, and an exploration of the involved nerve.
NEUROI.YSIS
The nerve was carefully isolated through the
area of the injury, freed from adhesions, the
sheath split to determine the condition of the
contained bundles, and frequently electro-con-
duction tests made with a small f aradic coil to
determine the permeability of the fibres and also
the arrangement of the nerve pattern. If nerve
bundles were seen, even though the nerve was
not electro-conductive, the nerve was sur-
rounded by muscle and the wound carefully
closed without drainage. These cases of neu-
rolysis made good recoveries, outstripping in
rapidity of improvement the parallel milder
cases treated only by physiotherapy. A num-
ber were cured as early as the fifth week and
, none required reoperation.
HERSAGE
If the interior of the nerve cord was foimd to
be fibrous or cicatricial, the area was freely but
carefully split open in a number of longitudinal
planes, and if no nerve bundles were seen the
incisions were repeated until the undamaged por-
tions of the nerve were connected by a multitude
of fine fibrous fibrils after the method described
by one of us in 1907* (Nerve Combing, Her-
sage, Fibre Disassociation). The nerves thus
treated had dense masses of nonconducting fibrous
tissue occupying from one-third to the entire
diameter of the nerve. Although many of the
lesions were very extensive, the months required
for regeneration after a nerve has been divided
and the fear of a possible failure after suture
made us very reluctant to resect and suture
nerves in the early months of our work. By
May, 1919, Major Spear found that in 75 cases
of hersage, 20 per cent, had remained the same
after the operation, 54 per cent, had improved,
16 per cent, much improved, and 10 per cent,
were cured. Even twelve weeks after the opera-
tion, 25 per cent, were markedly improved, and
within 24 weeks 7 were cured. A few of the
patients were temporarily made worse by the
operation, but in 142 milder contemporary cases
given physiotherapy but unoperated, only 67
per cent, had improved, as contrasted with 80
per cent, of the patients treated by hersage. By
January, 1920, of 169 cases of hersage, only 25,
or 14 per cent., had shown a persistent lack of
*Babcock; Nerve Disassociation; A New Method for the
Surgical Relief of Certain Painful or Paralytic Affections of
Nerve Trunks. Annals of Surgerjr, Nov., 1907.
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May, 1921
END RESULTS IN NERVE INJURY— BABCOCK
535
improvement, and only one patient was worse
than before his operation. For these patients
reoperation with excision and suture had been
advised or carried out. Hersage seems to have
a distinct value in causalgia and for cectain
large neuromas or fibroses in continuity asso-
dated with a severe form of physiologic block.
When the fibrosis produces a complete ana-
tomic block and involves over four centimeters
in length of the nerve, excision and an end to
end suture is indicated.
SUTURE
If the nerve at operation was found com-
pletely divided, the ends were trimmed squarely
back with a sharp razor blade until well formed
nerve bundles were shown, accurately aligned
and united by the finest (A-oooo) black sewing
silk in the finest (No. 12) straight bead thread-
ing needle. From 4 to 28 interrupted sutures,
according to the size of the nerve, were used,
only the sheath of the nerve being penetrated.
Catgut and especially the tension catgut sutures
of Gosset, so generally used, we have carefully
avoided after observing the absorptive reaction
and liquefaction produced in nerves by the cat-
gut introduced abroad, and the absence of reac-
tion from fine silk. Very fine, plain, unwaxed
silk produced no secondary reaction and was
used in nearly all of our cases.
We have no evidence from this series that
any divided nerve properly sutured, left in a
proper, well-vascularized, aseptic bed and given
appropriate after treatment will fail to unite
and more or less completely regenerate. If,
however, during the early weeks after suture
great tension is applied to the nerve, the suture
line may give way and the nerve ends separate.
The nerve about the area of suture usually rap-
idly adheres to the adjacent soft tissue, splinting
and strengthening the anastomosis. In one case
we found the supporting adhesions so, well de-
veloped twenty hours after the suture that con-
siderable tension could be made on the nerve
without affecting the suture line. In a second
case, the area of suture was so well supported
two weeks after operation that the ward sur-
geon, in thoughtlessly extending the arm forci-
bly, ruptured the nerve, not at the line of suture
but one centimeter above. Patients, especially
the more ignorant ones, will not infrequently
loosen their bandages and put great strain on the
shortened sutured nerve, and it is surprising
how rarely this tension tears the nerve ends
apart. It occurred in but three, or in less than
2 per cent, of our cases. Active suppuration
may melt doAvn the suture line and permit the
nerve ends to separate, and compression of the
nerve by the overgrowth of callous or fibro-con-
nective issue, may cause a physiologic block in
conductivity requiring reoperation for its relief.
After 182 sutures of peripheral nerves, np
evidence of regeneration within a reasonable
time was found in eight. It is noteworthy that
a mechanical reason for the nonregeneration
was found in each of the cases, as follows :
CAUSES OP FAILURE AETER NEURORRHAPHY
Rupture of nerve by external
violence 1 (Musculo-spiral)
Separation of nerve at suture /
line from external violence, ) (1 Ext. Poplieal.)
lack of external support, etc., 2 ( (i Sciatic.)
Multiple injury with one area
overlooked I (Brachial plexus.)
Separation from deep infection, i (Musculo-spiral.)
Compression from periosteal
overgrowth, 2
Chronic advanced muscle fibro-
sis I (Ant. tibial.)
Total 8
In two additional cases special muscles failed
to regenerate because the branches supplying
these muscles had not been included in the su-
ture.
Our experience as far as it has gone indicates
that when a nerve fails to regenerate after su-
ture, ainechanical cause is present and reopera-
tion should be done to remove the obstacle to
healing. This has been carried out in all but
the last of the above cases. Reoperation may
show that other structures were sutured in mis-
take for nerves; that the proper nerve ends
were not brought together ; that the nerve ends
were not properly prepared for suture ; that an
area of nerve injury had been overlooked ; that
the nerve ends had separated ; or that the nerve
was compressed or inflamed.
After neurorrhaphy the downgrowth of axis
cyUnders is usually considered to progress at the
rate of about one inch a month. We have arbi-
trarily taken one-half inch a mwith as the slow-
est possible rate of return and would class those
cases of suture as failures in which voluntary
return of movement to the larger muscles did
not occur within the time limits this rate of re-
generation would impose. Thus, with the ulnar
nerve sutured two inches above the point where
its fibres enter the flexor carpii ulnaris we would
expect voluntary contractions in this muscle in
four months. It is probable that motor regen-
eration is at times slower than this, but it is a
striking fact that excluding the eight cases
which had a mechanical obstacle to regeneration,
no neurorrhaphy of our series has failed to re-
generate within the estimated time limit. Thus,
of the 32 earlier sutures of the sciatic nerve, 31
Digitized by VjOOQIC
536
THE PENNSYLVANIA MEDICAL JOURNAL
May, 1921
show the progress of deep pressure tingling
along the course of the nerve below the line of
suture, 22 have distinct sensory return, 15 have
more or less complete motor return. The one
case showing no improvement was found at re-
operation to have pulled apart. In the remain-
ing 16 cases, ten months was the maximum time
that had elapsed without motor return after a
high sciatic division and seven months after a
mid or low sciatic division. As three years
might not be considered an unduly long time for
the regeneration of the eighteen inches of nerve
lying between a high point of division and the
entrance of the branches of the nerve into the
gastrocnemius muscle, it would appear that re-
generations after neurorrhaphy have been quite
uniform and relatively early. By January, 1920,
sixty patients, upon whom suture of the ulnar,
sciatic, musculo-spiral, median, peroneal or
tibial nerves had been carried out, had motor
return in one or more muscles, a speed in re-
generation in some cases of one inch in four-
teen days. In other words, our present evidence
is that neurorrhaphy for the division of a pe-
ripheral nerve should cure the paralysis with
somewhat of the certainty that a herniorrhaphy
cures hernia. As in hernia, great delay, large
gaps, degenerated tissues, infection and espe-
cially poor technique and poor after-treatment
will vitiate results that otherwise should uni-
formly be good.
The following table gives the number of op-
erations, reoperations, and also the number of
cases that from failure to regenerate should
have had reoperation, but the patient refused :
Nearly all of the operations were conducted
under spinal, local or brachial plexus anesthesia.
In a small series, regional anesthesia, by intra-
vascular injections, was employed. Local anes-
thesia, by the free use of a one-half or one per
cent, solution of procain with epinephrin, gave
satisfactory analgesia that lasted as long as four
and a half hours. . Despite the fairly generous,
eight- to seventeen-inch incisions employed the
operations gave marked cosmetic improvement,
for conditions in France were not conducive to
comely scars.
RATES OP REGENERATION AFTER SUTURE
Regeneration is more rapid with the large
nerve trunks of the arm and thigh than with the
nerves of the forearm and leg, and is particu-
larly slow in the hand. Relative simplicity of
function of a nerve, as with the musculo-spiral
and posterior tibial, favors regeneration, which
is slower in those nerves having multiple and
complicated functions, as the anterior tibial and
especially the ulnar. Interference with the nerve
TABLE OP OPERATIONS ON PERIPHERAL NERVES
1
1
Reopera-
tive.
Refiued
,reopen-
1 tiOD.
<;
6
g
Nerve.
i
rf
1
S
3
i
S
SI ^
1
1 i
1
0
0
f,
1
8 S
3il
m
V
m S
2
SS
0.
o<
H 0.
04
Ulnar 47 30 * »*
Sciatic, 40 34 10 29
Musculo-spiral 28 3a 9
Median ao a6 10
Peroneal, 9 7 i
Brachial Plexus 3 10 1
Posterior interosseous, .371
Musculo • cutaneous of
arm, 3 S 3
Anterior tibial, 5 4 a
Posterior tibial 4 S 3
Facial a i 1
Internal cutaneous of
arm 3 4 a
External popliteal 4 1 i
Internal popliteal, a 4 i
Musculo - cutaneous of
leg, 4 •• «
Internal saphenous, ... a ■ i
Radial, 1 3 •
External saphenous, ... 1 i i
Internal cutaneous of
thigh, I I a
Circumflex i
Anterior crural 1
Cervical plexus, a
Anterior interosseous, . . . i . .
Lumbar plexus,
Coccygeal plexus,
Small sciatic, ' . .
Spinal accessory, i
16
•4
•i
6
6
4 "S ••
4 108 . .
4 94 •■
a 83 ..
3 36 ..
. . 27 ■■
a 19 ..
:: \l M
.. 14 .-
.. 10 ..
Total, 183 169 64 166 7 ao 608 i 7
'Advanced muscle fibrosis.
SuMliAKY
Total number of patients, .... S34
Number of nerve injuries, . . . 583
Number of nerves operated on, 417 — 7i.s%
Number of nerves not operated, 166 — 28.5%
Number of nerves sutured, ... 184 — 44.1%
Number of nerves hersaged, .. 160—40.6%
Number of nerves neurofized, . 64 — is.3%
Number of nerves requiring re-
operation 35 or 8. 4% of operative cases.
Number of cases reoperated on, 37
Number of eases refusing reop-
eration, 8
Number of reoperative cases
previously sutured 7 (G. H. No. 6.)
Number of reoperative cases
previously hersaged, ao
over joints, as at the wrltet, elbow and knee
seems to delay regeneration, perhaps from inter-
ference with the intrinsic blood supply. Re-
generation is also slower with large defects and
after a rerouting operation has been carried out.
The following table shows the average rate of
daily growth of sensory fibres below the point
of nerve division, as determined by the progress
of deep pressure tingling.:
RATE OF DAaV PROGRESS OF FORNICATION FOIXOWING
SUTURfi*
Sciatic, 1/13 inch.
Posterior tibial, i/is inch.
Peroneal, 1/18 inch.
Anterior tibial, 1/29 inch.
Musculo-cutaneous 1/24 inch.
*Trombetta-Treves Applied Anatomy.
Digitized by VjOOQIC
May, 1921 END RESULTS IN NERVE INJURY— BABCOCK 537
Musculo-spiral 1/18 indi. fragments, sequestra from bone or other septic
Ult*r=re'arm;:::::::::::; \% ."ct foreign bodies. Especially dangerous were old
Ulnar— rerouted, 1/38 inch. <^*^^s of bone infection that had healed, which
Median— arm 1/18 inch. usually would break down and suppurate after
Median— forearm i/ao inch. operation or even sometimes after simple ma-
Posterior interosseous 1/34 inch. nipulation. It has been a rule in the war service
INFECTION ^° ^^** three months after complete wound
„ . . , -.. .L • . 1. . .. J healing before operating for a nerve injury.
Peripheral nerves with their tough sheath and Unfortunately this delay does not eliminate deep
independent blood supply are relatively strong ^^^ ^j j^^^^j^^ ^^^^^ ^^.^^ ^J
and resistant to trauma and infection. From a .^ t^ \. v /n. iT 1 j j
•I » _^i. £ - J £ 4.U 1 months after healing. The unhealed wound
tensile strength of 59 pounds for the ulnar nerve „^„ ^. r • r *• c^ •%
JO At iu J- iu 1 presents a source of infection often more easily
and 83 pounds for the median nerve, the larger T .. . ., ^i. j ^l • r x- r 1 . j
nerves show increasing strength gradations to ^^"^^^^ *"" ^^^ ^^P*^, infections of healed
the 183 pound breaking strain of the sciatic r,?''f^- I" fourteen unhealed wounds we ster-
nerve.* The peripheral nerves have intrinsic '''ff. *^" granulating surface with a saturated
blood vessels and may be isolated for long dis- ^^^^^Ta T^ T. ' "^T^ "^^ f ^^ ^u''
tances and then reimbedded in healthy soft tis- ^'^'^^''^ surface en bloc and operated on th§
sue without degenerating. In dividing the sci- "J"^^.*^ °<="'«- . twelve of these wounds healed
atic nerve one is impressed by the two spouting by primary union, one suppurated and one had
arteries within the nerve. We have seen the * s"&nt superficial infection. In twelve old and
outside of the sciatic nerve turn white and hard apparently soundly healed wounds, the opera-
for a distance of several inches from accidental ^°^ relighted a suppurative infection. Most of
contact with a saturated solution of zinc the combined operations upon bone and nerve
chloride, and yet no evidence of nerve interrup- aroused latent infections. The British, to avoid
tion follow. An infection sufficient to prevent such wound infection, advise that no aseptic
the union of tendon, bone or adipose tissue may operation upon bone be attempted for gunshot
fail to prevent the union of a sutured nerve, injury until the wound has been healed one year.
How rare is a palsy due to the spread of in- Obviously, such a long delay may permit such
fection to an uninjured peripheral nerve? Of extensive degeneration in nerve and muscle as
our series, in eight wound infections, relighted to render an operation upon the nerve of little
to activity by operation for the suture of nerves, use, while even a year's delay does not always
the regeneration has progressed to a return of give a sterile operative field. With the resist-
motion, the healing of the nerves apparently ance of nerves to infection, and relatively small
being little influenced by the infection. Out of a percentage of operative failures from this cause,
total of fourteen wound infections following we think it better not to unduly delay operation
nerve suture, in only one was the nerve found to for a serious nerve injury. To reduce the
have definitely separated as a result of the in- danger of infection, the skin should be care-
fection. In this case, the lack of living soft fully sterilized, granulation tissue destroyed by
tissues left the sutured area exposed in an ab- zinc chloride, no associated operation on bone
scess cavity. Despite the remarkable resistance or joint attempted, and the nerve sequestered at
of peripheral nerves, even nonsuppurative forms the completion of the operation in healthy, well
of infection may delay regeneration, produce vascularized soft tissue, preferably muscle,
causalgia or induce an overgrowth of adjacent
connective tissue with compression and nerve 11,1, effects of operation
blocking. Infection not severe enough to melt ^, •■, ^ •,, a ^ a x- •
down the line of suture will usually not entirely ^^^ accidents or ill effects from operation m
prevent regeneration. We saw two cases of post- o""" series mclude one case in which a toe drop
operative inflammatory causalgia and two cases was converted into a foot drop by our acci-
of nerve blocking from the pressure of inflam- dental division of the peroneal nerve. In this
matory tissue after operation. The danger of case primary suture was followed by complete
infection to nerves is greater after a primary recovery in one year.
suture than in those cases that have acquired a No ill effects followed neurolysis, but from
d^^ee of resistance from a previous long-stand- hersage there was one persistent and three tem-
ing infection, and in our series we have recog- porary increases in the palsy, while a small per-
liized no new infection, but only old infections centage had a transient increase in the area of
relighted to activity by the operative manipula- sensory loss and two cases developed causalgia
tion, often from embedded bits of clothing, shell relieved by reoperation.
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THE PENNSYLVANIA MEDICAL JOURNAL
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TRBATMENT Ot IWVRGE DEFECTS IN NEKVES
We soon found that the extensive losses of
nerve substance with large gaps, usually treated
by implanting a graft from another nerve, by
making a flap from the nerve trunk, by implant-
ing a trellis of catgut or alcohoUzed nerve or a
conducting tube of hardened artery or other
material, or by shortening the limb by resecting
a portion of bone, may be so well overcome
merely by certain operative manipulations as to
enable an end to end suture.
We would express the law, which we think
has few exceptions, that when a nerve is so ex-
tensively destroyed by injury that the ends can-
not by any manipulation be brought together,
then the limb will be found so disorganized that
A nerve suture would be of no avail. As a
corollary: when we fail as surgeons to do an
end to end anastomosis of a divided nerve, we
have failed to use the full resources of our art.
Gaps in divided peripheral nerves are to be
overcome by utilizing the normal slack in the
nerve plus that obtained by slight traction and
by flexing, extending, rotating or adducting ad-
jacent joints, and in some instances, by also re-
routing the nerve to give it a shorter course.
For example, a gap of two or three centimeters
in the median nerve may be overcome by the
normal slack and elasticity of the nerve, five
more centimeters may be overcome by strongly
flexing the elbow, four additional centimeters,
by strongly flexing the wrist, and finally five
added centimeters by transposing the nerve to
a subcutaneous position in the forearm and at
the elbow. By combining all of these expedi-
ents and freeing the median nerve from the
hand nearly to the axilla, the nerve ends may
be brought together and sutured, even when
there is a gap of fifteen to seventeen centimeters
(six to seven inches). Surgeons who have ex-
posed injured nerves only through short (four
to six inch) incisions cannot appreciate how
much may be gained by the extensive liberation
of a nerve. While regeneration proceeds more
slowly after large gaps in nerve trunks have
thus been overcome, of our fourteen older cases,
in which it was necessary to reroute the ulnar
or median nerve to enable an end to end suture,
all show some evidences of sensory return and
five have already regained motion in one or
more of the muscles that were paralyzed.
Nerves quite rapidly increase in length under
traction so a surgeon may overcome a part of
the gap, fix the nerve ends by suture, then
slowly elongate the nerve by very gradually
moving an adjacent joint and at a later second-
ary operation overcome the remainder of the
gap. Thus in one case of our series, gaps of
fifteen to seventeen centimeters in ulnar and
median nerves were overcome by such a two-
stage operation. We have used grafts from
superficial sensory to deep mixed nerves in two
cases — once for a ten centimeter (four inch)
defect in the median nerve because we did not
then know how to overcome the gap, and once
from reluctance in breaking up a bony ankylosis
of the elbow, in the presence of a recently healed
osteomyelitis. Thus far there has been no evi-
dence of regeneration in these two cases, and
from the usual experience of others, we expect
none.
CAUSALGIA
The severe pain following nerve injury,
termed by Weir Mitchell causalgia, was quite
uniformly relieved in our series by operation. In
the most severe case, the nerve had been exposed
by operation abroad three times and alcohol in-
jected without relief. In this patient we found
a large fibrous neuroma of the sciatic which
was treated by excision and end to end suture
with complete relief. As a rule, these patients
obtained relief after neurolysis or hersage of the
affected nerve. In two cases, however, severe
causalgia followed hersage. In one case the
ulnar neuroma, possibly from an aroused latent
infection, had doubled in size, although there
had been complete motor return after the opera-
tion. The reflection of a part of the nerve
sheath at the reoperation gave complete relief.
In the second case, the ulnar nerve showed dense
adhesions to the bone and the freeing of the
nerve with the interposition of a muscle flap
likewise gave complete relief. Our experience
suggests that some of the cures attributed to the
injection of alcohol may have been due to the
associated operative manipulation
ASSOCIATED ANEURYSM
In five cases the missile had also damaged an
artery adjacent to the affected nerve and an
aneurism had formed. In one case (axillary)
the artery was ligated, while in the other four
the aneurism was excised and the arterial ends
united by suture, restoring the continuity of the
artery. These operations were associated with
operations on the damaged nerve trtmks and
gave satisfactory results. An additional case, a
diflicult combined neurorrhaphy of the sciatic
nerve and arteriorrhaphy of the femoral artery,
was followed by pulmonary embolism and gave
the only death in the series secondary to opera-
tion upon a peripheral nerve.
POSTOPERATIVE TREATMENT
Of great importance is the proper use of
splints, massage and electricity, both in the pre-
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May, 1921
END RESULTS IN NERVE INJURY— DISCUSSION
539
and postoperative treatment. Dropped hands
and feet should not be permitted to dangle, and
paralyzed muscles should continuously be kept
in relaxation by appropriate splints. After op-
eration flexed joints should not be left for weeks
in plaster, but beginning on the tenth day should
progressively be extended at the rate of two de-
grees on a measured arc each day. Curiously
there is less danger of tearing the nerve apart if
this is done, for the shortened nerve does not
acquire points of strong fixation that interfere
with later elongation. This was well shown in
the case of ruptured nerve transferred from an-
other hospital with the history of having been
immobilized in plaster for six weeks after the
neurorrhaphy.
The best guide as to the condition of an in-
jured nerve is obtained by inspecting the ex-
posed incised trunk. The best early guide as to
returning function is Tinel's sign, the progres-
sive downward extension from the point of in-
jury of tingling produced by tapping over the
nerve trunk. This only shows, however, that
there is some degree of sensory regeneration
and has no quantitative or motor value. The
important examinations are simple but must be
very carefully done. The loss to tactile and
painful impression may be worked out by a
camel's hair brush and a pin, the motor loss by
very carefully stud)ang voluntary contractions
in muscles. The electrical reactions while use-
ful, so lag behind the sensory and motor returns
as to have a limited practical value in determining
the regeneration of a nerve. If regeneration
does not occur within a reasonable time, the
surgeon should not hesitate to reoperate.
DISCUSSION
Dr. Craii]:,es H. Frazier (Philadelphia) : In one
sense it was to the American surgeon's advantage that
we entered the war late and could profit by the mis-
takes of the European surgeons in the earlier period.
In one sense it was to our disadvantage, in that the
material had been so carefully digested that there was
little opportunity to discover new truths. However, a
number of notable contributions were made and I
would particularly emphasize the work of Pollock on
disturbed sensibility, of Carl Huber, in his studies of
the nerve transplant, and of Kraus and Ingham on the
internal topography of nerves. There were others of
less importance, but these three stand out conspicu-
ously as of superior merit
As to the surgical aspects, the early experience of
European surgeons taught us that we should use the
flap operation, should not use tubulization and lateral
implantation and could not use the nerve transplant
with any hope of success in but the exceptional case.
There remained but one operation to be considered
where there was a complete anatomical block, namely,
the end-to-end suture. There has always been an air
of mystery which surrounded nerve repair as com-
pared with repair of other structures and for no rea-
son whatsoever. We know just as much about nerve
repair as bone repair. We know just as much of the
conditions favorable for one as for the other. Ac-
cording to whether these conditions are favorable or
unfavorable will the results be good, bad or indiffer-
ent As a matter of fact the power of regeneration
in the peripheral nerves is very extraordinary and
quite as active as the process of repair and regenera-
tion in other tissues. There are certain factors we
should bear in mind as affecting prognosis. The first
is the question of adequate circulation. Those of you
familiar with circulation of peripheral nerves know
that they receive their blood supply from minute blood
vessels throughout their entire extent and it stands to
reason that when the nerve is conq)letely isolated (as
it so often is in the course of the dissection) from lo
to 20 cm. from its source of nutrition, the process of
regeneration at the time of suture may be seriously
impaired. Another point which we should bear in
mind and always do, is the freedom from scar within
the nerve. Lewis suggests the use of the frozen sec-
tion method of study at the operating table to deter-
mine whether the nerve is free enough from scar
tissue to warrant suture at that level. The third factor
which deserves perhaps more consideration than any
other is the preservation of the nerve pattern. It is
of the utmost importance that there shall be no axial
rotation of the nerve segments at the line of suture.
The more accurate our approximation of the nerve
segments according to their axial plane the greater
the likelihood of restoration of function. These thre'e
factors cannot be emphasized too strongly. Of course,
the most important aspect of the subject is the end
results. Given a group of surgeons, equally familiar
with the principles involved, there can be no startling
difference between the results. This general statement
is borne out by the statistics from the study of the
larger peripheral nerve centers abroad. I find, taking
the French, German and Italian statistics, that there
is no great difference in their percentages of successes
and failures. They run somewhat as follows : Re-
coveries, i6 per cent; marked improvements, 30 per
cent ; improvement 28 per cent ; failures, 32 per cent
The end results of the operation in the peripheral
nerve centers of the American service have not as yet
been computed, but when they are I doubt whether the
percentages will vary much from those above quoted.
We must recognize our limitations and the unfavor-
able conditions that must be contended with. Failure
does not of necessity imply lack of skill or judgment
on the part of the operator, but limitation of the nat-
ural processes of repair under great physical handi-
caps.
Dr. Henry C. WjestervElt (Pittsburgh) : It seems
to me it is worthy of note that three men could ex-
perience the hectic three months that Dr. Babcock,
Dr. Bower and I went through during the war and
come out of it affectionate friends. At Fort McPher-
son we had a better showing of these results and it
was because of that wonderful, cordial, courteous co-
operation. Each man was always on his job, without
interfering, but always cooperating and never was
there a question that was not decided on its merits.
There was an endeavor made in spite of the volume of
work to secure definite accuracy of diagnosis, together
with just as definite accuracy of treatment I am con-
vinced in many of the reports of failures in cases
such as these, that these are the factors which lie at
the bottom of the' failure. It is not enough to have an
accurate diagnosis of the group of muscles involved
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540
THE PENNSYLVANIA MEDICAL JOURNAL
May, 1921
and recommend that they be electrically exercised.
There has been considerate discussion in the papers
of late along these lines. I am satisfied without pick-
ing any quarrel with the physiologists and with the
background of something like 60,000 treatments as the
basis for opinion, that it is because of inaccuracy in
picking out the muscle and inaccuracy of dosage. We
abolished the old rule of thumb. The fact is we never
started it The treatment was tiring of the muscle.
That was the dose whether ten contractions or a hun-
dred and fifty. Furthermore, in regard to the matter
of small muscles, most of this research work has been
done on rabbits or ganglions of frogs. The greatest
difficulty lay in the small muscles of the hand. We
could not get at them. It was just as difficult to get at
them because of the pain of the treatment These are
all things of value in that service without critical as-
pect whatever in that attitude of the profession
towards this work. Again, may I emphasize the co-
operation and courtesy that existed in tiie service with
Dr. Babcock. Is it too much to hope that that Utopian
condition may take root and flourish in civil practice?
Dr. John O. Bovmi (Wyncote, Pa.) : The first es-
sential in the operative treatment of peripheral nerve
lesions is a long incision, exposing the nerve well
above and below the suspected lesion. The second
essential is an appreciation of the exact pathology.
With a simple adherent nerve neurolysis or excision
of the scar, freeing of the trunk with proper inter-po-
sition or approximation of the soft parts is all that is
necessary. Where yellowish degeneration is present
a simple splitting of the sheath is sufficient
In the constricted group, however, if the trunk is
edematous and enlarged the constriction is removed,
the sheath split and the trunk placed in a healthy bed.
If, after splitting the sheath, the nerve trunk at the
constricted area is found to be fibrosed, resection with
end to end anastomosis is necessary. In complete di-
vision with proximal and perhaps distal neuroma,
resection of the neuromas with end to end suture
should be done. Where a partial neuroma exists, com-
plete resection with end to end suture should be done
if the neuromatous mass occupies two-thirds of the
nerve trunk. If less than this, partial suture with
preservation of the remaining healthy fibres may be
attempted.
I should like to call attention to the symmetrical
spindle-shaped neuroma in the continuity of the nerve
trunk. This condition is usually the result of con-
tusion of a nerve trunk, a small hemorrhage having
taken place beneath the sheath. In a small percentage
'ii cases these neuromse are the result of embedded
foreign bodies. These cases with the spindle-shaped
neuroma usually recover with a simple splitting of the
sheath or removal of the foreign body.
The last group is the whitish gray homogenous
group which is indurated and hard and with which we
frequently associate causalgia. In these cases resec-
tion is usually undertaken. Hersage or neurolysis will
not effect a cure.
Dr. Babcock has mentioned the combined operation
and the infection which followed them. Later on in
the work we found that we could do a combined
operation in the same type of case and not have an
infection. This, we believe, was due to the fact that
enough time had elapsed for the causative germ in
most instances, the hsemolytic streptococcus, to become
attenuated.
Dr. Babcock (in closing) : We would take excep-
tion to the statement that the peripheral nerves have
no intrinsic blood supply. On incisii% a nerve that
has been isolated for a considerable distance. Mood
may be observed to flow from the cut ends, while from
the divided sciatic nerve two distinct arteries spout
The presence of intrinsic blood vessels in nerves gavt
us at times considerable hemorrhage during the opera-
tion of nerve suture. The fact that nerves carry a
sufficient intrinsic blood supply to keep them alive is
shown by the regeneration of nerves sutured after
being transplanted to a distance from their original
bed, in order to bridge large defects. In twelve such
cases in which the nerves were taken from their nor-
mal beds and rerouted, by January, 1920, five already
had regenerated to the point of return of motion in
some of the supplied muscles, while with most of the
others, there was sensory improvement, indicating the
downgrowth of sensory neuraxones. It would seem
because of their good intrinsic blood supply that we
can separate a greater length of peripheral nerve with-
out secondary degeneration than nearly any other
tissue.
PERICARDITIS*
GEORGE E. HOLZAPPLE, M.D.
YORK, PA.
This is a disease that is sometimes diagnosed
when it does not exist but exists much more fre-
quently when it is not diagnosed. It is some-
times overlooked because of the absence of symp-
toms and physical signs. It is more frequently
overlooked because it is not anticipated, or for
lack of a careful routine method of examina-
tion. The best clinicians who make careful sys-
tematic examination, at times fail to diagnose
this disease when it is present and this shows
how difficult it may be of recognition. In hos-
pitals where many postmortem examinations are
made, the pathologist usually finds this disease
much more frequently than the attending physi-
cian. If the skillful diagnostician every now and
then fails to recognize the disease it is easy to
understand why some physicians almost never
encounter it. Most of the mistakes in diagnosis
in internal medicine are due to incomplete and
inaccurate histories and incomplete physical ex-
aminations. The up-to-date internal medical
man needs a knowledge of the symptom com-
plex and a ready method of systematic physical
examination that he can apply quickly and with
the same facility that the surgeon applies his
surgical technique in the performance of a
major operation. If every man who does in-
ternal medical work would acquire such knowl-
edge and such skill of investigation, some cases
of pericarditis, as well as many other conditions,
would be recognized instead of wholly over-
looked.
Most of the present-day knowledge of the
'Read before the Section on Medicine of the Medical Society
of the State of Pennsylvania, Pittsburgh Session, October j,
1930.
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May, 1921
PERICARDITIS— HOLZAPPLE
541
diagnosis of pericarditis has been ours for
many years. The most valuable addition to the
subject in recent years is the x-ray and fluoro-
scope. It is a lamentable fact that there are
many men in active practice to-day who have
not at their command the diagnostic knowledge
that was possessed and taught by men like Aus-
tin Flint, St., and some of his contemporaries
forty years ago. In order to make the diagnosis
of pericarditis it is necessary to have a clear
conception of the nature of the disease, of the
tissues commonly involved, and of the variation
in the symptomatology when the inflammation
extends or is associated by the involvement of
neighboring tissues, structures and organs above
and below the diaphragm. It is necessary to
have a clear knowledge of its relation to the vari-
ous infectious diseases in which it is frequently
encountered.
Pericarditis is an inflammation that may in-
volve only the serous layer of the pericardial sac,
but it frequently extends through to the fibrous
layer and to the surrounding structures as well
as to the myocardium and endocardium. It may
be associated with an inflammation of the struc-
tures in the mediastinum, the lungs and pleurae
as well as structures and organs below the dia-
phragm. It is always due to a bacterial invasion,
even in the case of trauma the inflammation is
due to infection. There are few infectious dis-
eases in which pericarditis may not occur, and
while usually associated with infection involving
other tissues it may be the only disease discover-
able. This has happened a number of times in
the writer's experience. The infection may be
carried to the pericardium through the blood ves-
sels or lymphatics.
Pericarditis occurs most frequently in cases of
rheumatic arthritis from the ages of five to
twenty-five. The writer has seen it following
tonsilitis and chorea.-. It may occur and should
be anticipated in any cases of the rheumatic or
streptococcic group. In the writer's experience
it occurred with about the same frequency in
both sexes. It is more prone to occur in the
young who suffer from a chronic endocarditis
with resulting hypertrophy and dilatation. The
resulting tumultous action of the heart predis-
poses to an inflammation of the pericardium.
The same predisposing factor exists in chronic
interstitial nephritis. Here it is often a terminal
infection, and likewise in cases of marked ar-
teriosclerosis. Pericarditis is frequentiy asso-
ciated with pneumonia and pleurisy. In such an
event it is usually due to the pneumococcus or to
the organism that causes the pneumonia or pleu-
risy. It seems more common when the right
lower lobe is involved than the left. It is not un-
commonly associated with endocarditis. I well
recall the teaching of the late Austin Flint many
years ago, that pericarditis seldom occurred
without endocarditis, but that endocarditis often
occurred without pericarditis. I do not believe
that observations since the time of Flint cor-
roborate this teaching. Endocarditis and peri-
carditis perhaps never occur without a certain
amount of myocarditis. The latter pathological
condition is of the utmost prognostic signifi-
cance, for the more marked the associated myo-
carditis the graver the outlook. An acute myo-
carditis is a very serious condition in any infec-
tion. In pericarditis there is not only danger
of an acute dilatation and death from an asso-
ciated myocarditis, but in the presence of an
extensive effusion a badly diseased myocardium
may not be able to overcome the pressure of the
fluid during diastcrfe. The danger of an exten-
sive effusion is the pressure of the fluid on the
auricles and great vessels at the base, interfer-
ing with the filling of the heart with blood dur-
ing diastole. This danger is much increased if
there is much myocarditis. This leads to venous
engorgement and a feeble pulse. Under such
circumstances every possible source of cardiac
strain should be prevented. A mild attack of
pericarditis, like that of pleurisy and peritonitis,
may exist without symptoms or signs and this
explains the postmortem findings at times of
adhesions without a history of having previ-
ously suffered from any one of these conditions.
Pain in pericarditis is no prominent symptom
until the inflammation reaches the fibrous layer
of the pericardial sac which is richly supplied
with nerves. In every case of rheumatism, ton-
silitis, pneumonia and pleurisy the heart should
be examined carefully every day and the possi-
ble existence or development of pericarditis
should be anticipated. The onset and course of
pericarditis is sometimes . very insidious and if
not anticipated is easily; overlooked. It is very
important to note carefully the daily changes in
the physical signs over the precordia, for only
in this way may the onset be detected and a cor-
rect diagnosis made.
The symptoms that may be encountered in a
case of pericarditis are usually some fever, pain
and tenderness in the region of the precordia, a
sense of constriction and oppression in the
chest, a feeling of anxiety that is sometimes very
manifest, more or less dyspnea, at times orthop-
nea, an improductive cough, sometimes dys-
phagia from pressure on the esophagus, at times
painful swallowing from pressure of a bolus of
food against the inflamed pericardial sac, im-
pairment of the voice or aphonia from irritation
or pressure of the left recurrent laryngeal nerve.
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THE PENNSYLVANIA MEDICAL JOURNAL
May, 1921
nausea and vomiting and at times slowing of the
pulse from irritation of the vagus, and hiccough
from irritation of the phrenic. There may also
be present engorgement of the veins of the neck,
and in very bad cases general venous engorge-
ment, with marked enlargement of the liver and
spleen, ascites, venous engorgement of the lower
extremities and edema and a diminished secre-
tion of urine, a feeble and irregular pulse and
low blood pressure. There is often a para-
doxical pulse with cyanosis and at times in some
cases paroxysms like true angina pectoris. The
latter is probably due to involvement of cardiac
plexus and may prove fatal. Sleep is usually
greatly disturbed by pain and restlessness. In
addition to these symptoms we may find at the
beginning fixation of the diaphragm from pain
and later from an effusion or cardiac dilatation, a
prominence of the precordia, a diffuse visible
cardiac impulse, most marked usually in the
third and fourth left interspaces. When there
is much effusion there is fullness of the inter-
costal spaces, most marked on the left side of
the sternum, also a fullness along the left costal
border in the epigastrium from a depression of
the diaphragm and left lobe of the liver by the
fluid in the pericardial sac. When there is much
compression of the lung there is limitation of
chest expansion on the left side. From the pres-
ence of an effusion or cardiac dilatation there is
an increase in the area of cardiac dullness. If
this is due to an effusion the outline of the area
of dullness may change with a change in the
position of the patient. When the patient is
sitting the base of the triangular area of dull-
ness is below with a rounded apex above. In
a very marked accumulation of fluid in the peri-
cardial sac the upper limit of cardiac dullness
reaches higher and is wider than that found in
cases of simple cardiac dilatation. The upper
limit of dullness may reach to the third or even
to the second costal cartilage. As the fluid
exudate increases in the pericardial sac there is
usually a change in the outline of the cardio-
hepatic angle in the right fifth interspace and it
soon becomes obtuse. There is also a perceptible
approximation of the superficial and deep areas
of cardiac dullness due to the compression of
the lung that borders on the pericardial sac.
The compressed lung can usually be demon-
strated by the Skodiac resonance or tympany in
the left infraclavicular region, and the physical
signs of atalectasis are still more marked in the
left infrascapular region by the dullness or flat-
ness on percussion and the bronchial breathing
and bronchophony.
One must be careful not to mistake an atalec-
tasis for a pneumonia. If the effusion is large
the apex impulse, if perceptible, will be felt in-
side of the outer limit of cardiac dullness. This
physical sign should be studied very carefully
from day to day, for it is perhaps the most
valuable physical sign in differentiating a peri-
cardial effusion from a very marked cardiac dil-
atation. As the effusion increases the cardiac
and apex impulse become enfeebled and may
finally be lost. They may not be perceptible in
the recumbent posture but may reappear if the
patient is raised and made to lean forward. If
the area of cardiac dullness has been much in-
creased, and the apex impulse corresponds to
the left lower limit of cardiac dullness we can be
quite certain that very little or no effusion exists,
even in the presence of a pericardial friction
murmur. In such a case the area of cardiac
dullness is likely due to cardiac dilatation and
the friction rub due to pericarditis, sicca or to
an inflammation in the anterior mediastinum —
the friction sound caused by the enlarged heart
beating against the inflamed area.
The most valuable diagnostic sign is the peri-
cardial friction rub or murmur which is usually
audible and sometimes palpable. The character
of this friction rub is not easily learned from
the description given in books. When once
heard it is usually recognized afterward. Laen-
nec was the first to observe it and he described
it as resembling the sound of a creaking saddle.
It may be imitated fairly well by placing the
palm of one hand over the ear and by scratching
the finger nail to and fro on the back of the
hand. The murmur is, however, not always the
same and it must be heard repeatedly to become
familiar with its variable character. It may be
heard anywhere over the whole precordia. It
may be heard only in the beginning of the at-
tack. It may be heard on some days and not on
others. If an effusion occurs separating the
pericardial layers it usually disappears first in
the lower part of the precordia, and is heard last
over the base of the heart where the great ves-
sels issue from the pericardium. Here the
pericardial layers remain in contact longer than
anywhere else when an effusion occurs.
In pericarditis with a plastic exudate, the
myocardium may be so profoundly involved that
it results in great dilatation, increasing very
much the area of cardiac dullness, attended by
very feeble heart sounds; the impact of the
heart against the chest being perceptible over
only the most prominent portion of the heart,
well inside the left limit of cardiac dullness,
causing it to appear like a case of effusion,
whereas the increased area of cardiac dullness
is wholly due to dilatation of the heart. Rotch
and Ewart regarded dullness in the right fifth
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PERICARDITIS— HOLZAPPLE
543
interspace as evidence of an effusion, but Broad-
bent found it in a number of cases and on post-
mortem there was no effusion, but only a dilated
heart with adherent pericardium. The bound-
ary of dullness of an effusion is usually more
abrupt than that of a cardiac dilatation or en-
largement. The change from a flat percussion
note over an effusion to that of a resonant one
over the lung is usually sudden. Increasing
weakness of the cardiac impulse until it is finally
lost, and growing enfeeblement of the heart
sounds with a rapid increase of the area of car-
diac dullness, are indicative of pericardial ef-
fusion.
If the friction murmur continues over the
lower part of the precordia in the presence of
a large effusion it usually indicates adhesions
binding the heart to the anterior layer of the
pericardial sac. This friction rub is usually
superficial and is heard with greater intensity
by a gentle pressure of the bell of the stetho-
scope. Strong pressure may obliterate it. The
friction murmur is usually double and does not
correspond exactly to systole and diastole.
When heard over one of the valvular areas it
must be distinguished from endocardial mur-
murs. The latter are not intermittent and sys-
tolic murmurs are transmitted beyond the pre-
cordia. Pericardial friction murmurs are not
often heard with greatest intensity over a valvu-
lar area, and are not transmitted beyond the
precordia. When heard over the mitral area it
may have to be distinguished from the thrill of a
mitral stenosis. The latter has a vibratory char-
acter which the friction rub lacks. If the fric-
tion rub is heard along the left border of cardiac
dullness it must be distinguished from a pleuro-
pericardial murmur. The latter is usually
greatly modified by either deep inspiration or
expiration. In the presence of a pleurisy a fric-
tion rub is often heard beyond the precordia.
The friction rub may be absent in the presence
of a pericardial inflammatory exudate when the
latter is very soft and the heart action feeble.
If the friction rub is absent in the recumbent
posture it may be present if the patient is raised
and leans forward. Graves and Stokes tell us
that the serous membrane of the pericardial sac
may at times become so dry and lose its smooth-
ness so that in case of cardiac hypertrophy the
increased heart action may cause a friction
murmur. The writer has never met such an in-
stance.
The diagnosis of acute pericarditis is usually
simple in the young with a thin chest wall but in
stout individuals and in women with large
mammae it may be difficult.
The differential diagnosis between pericardial
effusion and cardiac dilatation is at times not as
easy at the bed-side as one might imagine from
the reading of books. The x-ray or fluoroscope
may show the presence of an effusion and enable
us to distinguish it from a cardiac dilatation. It
may show packets of encapsulated fluid and
even the presence of mediastinal adhesions. In
attempting to diagnose pericarditis one must
keep in mind the numerous other conditions in
the chest wall, in the chest, in the mediastinum,
above and below the diaphragm that give rise,
at least in part, to the same symptomatology.
If the case is obscure one must study carefully
the variable pathological significance of every
symptom and physical sign that may be present,
and by a careful exclusion a correct diagnosis
can often be made. I have met cases repeatedly
that were wholly overlooked or mistaken for
some obscure painful condition of the stomach.
I do not know of any other important and com-
mon disease that is so frequently unrecognized
as pericarditis.
The treatment of a case of acute pericarditis
depends on the nature of the case. Absolute rest
should be enjoined mentally and bodily to re-
duce the heart's action. An ice cap to the pre-
cordium is usually very soothing and acts as a
cardiac sedative. The writer has seen decidedly
better results from the application of a half
dozen or more leeches over the region of the
heart, and this followed by hot poultices, than
from any other local measure. It is remarkable
how rapidly a large effusion may disappear, and
a patient who was suffering from orthopnea,
having a rapid, irregular, almost imperceptible
pulse become comfortable, able to lie down,
breathing easily and having a good pulse. Blis-
ters to the precordia may also be applied to pro-
mote absorption of an effusion.
When these measures do not suffice to bring
about absorption and there are dangerpus symp-
toms from pressure, paracentesis of the peri-
cardium is indicated if the effusion is serous or
serofibrinous and free incision and drainage
if the exudate is purulent. Morphin or codein
is indicated if needed for pain and restlessness.
The writer has been in the habit of giving some
form of digitalis as soon as the pulse shows
signs of becoming feeble. The bowels should
be kept well open, and the diet nutritious and
easily digested. It is well not to allow too much
liquid for fear of favoring a large effusion. In
pericarditis following or associated with in-
fectious, arthritis, tonsilitis, chorea or any one
of the rheumatic group the writer institutes at
once antirheumatic treatment, preferably so-
dium salicylate with potassium citrate. Severe
purging and potassium iodide are of doubtful
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THE PENNSYLVANIA MEDICAL JOURNAL
May. 1921
utility. Ill tuberculous pericarditis with effusion,
repeated tapping may result in the prolongation
of life.
DISCUSSION
Ds. Arthur C. Morgan (Philadelphia) : It is al-
ways well for us to have a frequent review of some
of the classical affections such as Dr. Holzapple has
given us. A survey of the old established symptoms
of any affection is its practical application, as it will
recall to your mind some cases in which they apply,
especially in severe cases of acute articular rheuma-
tism. The obscure symptomatology and changeable
physical signs in pericarditis can be well explained by
the analogy which applies to the involvement of the
joints in the course of rheumatic fever. The affected
joint may be intensely inflamed, and in a few hours
or a couple of days it may be fixed because of this
intense inflammation and pain. The affected part,
almost in a twinkling of an eye and frequently over
night, may clear up entirely, leaving the previously af-
fected joint apparently normal; likewise the peri-
cardium may be similarly affected for a time. Then
clearing up may take place with extension of the
process to some other serous membrane.
I have seen a few cases of acute articular rheuma-
tism in which there was for a time a rheumatic
pleurisy accompanied by effusion. By refraining from
tapping and allowing the case to proceed, we some-
times have a marvelously rapid absorption of exudate
over night in the same manner that the rheumatic in-
flammation will sometimes leave an affected joint
The indications, therefore, in the case of articular
rheumatism in which the signs of sudden accumulation
of fluid in the chest occurs, would be, unless symptoms
of marked medianical embarrassment of circulation
or respiration occur, to let the fluid alone, because of
the great likelihood of resorption in these cases.
Simply because you find a fluid, temper your judgment
with caution and do not tap unless urgent symptoms
for interference present themselves.
Dr. Holzapple should perhaps have mentioned and
emphasized a little bit more the role of tuberculosis in
connection with the etiology of pericarditis. In the
hospital, where we are dealing chiefly with tubercu-
losis patients, we have not made a diagnosis of peri-
carditis ante mortem in many cases because of the
insidious onset and absence of sharp pain for the
reason that nonsensory nerves are involved and be-
cause of the rare condition of great effusion compli-
cating these tuberculosis cases. However, when we
find a very extensive patch of pleurisy involving the
upper left chest anteriorly, or the second or third right
interspace, as Dr. Holzapple has mentioned, we can in
a majority of instances make the deduction that at
autopsy we are going to find pleuro-cardial adhesions.
In the cases of marked effusion, whether pleural or
pericardial, we have found in some cases that the pa-
tient frequently wakes suddenly just after falling
asleep, whether or not there is a hypnotic, complaining
bitterly of a sense of heaviness and weight around the
zone of the diaphragm. This is not accompanied by
sharp pain, but seems to be due to a mechanical evi-
dence of the fluid pressing downward on the dia-
phragm just when relaxation of the muscles takes
place that had been held in tonic contraction during
the waking moments. This we have found to be a
very suggestive symptom, which has caused us to look
for physical signs of fluid.
SOME SUGGESTIONS FOR THE TREAT-
MENT OF HYPERTHYROIDISM*
FREDERICK B. UTLEY, M.D.
PITTSBURGH
The normal fimction of the thyroid gland as
given by the various physiologists and investi-
gators is its control over cell growth, calcium
metabolism, catabolism and the antitoxic and
immunizing action against the products of the
body's own metabolism as well as those result-
ing from the invasion of disease-produdng or-
ganisms. Its antitoxic properties are its chief
function and, in connection with its control over
cell growth and cell metabolism, it regulates tiie
defensive mechanism of the body.
An increase in the activity of the gland causes
an increase in its size. In fact, a measure of
the activity of the gland is the degree of paren-
chyma hyperplasia together with the amount of
secretion lying between the cells and in the
lymph spaces. Perhaps the most common ex-
emplification of the increased f tmction and the
associated increase in size of the gland is that
seen at puberty in girls, and during pr^nancj
in women. This, imder normal conditions, is
regarded within physiological limits A similar
increase is often noticed in variotis acute infec-
tions. A persistence in the hyperactivity of the
gland, 'however, results in more or less perma-
nent damage to the gland with such symptoms
as rapid heart action, tremor, nervousness, and
in many cases exopthalmos, giving the complete
picture of exopthalmic goitre. These symptoms
are not due alone to the action of the thyroid
but in part to the adrenals and the pituitary
which have been shown to interact with the thy-
roid, and also to the direct toxic effect of the
agent serving as the etiological factor in each
case. Abnormal action of the thyroid gland is
seen in unsanitary surroimdings, bacterial or
parasitical invasions, the acute infectious dis-
eases, intestinal stasis, and the emotions such as
fright, grief, worry, mental distress, etc.
That tmsanitary surroundings will cause ab-
normal action of die thyroid gland has been well
shown by Marine, Lenhardt and Gaylord in
artificially bred trout in tanks superimposed
upon each other so that the concentration of the
pollution in the tanks of lower level is greater
than that at a higher level. This has also been
shown for man by McCarrison in towms in the
Himalayas situated at lower levels on the same
streams containing goitrigenous water.
The bacteria exerting the greatest influence
belong to the B. Coli group which are seen also
'Read before the Section on Uedicine of the Medical Soci<<T
of the State of Pennsjrlvania, Pittsburgh Session, October s.
■ 920.
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TREATMENT OF HYPERTHYROIDISM— UTLEY
545
to cause trouble in cases of intestinal stasis,
which has been shown so often by Lane. In-
testinal parasites also will often give rise to
thyrotoxic symptoms.
Practically all of the infectious diseases may
have a deleterious effect on the thyroid gland;
especially syphilis, tuberculosis, pyorrhea alveo-
laris and chronic tonsilitis.
The emotional or psychic influences have been
notably considered by Crile, and in the more
extreme cases these influences not only call into
play the thyroid gland but also the adrenals,
resulting in the continuous fear with the star-
ing eyes, rapid pulse, rapid breathing, tremor,
general excitability or the characteristic features
of Graves' disease. It is not believed that these
symptoms are caused by the emotions alone, but
rather that they are an increment added to the
more fundamental nutritional, bacterial and in-
fectious etiological factors in the development
of the symptoms usually seen in cases of hyper-
thyroidism or Graves' disease.
Overactivity of the thyroid apparatus due to
any of the above etiological factors results in
increased size, thicker capsule, irregular vesicles,
thickened arteries, veins and lymph vessels.
With successive attacks, the colloid finds its way
out more difficult, and hence there may be a re-
tention resulting in the cystic goitres. Or,
there may be rounded masses of cell prolifera-
tion resulting in adenomata. In other cases, the
overactivity goes on without rest, ending in
Graves' disease. The accumulation of demand
results in a diminution of iodine which is fol-
lowed in turn by hyperplasia and enlargement
as above noted. The alpha-iodine of Kendal in
cases of exopthalmic goitre is reduced to about
1/15 normal. Here is a suggestion for therapy
in these cases which will be taken advantage of
later.
In the treatment of thyroid diseases, it is un-
derstood, of course, that cysts, adenomata,
fibromata and calcification of the thyroid are
not amenable to medical therapy but require
surgical procedures on the gland where indi-
cated. In all other abnormal manifestations of
the thyroid gland it is believed that surgery is
indicated primarily as a means of eradicating
the etiological factors such as appendix, gall
bladder, tonsils, teeth, infected genito-urinary
tract, etc. A thorough review of all possible
etiological factors, nutritional, toxic and psychic
is incumbent, and each and every one should be
completely removed. With this procedure, it
is surprising how completely and how rapidly a
thyroid gland may be restored to a compara-
tively normal function. But such restitution
depends upon the degree of the abnormal proc-
ess, the time it has existed, the degree of cell
death and fibrosis, and to the damage done to
the other parts of the body secondarily, namely,
heart and skeletal muscles, the nervous system,
the eyes and the associated endocrine glands,
particularly to the adrenals and to the pituitary.
Hence the importance of recognizing early any
abnormality in the thyroid gland and its func-
tion, and the thorough elimination of every etio-
logical factor pertaining thereto. And it is be-
lieved that most cases seen sufficiently early
are amenable to this treatment.
There may be some doubt in well-developed
cases of exopthalmic goitre. These cases should
be rested in bed in quiet, congenial surround-
ings, and an endeavor made to determine every
etiological factor, nutritional, toxic or psychic.
Every nutritional and psychic cause can and
should be eliminated immediately. The elimina-
tion of the toxic factors will depend upon the
condition of the patient and his ability to with-
stand the shock of the necessary operations. In
the older cases or the fulminating ones, it is ex-
pedient to lessen the drive at once by appropri-
ate surgery upon the gland, and to wait for the
temporary improvement in the general physical
condition before subjecting the patient to the
shock of an operation necessary to eradicate the
focus of infection. Even then some of these
cases may be lost through the development of
fulminating thyroid symptoms after operation.
This is not a censure of the procedure but a
censure of the patient, family or physician who
did not recognize the condition early and insti-
tute proper treatment before a state of organic
exhaustion developed, precluding any safe sur-
gical procedure whether it be on the thyroid
gland itself, or other parts of the body.
If it could be demonstrated that the overac-
tivity of the thyroid gland alone is responsible
for the clinical manifestations grouped under
the term exopthalmic goitre or Graves' disease,
then the ligation of its blood supply, or the re-
moval of the gland in part could be regarded
rational therapy. But it has been shown that
the alpha-iodine of Kendal or the thyroxin
when injected will not produce the picture of
exopthalmic goitre. It takes this plus the over-
active adrenals and possibly the pituitary to pro-
duce the complete picture of exopthalmic goitre.
It has further been shown that everything which
will cause the excitation of the cervical sympa-
thetic will cause the complete picture. The in-
jection of amins will also cause the same.
Amins are produced largely by protein catabol-
ism in the gastro-intestinal tract which is seen
in intestinal stasis due to any cause. Here, then,
is a strong therapeutic stiggestion. SeY^h dili- 1
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THE PENNSYLVANIA MEDICAL JOURNAL
May, 1921
gently the entire gastro-intestinal tract by every
known medical means for evidence of derange-
ment ; not only this, but other parts of the body
which may affect the gastro-intestinal tract re-
flexly, notably the teeth, tonsils and the genito-
urinary tract.
That the removal of a part of the thyroid
gland results in improvement, even marked im-
provement in some cases, there is no doubt.
This may be on the ground that the thyroid se-
cretion in these cases has been altered in some
way, and rendered more toxic by the action of
the bacteria or their toxins. By the operation
part of the toxic load the body is carrying is
removed. However, the removal of the supply
of one of the essential agents in the body
economy, instead of the bacterial toxic agent
which is harmful not only to the thyroid but
more or less so to all the rest of the body, must
be regarded as a poor practice of medicine and
is to be deprecated. It seems as illc^cal as it
would be to remove the carburetor from a
trembling, vibrating automobile whose engine is
racing madly. The remaining small portion of
the gland following operation can carry on the
necessary function for the body for a period of
time in the presence of the stimulating factors
thus causing a hyperplasia of the gland. But
Granger has shown that the usual cycle from the
development of hyperthyroidism to hypothy-
roidism spans on the average six years. Follow-
ing the thyroid surgery the same etiological
factor is ever at work upon the rest of the body,
and sooner or later all of the symptoms of thy-
roid priva manifest themselves. In other words,
without the removal of the etiological factors
causing hyperthyroidism these cases pass into
an asthenic state with worn out heart, skeletal
muscles, and nervous system and finally end in
death. Every case whose gland has been re-
moved, and whose irritating foci of infection
have subsequently been removed runs so much
the greater risk of developing a myxedema re-
quiring the feeding of thyroid extract ever after;
providing the patient is fortunate enough to be
under the care of a physician who recognizes the
condition. If he is less fortunate, he will grow
progressively more asthenic, finally ending in
invalidism and death.
The treatment, then, for hyperthyroidism
would be rest in bed in congenial surroundings
with an abundance of fresh air and nourishing
food, the removal of all etiological factors —
psychic, nutritional, toxic — an ice bag to the
gland and heart when well tolerated, no mor-
phine or bromides except the neutral hydro-
bromide of quinine grs. 5, t. i. d. as suggested
by Jackson and Meade of Boston. In those
cases who have lost considerable weight calcium
chloride grs. 10, t. i. d. or sodium phosphate
drams J^, t. i. d. seems to make up the deficit
of calcium and phosphorus salts and to improve
the metabolism. The gastro-intestinal symp-
toms should receive prompt and definite atten-
tion, and every method of study at our com-
mand should be employed to determine the
cause of the gastro-intestinal symptoms. If
surgery is indicated to correct the fault, it should
be employed. If this fault cannot be corrected
by surgery, such medical measures as are indi-
cated plus the administration of an intestinal
antiseptic such as beta-napthol, thymol or salol
will repay one for the effort.
Syrup of the iodide of iron is useful, the
iodine causing an increase in the available
iodine for the thyroid and for metabolism, a
reversion to the colloid state by the lessened
demand on the thyroid for iodine, and a de-
crease in the blood supply of the gland. In the
milder cases give m. 5, b. d. p. c. while in the
severe cases give m. 5, o. d. and increase the
dose in each type of case as indicated. Greater
dosage is apt to increase the thyroid activity
rather than to lessen it.
Surgery upon the gland should be practiced in
those cases where it is expedient to remove the
drive at once, when the removal of foci should
follow.
The following case history is submitted :
C. C. female, aged 33, white, and a nurse by
occupation, was admitted to St. Francis Hos-
pital, February 25, 1920, suffering from exop-
thalmic goitre complicated with an attack of
acute rheumatic fever and pericarditis.
The past history revealed scarlet fever and
typhoid fever at three years, measles at six
years. One year ago she noticed a failure in her
strength and was told that her eyes were promi-
nent.
Four months before her admission to the hos-
pital the eyes were very prominent, the thyroid
was considerably enlarged, the pulse was rapid,
being easily accelerated with slight excitement,
and there was considerable nervousness with
tremor. At this time an x-ray picture of her
upper teeth showed six apical abscesses together
with a considerable pyorrhea alveolaris. The
patient was urged to have the teeth showing ab-
scesses extracted. She, however, refused on
the ground that she had one year previonsly
spent a considerable sum for the crowns and
bridge work.
When seen, the following findings were
noted: T. 102 F., P. 156, R. 24. The patient
looked acutely ill and very toxic. There was a
marked exopthalmos, the palpebral fissure was
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TREATMENT OF HYPERTHYROIDISM— DISCUSSION
547
widened, the brows wrinkled slightly, the upper
lids lagged and followed the eye balls downward
inaccurately, and convergence was poor.
The tongue was moist, lightly coated, and
tremulous. Many teeth were absent. Most of
the upper teeth remaining were crowned or car-
ried bridge work. The gums were acutely in-
flamed at the margins, and pus could be ex-
pressed in places. The lower teeth and gums
were in fairly good condition. The tonsils were
small, deeply buried and did not look diseased.
The thyroid was considerably enlarged, sym-
metrically so, and showed the transmitted pul-
sation from the carotids. There was no bruit.
The circumference of the neck over the thyroid
was 35 c. m. The superficial lymph-nodes were
normal.
The heart showed the following: The apex
impulse was in the fifth interspace lo c. m. to
the left of the median line. The left limit of
dullness in the fifth interspace was 11.5 c. m.,
the right limit in the third interspace was 3.5
c. m. The action was regular, rapid, 156 to the
minute. Over the sternum opposite the second
and third interspaces and just to the left a peri-
cardial friction rub was easily heard. The blood
pressure was not taken because of the extreme
pain caused on movement of the arms. The
lungs showed a few scattered rales. The abdo-
men was normal with no tenderness or masses.
The joints of the hands, wrists, elbows, shoul-
ders and left knee were red, hot, swollen and
tender.
Course: The six infected teeth were ex-
tracted thirteen days after admission. Ten days
after the extraction, all joint pains had disap-
peared, the patient was less nervous, the tachy-
cardia less, the thyroid was smaller and the
exopthalmos less. From this time on the rheu-
matic arthritis and pericarditis rapidly cleared.
April 12, or a month later, the patient's father
died while she was still in the hospital. This
grief caused an exacerbation of all her exop-
thalmic goitre symptoms. She returned to the
hospital after the burial of her father to re-
sume her rest and medical treatment, and left
May 27, having been up and about for two
weeks with a pulse 70-80, no nervousness or
tremor, the goitre smaller, and the exopthalmos
less.
She was seen again August 26, 1920. She had
been on duty, nursing, for four weeks. Her
emotional and nervous stability was normal,
pulse 76, the circumference of the neck was 32
c. m. or 3 c. m. less than at the time of admission
as a patient, and the eyes were practically nor-
mal in every way. She regards herself cured
and she certainly appears so.
The teeth were extracted as a therapeutic
measure for the arthritis and pericarditis, the
exopthalmic goitre receiving at the time second-
ary consideration. The result has been all the
more striking, as the correct therapeutic meas-
ure was applied in this case for another exist-
ing group of symptoms.
It has been our fortune to have cases illustrat-
ing most of the other etiological factors above
noted, and the results have been equally gratify-
ing. In the words of McCarrison : "If we seek
the sources of infection we shall find them, and
if we remove them sufficiently early nature will
remove Graves' disease."
SUMMARY
1. The normarf unction of the thjroid gland
is believed to be its control over cell growth,
calcium metabolism, catabolism, antitoxic and
immune bodies.
2. The continued response of the thyroid
gland to abnormal stimulation finally results in
hyperthroidism with its various symptoms.
3. An early recognition of any abnormality
of the function of the thyroid gland is essential,
and all possible etiological factors, nutritional,
toxic and psychic, should be eliminated as
promptly as the patient's condition permits.
4. Surgical procedures should be directed
toward the etiological factors and not the gland
proper except in those cases where it is expedi-
ent to spare the patient at once from the drive
of the overactive thyroid when the removal of
foci should follow the surgery on the gland.
5. Further treatment consists of rest in bed
with suitable surroundings and diet, and the ad-
ministration where indicated of the neutral hy-
drobromide of quinine, calcium chloride, sodium
phosphate, intestinal antiseptics and the syrup of
the iodide of iron, the latter in small, properly
guarded doses.
DISCUSSION
Dr. Lawrence Litchfield (Pittsburgh) : Dr. Utley
has done well to emphasize the importance of consid-
ering the patient herself, and not merely the local dis-
turbance which may at the time be most prominent
That there is in many cases an association between
foci of infection and thyrotoxicosis is most probable.
To have cases react so promptly and favorably aftei
removal of such foci, as Dr. Utley's case has done, is
most rare. Personally, I have never seen it; the
nearest that I have come to it has been an immediate,
though but partial recovery from thyrotoxicosis, after
the use of neo-salvarsan, as indicated by a positive
blood Wassermann.
It seems evident that we have not yet gotten the
whole story of the etiology of so-called "thyroid dis-
turbances." We do not even know that these dis-
turbances originate in the thyroid gland, but we do
know that they are profoundly influenced by the
activity of the thyroid, and oftentimes by the thera-
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THE PENNSYLVANIA MEDICAL JOURNAL
May, 1921
peutic use of thyroid products. Why is it that the re-
cent epidemic offered us post-influenzal cases of hyper-
thyroidism so-called, and other cases with equally
definite hypothyroidism? It must be because there is
a factor in the production of thyrotoxicosis which we
cannot yet define. Why do some cases, immediately
after thyroidectomy for hyperactivity of the thyroid
gland, or during the x-ray treatment for the same,
show immediate improvement when fed, at short in-
tervals, a few grains of thyroid nucleo-protein?
In the management of a case of thyrotoxicosis, after
all possible foci of infection have been removed, after
the digestive organs and diet have been regulated, the
parents or husband tactfully but forcefully instructed
as to the effects of psychic traumata, and an enforced
rest with the best attainable environment has failed to
give definite evidence of improvement within a month,
what is to be done? A study of these cases will usu-
ally show a mixture of the signs. and symptoms of
hyper- and hypo-thyroidism. It is*on this account that
I much prefer the term of thyrotoxicosis for these
cases, but whatever term is employed the findings must
be carefully analyzed before treatment is undertaken.
If hyper symptoms predominate, such as flushed face,
rapid, nervous, pounding heart action (without cardiac
dilatation), alert nervous restlessness or apprehen-
sion, profuse perspiration, an excessive appetite, and
possibly salivation and diuresis, with a recently ac-
quired exopthalmos, and the usual eye signs, Geoffrey,
von Graefe, Moebbus, etc., under these circumstances
we try to inhibit the thyroid activity by adrenal
therapy, which seems to have an influence in rare
cases, or by the long-continued application of suitable
x-ray treatment, at intervals of from five to fourteen
days. If this fails to give satisfactory results, we
must refer our case to a surgeon for the removal of
more or less of the gland. If, however, the enlarge-
ment of the thyroid and the exopthalmos have existed
for a long time as well as the tremor, if the skin is
dry and pale, the extremities cold, and the patient
complains of anorexia, constipation, headache, oppres-
sion in the chest, extreme weariness, lethargy, loss of
memory, loss of hair, possibly even some myxedema,
and a rapid pulse which can be accounted for by a
chronic cardiac dilatation, under such conditions the
thyroid is insufficient and further inhibition, or an
ablation of part of the gland would be disastrous.
On the contrary, the "thyroid drive," as Rogers calls
it, should be increased by feeding thyroid gland, or
its derivatives. Yet how often is the diagnosis made
of hyperthyroidism, and an operation recommended
because of a large thyroid gland, exopthalmos, tremor,
and tachycardia — signs which taken individually- or
collectively are not necessarily indicative of hyperac-
tivity of the thyroid gland, although they may have
been associated previously with such hyperactivity.
The point I wish to emphasize is the importance of
a careful unraveling of the signs and symptoms, and
the application of vagus drive or sympathetic check, or
both at once, according to the findings. Whether the
hyper or hsrpo influences predominate will be best
shown by a study of the basal metabolism ; and one of
the most valuable additions to our armamentarium
is the development of clinical methods of determin-
ing the basal metabolism, and its application to the
differentiation of these cases. I wish to stress also
my strong conviction that the x-ray treatment should
be thoroughly tried, before surgery is resorted to and
that cases that are cured by the x-ray treatment are
just as well cured as those that have been cured by
surgical operation, and that inasmuch as the x-ray
cure is a matter of repeated applications, with consid-
erable intervals between them extending over a period
of months — possibly a year or more — there would
seem to be much less danger of reducing the thyroid
gland more than necessary.
I have, at the present time, seven cases under x-ray
treatment, and all are improving. One case was greatly
benefited by several injections of neo-salvarsan, hav-
ing had a positive blood Wassermann, and another has
been greatly benefited by the exhibition of thyroid
nucleo-protein, because of the association of hypo
symptoms.
In considering thyrotoxicosis, we must not forget
that prophylaxis is better than cure, that there is a
possible predisposition to Basedow's disease in simple
goiter, and that Marine has demonstrated that simple
goiter in school children can be prevented and removed
by the very moderate use of the iodides.
Dk. Uhey (in closing) : I was pleased to have Dr.
Litchfield paint the picture of the burnt-out thyroid
which so often comes to surgery with disaster. I saw
that happen last spring. It only tends to emphasize the
value of early diagnosis of thyrotoxicosis.
The x-ray treatment of the thyroid gland, as Dr.
Litchfield has brought out, is a valuable therapeutic
measure. His own series of cases is too convincing
to overlook. However, I have under my care at the
present time a g^rl eighteen years old with marked
thyrotoxic symptoms who had been treated with the
x-ray for two months. She gave a definite history
of exacerbation of all of her thyrotoxic symptoms fol-
lowing each treatment by the x-ray which exacerba-
tion continued throughout the interval between treat-
ments. These exacerbations were also observed by the
family physician. In the hands of a skilled radiogra-
pher it is unquestionably a valuable therapeutic agent
But in the hands of many men who are using the x-ray
throughout the country, it is apparently dangerous.
Basal metabolism is of value in determining the de-
gree of thyrotoxicosis existing in a given patient so
that one may outline the best therapeutic measures to
be followed. Further basal metabolism observations
will determine the efficiency of the therapeutic meas-
ures adopted, but of course the metabolism studies are
not a direct therapeutic agent in themselves.
OVARIAN PREGNANCY WITH REPORT
OF A CASE
SIDNEY A. CHALFANT, M.D., FA.C.S.
PITTSBURGH
There have been several very complete re-
views of the literature on this subject. In 1908
Norris and Mitchell' found fifteen positive
cases, all of three months or shorter duration,
fifteen highly probable cases, twelve of which
were at term, and nine fairly probable cases.
Norris in 1909^ reported a second case that
was combined with an intra-uterine gestation.
This was especially interesting in that there had
been an ovarian pregnancy that had developed
to five months, died, and remained in situ. The
*Read before the Section on Surgery of the Medical Society
of the State of Pennsylvania, Pittsburgh Session, October 7,
1930.
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OVARIAN PREGNANCY— CHALFANT
549
intra-uterine pregnancy had occurred later and
had developed to about three months at the time
of operation. Williams in 1908* considered
thirteen cases positive and seventeen highly
probable. Lockyear* in 1917 reported two cases
and again reviewred the literature and in 1919
Meyer and Wynne' brought the subject up to
date. There does not seem to be any authentic
case reported in the past year.
The criteria as suggested by Spiegelberg* in
1878 have been generally adopted. According
to him ( I ) the tube on the affected side must be
intact, (2) the fetal sac must occupy the posi-
tion of the ovary, (3) it must be connected to
the uterus by the utero-ovarian ligament and
(4) definite ovarian tissue should be foimd in
the sac wall. Williams' modified this last point
by suggesting that ovarian tissue should be
found in several places in the sac wall at some
distance from each other. Norris' suggests that
the tube shall be microscopically as well as
macroscopically normal. In examining a case
of supposed ovarian pregnancy he found fetal
structures in the tube, showing that in this case
the pregnancy had been primarily tubal.
Ovarian pregnancy apparently occurs by fer-
tilization of the ovum in the graafian follicle.
Mall and Cullen* report a case in which luteal
cells surround the gestation sac. Some observ-
ers have claimed that the fertilized ovum in-
vaded the ovary from its surface. The case
we have to report apparently conforms to all
the Spiegelberg criteria.
REPORT OP CASE
Mrs. J. W. G., age forty, family and previous
personal history negative, two children, last nine
years ago. Menstruation regular, twenty-eight
type, lasting four days. On October 5th or 6th
her menstrual period began and was normal in
every respect. This was followed by amenor-
rhea and the patient developed all the subjective
and objective symptcMns of pregnancy. About
March 25, 1919, began to flow, at first without
pain but after a day or two had severe pain
generally distributed throughout the lower abdo-
men and profuse bleeding from the vagina.
This flow lasted ten days. During this time the
fetal movements ceased and shortly afterwards
the abdomen began to decrease in size. Men-
struation recurred regularly after this time
every twenty-eight days, the flow at first ex-
cessive but decreasing to practically the normal
amount and the abdomen and breasts become
smaller. Last menstruation July 27th.
First seen August 5, 1919: Examination
showed a smooth tumor in the midline of the
lower abdomen extending half way up to the
umbilicus. On vaginal examination the uterus
was found to be slightly decreased in size, firm
and displaced upward and to the right by a mass
which filled the culdesac. This was irregular
in density and was diagnosed as a dead fetus,
from the history, of about five and one-half
months development.
Operation, August 7, 1919: On opening the
abdomen there was no evidence of recent or
old hemorrhage. The left tube and ovary were
normal. The uterus was bicomate and slightly
larger than normal. The right tube was normal
with the exception of a few frail adhesions to
the ovary. The ovary was enlarged to the di-
mensions described below and within it could be
felt a fetus. The right tube and ovary were re-
moved without difficulty. The only dense ad-
hesions were to the right pelvic wall where the
placenta had penetrated and become attached,
and a few frail ones to the sigmoid. Recovery
was uneventful.
Fig. I. — View of tumor from above showing probe through the
tube.
Macroscopic Description : Specimen consisted
of greatly enlarged ovary with attached fallo-
pian tube. The ovary was somewhat flattened
and rounded and measured iij^xiij^x6 cm.
The tube appeared as a small structure measuring
7 cm. in length and 0.6 cm. in diameter in ampu-
lar portion. The tube was clearly defined, quite
distinct and uterine and fimbriated ends were
easily recognized. A few fine reddish adhesions
were noted on serosal surface of tube. The
fimbriated end was patent but some fimbriae
were bound to surface of ovary The organ was
well convuluted and soft throughout. A short
distance from the tube the ovary presented a
large raw area iox5j4 cm., which was made up
chiefly of a dull, reddish-brown, sponsy-lookine
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550
THE PENNSYLVANIA MEDICAL JOURNAL
May, 1921
tissue which closely resembled placental tissue.
Farthest removed from the tube this spongy
mass was bordered by a small structure about
I cm. in diameter which appeared to have un-
dergone prolonged maceration and postmortem
discoloration. Towards the tube the ovarian
surface presented numerous granules as well
as a diffuse deposit of opaque yellow material.
This material really was beneath the surface.
Here and there small, torn fibrous bands of ad-
hesion were seen on the surface. The greater
part of the surface was of a reddish-gray color
and quite smooth and glistening, though in
places the dull, opaque, white ovarian tissue still
showed through. The blood vessels beneath the
surface were abundant. At one point towards
the ovarian ligament a flat clear cyst 2 cm. in
diameter and another livid black hemorrhagic
cyst Ij4 cm. in diameter was seen. On palpa-
tion shell-like, bony structures were found at
the point farthest removed from the tube, whilst
a prominence just beneath the tube resembled
the buttocks. One could also make out what
felt like the os innominatum and the spinal
column. On opening the ovarian sac the shoul-
der and upper arm were encountered.
Fig. a. — Side view of tumor showing probe through the tube
with secitons removed for examination.
The ovary formed a thin wall in which the
amniotic sac could be recognized. When de-
livered the fetus measured 23^^ cm. in length.
The fetus was of a brownish color and showed
quite marked maceration. Vernix caseosa
was abundant over head and shoulders. The
head and face were considerably compressed
but were well formed. From the placental site
the amnion could be clearly defined, but in places
on the inner surface of the ovarian wall the am-
nion was no longer found. The placenta was
relatively quite large.
In selecting the sections several pieces were
Fig. 3.-
-Same view of tumor opeend showing head, arm and
shoulder of fetus with placental tissue above.
taken from the thin wall. These portions were
not in direct contact with the placenta but were
in contact with some adherent blood clot which
completely surrounded the fetus. Other sec-
tions were taken from the rather thick portions
of the wall and one section was taken from a
-ifv-.
L ■^2''
L.
♦ •.»
Fig. 4. — Microphotograph showing normal tube.
portion of the wall which contained a follicular
cyst.
Microscopic Description : Section one, taken
from the thicker portion of the sac wall, shows
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May, 1921
ACCESSORY SINUS DISEASE— DICKINSON
551
a considerable amount of blood clot adherent to
one side. At the margin where this clot joins
the ovarian wall there are large numbers of
phagocytic endothelial cells which are filled with
golden pigment. The sac wall at this point is
made up of typical ovarian tissue showing the
characteristic arrangement of smooth muscle
and fibrous tissue, the large hyalin vessels, and
several distinct ribbon-like hyalin bodies which
mark the sites of former corpora fibrosa.
Fig. s. — Microphotorraph of follicular cyst. Taken from cyst
shown in Fig. 2. (Upper section removed.)
Section two, taken from the areas showing
the cystic follicle. The concave side of the wall
contains blood clot and golden pigment bearing
endothelial leucocytes. Bordering on the clot is
a thin layer of fibrin containing numerous lym-
phocytes. The wall is made up of typical ovarian
tissue and contains a large cystic follicle, the
central portion of which is filled with a some-
what hyalin tissue and the margins of which are
lined with compressed follicular epithelium.
The wall contains some nests of lymphocytes.
Section three is taken from a thinner portion
of the wall. The clot at this point contains num-
erous large necrotic chorionic villi. The wall
proper contains several old hyalin corpora
fibrosa.
Section four is taken from the thinnest part
of the wall. The typical ovarian tissue is so
stretched as to have lost some of its characteris-
tics, but one large compressed corpus fibrosum
is present and a large piece of the necrotic am-
nion is attached to the wall. Sections from four
other areas show similar pictures.
Sections taken from the placenta show numer-
ous necrotic chorionic villi with numerous foci
of calcification and several fibrous ingrowths.
Sections taken from two portions of the tube
show it to be entirely normal and free from all
products of conception.
Diagnosis : Extra-uterine pregnancy. Ovarian
pregnancy.
B^^^SjB^t^^^v-^— _^
IL
A
Fig. 6. — Ovarian wall and portion of tropboblast removed from
point opposite section shown in Fig. s.
BIBLIOGRAPHY
1. Norris and Mitchell, Surgery, Gynecology and Obstetricsi
1908, VI, 460.
2. Norris, Surgery, Gynecology and Obstetrics, IX, 123.
3. Williams, Gynecology and Abdominal Surgery, Kelly &
Noble, IQ08, II, 139.
4. Lockyear, Proceedings of the Royal Society of Medicine,
Section on Obstetrics and Gynecology, X, No. VIII, 158,
5. Meyer and Wynne, Johns Hopkins, Hospital Bulletin,
XXX, 92.
6. Spiegelberg. Archives of Gynecology, XIII, 73.
7. Williams, Textbook of Obstetrics, 537.
8. Norris, Surgery, Gynecology and Obstetrics, IX. 123.
o. Mall and Cutlen, Surgery, Gynecology and Obstetrics,
XVIII, 698.
A PHASE OF ACCESSORY SINUS
DISEASE*
B. M. DICKINSON, M.D.
PITTSBURGH
Most of our practical knowledge of nasal ac-
cessory sinus disease has been acquired within
the past two decades and certainly our advance
in it during the past decade is greater than in
any other branch of otorhinolaryngology. Still
if we are to be honest there is no harm in admit-
ting that our present grasp of the subject is
quite elementary. This becomes quite ev.ident
when we see a patient who has been under the
care of the most eminent writers for months or
years and is still very much a sinus case. There
is consolation, however, in the fact that when
the explanation is finally found it places the
blame on the patient more often than on the
physician. That is, the anatomy is atypical, or
'Read before the Section on Eye, Ear, Nose and Throat Dis-
eases of the Medical Society of the State of Pennsylvania,
Pittsburgh Session, October 6, 1920.
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THE PENNSYLVANIA MEDICAL JOURNAL
May, 1921
there may be a latent constitutional state of a
nature to circumvent all healing.
But if we have our shortcomings in treatment
.we can now boast a systematic and almost un-
failing system of diagnosis in suppurative si-
nusitis. Ninety-nine per cent, of such cases
can be diagnosed as sinus disease by inpection
alone. The determination of the particular si-
nuses involved requires a knowledge of the his-
tory of the case, and the use of transillumina-
tion or the x-rays. The remaining one per cent,
or less is latent sinusitis and manifests itself by
symptoms, distant and not necessarily referable
to the nose. There may be perfect nasal res-
piration and no discharge and no pus visible on
inspection. It may manifest itself by neuralgia,
especially in the mastoid region, the occiput, or
the teeth. It may be the cause of general head-
ache often periodic in type. It may be evi-
denced alone by anemia or arthritis. It is often
the cause of general loss of tone, neurasthenia
and hysteria. The true condition is revealed in
the course of a routine examination, which in
these days, includes an examination of the nose,
throat and ears and this means a transillumina-
tion or x-ray examination of the sinuses in every
case.
The phase of sinus disease with which this
paper is chiefly concerned (hyperplastic non-
suppurative sinusitis) coincides almost perfectly
in symptomatology with this latent suppurative
type. Pathogenically and in the surgical aspect
it is quite different. In frequency it ranks near
or even higher than the frank suppurative form.
Its chronicity and unobtrusiveness, allow it to
go unrecognized to a great extent. Onodi, Ha-
jek, Douglas, Mosher, Sluder, Turner, of Pitts-
burgh, and many others deserve credit for popu-
larizing a knowledge of this affection whereby
an increasing number of cases is constantly
being brought to light.
The matter of diagnosis is naturally greatly
more difficult than in frank suppurative sinu-
sitis. A diagnosis can only be made by a careful
study and full cooperation on the part of both
rhinologist and ophthalmologist with both using
all the resources available The cooperation of
the patient is essential and often difficult to ob-
tain. His symptoms are not often nasal. He
may breathe freely and be unable to connect his
discomfort with his nose at all. His common
horse sense may make him feel that he is being
exploited and in this he may be encouraged by
his long-time medical adviser. Occasionally
even the ophthalmological brother may be
slightly antiquated in this one particular and the
patient's apprehension definitely confirmed. Let
me hasten to state that this is seldom the case
and then to admit that most of my cases have
been first suspected or definitely diagnosed by
the ophthalmologist. The certainty and celerity
with which my friend Dr. H. H. Turner detects
them has seemed almost uncanny to me. He
states that congestion of the conjtmctiva and
retina together with muscular imbalance, asthe-
nopia, and more or less headache, are highly
suggestive symptoms. Glasses that gave com-
fort and relief last month may now be worse
than useless and frequent changes fail to give
relief. Nasal examination will usually reveal a
more or less deflected septum and some inter-
orbital pressure. The mucous membrane is
somewhat thickened and congested. There are
evidences of delayed drainage but often no se-
cretion is seen.
X-ray and transillumination are relatively
negative. No one sinus or set of sinuses is dark.
The discerning observer will, however, gen-
erally note a general lack of translucency. A
lamp that gave a clear picture in a previous pa-
tient of the same apparent skeletal structure
seems feeble and useless. No sharp outlines
are visible. The suction apparatus or swabbing
may reveal a little grayish mucous secretion.
The use of adrenalin is disappointing, little
change being produced in the mucous mem-
brane. The use of the probe reveals a rather
tough, spongy submucosa especially in the upper
and in the posterior half of the nose. If the
examination happens to be made during an at-
tack, the mucous membrane will be dark red
and often will be prolapsed into the middle
meatus. Secretion will likely be slight, grayish
in color and of viscid consistency. If this state
of afTairs is discovered it is safe to say the
"makings" are present for neuralgia, headache
and various ocular symptoms.
The prognosis will depend on the pathologic
changes noted and the length of time the condi-
tion has been present. Early attention will give
early relief, usually without operation on the
sinus at all. Often a deflected septum or other
obstructions will require surgical attention.
Before deciding on a line of treatment a thor-
ough understanding of the patient's constitution
and general health is highly essential, and treat-
ment of the nasal condition should be coor-
dinated with that of any associated illness. It is
a waste of time to attempt relief by attention to
the nose alone in a patient suffering serious di-
gestive disease, tuberculosis, and especially lues.
As a class these patients are sluggish, and of
low vasomotor tone. Some early cases can be
cured by the use of an antiseptic oil spray and
attention to these two points alone. It is wise,
therefore, to have the patient retain or continue
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May, 1921
ACCESSORY SINUS DISEASE— DICKINSON
553
the services of a. first-class medical man to di-
rect the fight against constitutional disease and
to make such changes in his diet and habits as
are necessary to sound general health. Thus
fortified we are in a position to b^n special
treatment with reasonable hope of success.
Cases will classify themselves for treatment
according to the degree of interference re-
quired :
First.-^Those requiring in addition to medi-
cal treatment only local treatment.
Second. — Those requiring the above and the
surgical relief of obstruction. The great ma-
jority of cases have a deflected and thickened
septum in the upper half of the nose.
Third. — Those requiring operative treatment
of the sinuses themselves. It will be found
that the internist and ophthalmologist try to put
all cases in this class, hoping thus to be relieved
of further responsibility. This is very much
opposed to the best interests of the patient.
He may thus readily get an operation he does
not need, and fail to get effective constitutional
treatment he very much does need.
Time will not permit a lengthy discussion of
operative technique. It will require, however,
very few words to state what I believe to be the
basic principles of surgical attack:
First. — The aim should be to leave the nose
open and free for respiration and drainage, but
this should not be carried to excess, which is the
reason for-
Second. — The sinus work should be limited
to the sinuses involved. The entire nostril
should not be excavated.
Third. — The work on the involved sinus or
sinuses should be thorough.
In practice it will be found that the anterior
ethmoid cells are nearly always the point of
invasion and the infection spreads upward or
backward. Frequently, however, the process
begins in the sphenoid or post ethmoid cells.
The essential hyperplastic process seems to be
limited to the ethmoid and sphenoid sinuses and
to the turbinates. If the frontal and antrum
are affected it is chiefly by interference with
natural drainage, and not by any extension of
the hyperplastic process into these sinuses. It
is consequently scarcely ever necessary to op-
erate by the external route in these cases. In
fact the external operation is reserved, even in
suppurative sinusitis, for the constantly decreas-
ing cases in which intranasal operation fails.
I have found it advantageous to outline and de-
tach the portions to be removed with the hooked
or angle knife to full width and height. We
are thus less likely to leave one or more diseased
cells which seem to perpetuate the disease much
more fully than their mass would seem to jus-
tify.
After-treatment in my cases has consisted in
local cleanliness, and the application of silver
nitrate in suitable strength, and an antiseptic oil
frequently. Internally I give hexamethylenete-
tramin in full dose for a few days.
Prognosis in operative cases depends on the
curability of the condition for which operation
is done, and on the thoroughness of the opera-
tion.
Case I. — Mr. C. R. R., age 42, referred by
Dr. H. H. Donaldson, March 7, 1920. He com-
plained of progressively failing vision in left
eye for six months with pain over left antrum
and about the eye. Dr. H. H. Turner reported
viterous opacities making a view of the retina
impossible. Transillumination showed left an-
trum more opaque than right. Frontals clear,
x-ray of teeth negative, Wasserman negative,
general attitude pessimistic and neurasthenic.
Inspection revealed the left nostril obstructed
above middle meatus and marked pressure be-
tween the deflected septum and the middle tur-
binate and ethmoid. Little change was noted
on the use of adrenalin. The tissues were dark
red. The swab culture developed staphylococ-
cus in pure culture.
The septum was straightened, the left eth-
moids exenterated and the antrum opened in
the inferior meatus. The patient was relieved
and his general condition improved.
On July 31st, following a coryza, he devel-
oped pus in the right antrum and it was opened
similar to the left one.
After an extended vacation in August he re-
appeared greatly improved in weight and health.
His vision was somewhat better. Head pains
gone and with a confident hopefulness that was
fine to see. The outcome of the old vitreous
opacities, however, I consider a problem for the
ophthalmologist.
Case 2. — Mrs. H. P. G., age 56, April 5, 1920.
Complained of frequent severe headache since
childhood, worse on using eyes. Had refractive
error and had changed glasses many times with
temporary relief. Her headaches extended over
head, nedc and shoulders, and were often severe
over left cheek. Wasserman negative, teeth
negative by x-ray. Nasal examination revealed
a deflected septum with marked interorbital
pressure. The tissues in the upper half of the
nose were dark red in color, and doughy in
consistency. The nasal secretion was scant and
grayish in color. Swab culture developed a bac-
terial mixture with streptococcus pyogenes much
in evidence. Transillumination was negative
except that all seemed heavy and opaque. The
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THE PENNSYLVANIA MEDICAL JOURNAL
May, 1921
septum was straightened, the ethmoids exenter-
ated, the sphenoids widely opened as also the
nasofrontal ducts. To date she has not had a
single headache since, and the new glasses con-
tinue to give satisfaction and she is able to enjoy
her duties of nursing and hospital administra-
tion.
Case 3.— Mrs. S. M., age 53, July 8, 1919,
complained of severe pain behind mastoid tips,
worse on right side. First noticed in January,
1918. Had been a sufferer from headache since
childhood. She had been a mouth-breather for
years. Of late she had had constant sore throat,
had lost eighteen pounds in weight during the
past three months.
Examination: The pharynx was very red,
dry and studded with ten or twelve vesicles, ton-
sils small and free of pus and caseous material.
Traasilltuninaticm was negative except that both
frontals and Qiaxillaries were all gloomy. The
nose appeared to be completely obstructed. The
lower turbinate borders rested on the floor of
the nose and on pressing them away from the
septum the latter presented an accurate cast of
them. The middle meatus was obliterated by
a prolapsed ethmoid mucosa. The septum was
deflected and much thickened, its mucosa boggy
and almost pendulous. The interstices were
filled with a clear thin secretion. A culture was
staph, albus almost pure. The teeth had al-
ready been extracted.
Local treatment was tried for a couple of
weeks and after each treatment there was relief
of the mastoid pain for about thirty-six hours.
At operation, July 22, 1919, the septum was
straightened, the lower tuittinates shortened, the
middle turbinates removed and the ethmoids
and sphenoids exenterated as thoroughly as pos-
sible. Numerous small polypi were removed
from the cells. The bone was greatly thickened
about the posterior ends of the middle tur-
binates and the anterior wall of the sphenoids.
No discolored secretion was noted anywhere.
The nasofrontal ducts were enlarged so that a
probe could be easily introduced into the fron-
tals. Openings were also made into the antra
beneath the lower turbinates.
Following operation she had severe angina
with fibinous exudate over the pharynx and ton-
sils, which later extended into the nose. Cul-
tures were staph, albus in almost pure culture.
This subsided in a few days and she made the
usual recovery.
Since operation she has been entirely free of
mastoid and other pain. The mucous mem-
brane, however, was very sluggish and main-
tained a pallid edematus appearance. The se-
cretion became yellow and large crusts began to
collect in the nose. She was given iodide of po-
tassium in moderate doses for several months,
but did not improve and seemed to be failing in
health. Her lately acquired weight and color
were going. In spite of a family of healthy
children and a vigorous denial of the possibility
of infection the Wassermann was strongly posi-
tive and the case was made a happy memory by
a few weeks of active constitutional treatment.
<Jj7 Union Arcade.
DISCUSSION
Dr. George M. Coates (Philadelphia) : Dr. Dick-
inson has said very truly that we have still a great
deal to learn about accessory sinus disease. The
suppurating phase I think has been much more care-
fully worked out by most of us than the hyperplastic
conditions that we find, particularly in the ethmoid
cells. These hyperplastic conditions do not show se-
cretion, or in limited amounts, and they give symptoms
of such an indefinite nature that are apt to be over-
looked. The symptomatology has not been carefully
worked out imd the diagnosis is harder to make be-
cause we do not have such definite signs to work from.
In these cases the assistance of the ophthalmologist, as
the doctor has said, is of very great importance. He
often calls our attention to these cases when patients
come back to see why their glasses do not work, or
why frequent changes are necessary.
The atypical anatomy that was mentioned of course
we all know. That was brought to my attention par-
ticularly by the recent work of Schaeffer, of Jefferson
College, on the anatomy of the sinus. It is not a book
to be read for pleasure, but it is a good thing to study.
He has gone deeply into the atypical anatomy, par-
ticularly of the sinuses.
The diagnosis of these hyperplastic conditions can
only be made by careful and repeated study, using all
the means we have at hand. If we use the x-ray we
should use it carefully. The trouble with x-ray work
is, that while there are many competent men to take
beautiful plates, a great many of them do not inter-
pret the plates to our satisfaction and it is difificult for
us to interpret their plates. We should of course en-
deavor to read the plates for ourselves, and to perfect
ourselves in the reading of these plates. In the diag-
nosis of these cases we find polypi, particularly small
polypi in the middle turbinate and even a polypoid
condition that does not show distinct polypi will give
symptoms. These cases are hard to deal with. Often
you do noiT'Wiuit to do an extensive operation where
you have so littiV pathological change, but even a small
operation will do a^foo<l deal of good. What we aim
to get is free ventilai^n and free drainage. Ventila-
tion is quite as important as drainage. If you have a
high deviation and a thidfeened septum it will help a
great deal to straighten it \* fracture of a turbinate
which is pushed over again^ the septum will help;
crushing the middle turbinate V't^'O"* Uking it off will
give free drainage in many caV*- ^^ other cases we
have to remove a polypoid mic^'* turbinate, and in
still other cases we have to renVy* ** hyperplastic
ethmoid cells and open the sphenV*' '" ^et dr^nage.
Drainage and ventilation are whatV* "**** *" ^'J'P*'"
plastic cases as much as in suppurat^(^*^***'
Dr. George W. Stimson (PittsburP^ ' ^" ** '"',
' instances of
icture of the
erature there appear reports of sixte'
serious phenomena attendant upon
pn
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INFANT FEEDING— GRAHAM
555
maxillary antrum: syncope, unconsciousness, convul-
sions and death. Death occurred in six of the sixteen
cases. The post mortems were for the most part nega-
tive and the deaths were variously attributed to co-
caine poisoning, or perhaps to some reflex of un-
known nature from the mucous membrane of the an-
trum, air embolus, etc., and it has been suggested that
in performing the puncture the needle might slip
through the opposite posterior superior wall of the
antrum and enter the orbit The air under pressure,
dissecting the soft tissues away from the bone finds
its way through the optic foramen or sphenoidal fis-
sure into the cranial cavity, where acting as an air
tumor it causes sudden increased intracranial pressure.
While these accidents fortunately occur but seldom,
they show that puncture of the antrum is not entirely
free from risk of serious complications which, when
they do occur, are fraught with the g^reatest danger to
the life of the patient
Various methods for their avoidance have been men-
tioned, chief among them being, of course, always to
inject air first before using a solution and, if undue
resistance is encountered due to stenosis of the ostium
maxillare, or the wall of the lower meatus is so thick,
that the needle can penetrate but very gradually,
either withdraw the. needle and choose the way
through the middle meatus, or make the opening suf-
ficiently large so that air and solution can pass through
without too greatly increasing the pressure in the
antrum ; or, if it is for diagnostic purposes only, omit
the injection of air and endeavor to establish the
diagnosis by aspiration.
It would be interesting to hear if any of these seri-
ous applications have arisen in the experience of the
members of this section, and to bring out a discussion
of their possible cause and methods to be employed for
their avoidance.
Dr. John F. Cute (Harrisburg) : I should like to
emphasize the futility of depending upon the x-ray
for proper diagnosis of many sinus conditions. We,
as rhinologists, when we exhaust all the means at our
command in the way of diagnosis, are likely to turn
our patients over to the x-ray man and when he gives
us a negative result we feel that we have done every-
thing we can for our patient and in a figurative sense
we wash our hands of that patient Notwithstanding
all this, frequently our patients do have latent sinus
disease that is tmrecognized and remains unrecognized
for years.
About 1905 I took a patient of mine to New York
to see a very prominent rhinologist I suspected sinus
disease, as did he, and he took her to Dr. Caldwell,
who at that time was probably the leading x-ray man
of the world, especially in taking pictures of the head.
These pictures came back to the rhinologist and the
x-ray man said there was absolutely no disease in
these sinuses, so we contented ourselves by doing a
minor operation. She had gone to New York with
the idea of having an operation, so we straightened the
septum. But her headaches and the distress of various
kinds continued. During the time I was in service in
the army I came up from the South on a few days'
leave of absence and found her in a pitiable condition.
Having no time to investigate her condition, I sent
her to one of the best rhinologists in Baltimore, who
found two diseased maxillary sinuses filled with cheesy
matter and with polypoid tissue degeneration. An
operation has done her a great deal of good. There
is no doubt in my mind that she had this condition all
these years and it had gone unrecognized simply be-
cause the leading x-ray man of this country if not
of the world at that time had given a negative diag-
nosis.
Now when the x-ray man tells me there is abso-
lutely no trouble with the sinuses, I take what he has
to say with a grain of salt and if in my own opinion
.the symptoms are such as to justify a diagnosis I will
stick to my opinion. I do believe if the x-ray picture
is properly taken and properly interpreted it is of great
value, but as Dr. Coates has said, very frequently the
interpretation is faulty. I should advise you, gentle-
men, not to depend too much on the x-ray to help you
out in your diagnosis.
Dr. Dickinson (in closing) : In regard to Dr. Stim-
son's observation about the antrum, I believe danger
in opening the antrum is practically a thing of the
past It used to be when we opened the antrum that
the instrument might be plunged through further than
we intended, but nowadays the attack is against the
bony wall between the nose and antrum and done in
that way we are not liable to carry the instrument be-
yond the wall which we are trying to break through.
Certainly the use of a slender, sharp instrument, long
enough to penetrate the eyeball is not usual any more,
and I believe the idea of putting in an instrument
which will aspirate pus and air as a diagnostic meas-
ure has become obsolete. For this reason we cannot
judge by the presence or absence of discharge whether
the antrum is diseased or not The mucous lining may
be diseased and still there may be no fluid discharge
from the antrum. But I think the opening should be
large enough in the inferior meatus to permit a view
of the antrum wall by direct inspection, and often we
can judge more about what the condition is than we
can by depending upon the washings in the old way. I
think the danger in opening the antrum is practically
eliminated by improved methods.
FEEDING DURING THE FIRST TWO
YEARS*
EDWIN E. GRAHAM, M.D.
PHII^DELPHIA
There have been certain very radical changes
in infant feeding proposed and practiced re-
cently. These embrace not only decided changes
in the food itself, but in the interval between
feedings. Some pediatricians are adhering to
the old views, others are cautiously trying out
the less radical of the newer methods and quite
a number have accepted the radical changes in
full and are convinced of their efficiency.
Before deciding positively as to the diet that
a child should receive during its first two years
of life, it is important to appreciate fully that
a diet may agree with some babies and yet may
not be the best diet for most babies. Further-
more, we have now certain definite standards as
to what constitutes a normal baby at birth, and
what is the normal development for a child dur-
ing its first and second year, and it seems only
proper, before we accept finally any radical
'Read before the Section on Pediatric* of the Medical Society
of the State of Pennsylvania, Pittsburgh Section, October 5,
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THE PENNSYLVANIA MEDICAL JOURNAL
May, 1921
changes in the well-established diet of the baby,
that these changes should be supported by clin-
ical data covering the first two years of life and
supported by a sufficiently large number of
cases actually to prove clinically that the newer
methods produce as good, if not better, results
in development of the baby than we now con-
sider normal. To be concise, do the records
show that the newer methods of feeding give us
babies that weigh more, have better muscula-
ture, cut their teeth earlier, creep, stand or walk
better? Is their bony development superior,
can they better resist infections, do they sleep
better, and are they less nervous ? To sum up,
is the baby fed by the new methods superior to
the baby fed by the older methods?
There are certain elements of infant feeding
that must be discussed and debated in order that
we can meet each other on common ground and
study this problem in a broad way, and one of
the most important of these is caloric require-
ments.
The food value or the number of calories any
certain diet contains is a direct measure of the
amount of nourishment given the baby. The
older method of feeding made milk the most
important single ingredient during the first two
years of life. An abundance of milk in the diet
is important. A quart of milk contains about
640 calories, one ounce of rice about 100 cal-
ories, one ounce of zweibach about 120 calories,
one ounce of boiled egg about 70 calories, and
one ounce of lean beef or mutton about 55 cal-
ories. On the other hand the calories contained
per ounce in the vegetables are asparagus, 7;
string beans, 12 ; peas, 29, and spinach, 7. The
diet of vegetables is certainly not overrich in
calories.
The digestibility of fats, proteins, and carbo-
hydrates must be carefully considered, no mat-
ter what plan one may follow in infant feeding.
Fat indigestion, which at one time we consid-
ered unusual, we now know to be very often
met with. Carbohydrate indigestion we recog-
nize and accept. In regard to the sugar content
of the food and how often and how severely it
may injuriously aflfect the young child, there is
still considerable discussion. As regards the
protein, most American pediatricians do not
agree with Czerny, who believed that protein did
practically no harm, but we have greatly modi-
fied our views from the former belief when, fol-
lowing the teachings of the truly great Ameri-
can pediatrician, Rotch, we considered it the
most difficult ingredient of the milk for the in-
fant to digest.
If the mother has a sufficient supply of breast
milk and the baby is developing normally, noth-
ing except breast milk should be given during
the first nine months. Then a bottle each day
may be given of properly prepared modifi«i
milk. The number of bottles should be gradu-
ally increased and the strength of the modified
milk gradually increased until, as a rule, the
baby of one year takes whole milk. If a bottle
baby, it should be taking starch in some form
when six or seven months old, usually in the
form of barley water; and if breast fed, it
should be given a cereal diluent with its bottle
of cow's milk. During the last two or three
months of the first year, it should be given a
well-cooked cereal once a day, and I always
allow a small amount of sugar as well as milk
on the cereal ; notice, I say a small amount of
sugar. Orange juice is practically always given.
Given a baby normal at birth, with good hered-
ity, proper environment and good hygiene, this
is the diet that gives us normal development
during the first year. If the newer diet will do
more for the baby then we ought to accept it.
The orange juice is given more for its anti-
scorbutic value than any other reason. The
baby, one year old, may also have apple sauce,
baked apple, or prune juice with the mashed
prune pulp added. The apple and prune are
useful if constipation is present. A well-baked
potato may be added to the diet when the baby
is a year and a half old, and a month or two
later a portion of a soft boiled or coddled ^^
may be added and, if it agrees, the whole ^g
may be later given. Zweibach, toast or twenty-
four-hour-old bread should be given during the
latter part of the first year, with one or more of
the feedings. They should always, of course,
be given with the feeding, better after than be-
fore, and never between feedings.
Cereals should be given when the baby is one
year old. Farina and cream of wheat are two
of the best. They must be well cooked and given
with milk and a little sugar. I am, of course,
aware that many pediatricians forbid the sugar.
Personally I have not found that it prevents
children taking other food that is not sweetened.
The increase in the diet of a baby depends
upon its ability to digest the food it is already
receiving and, to a certain extent, upon the time
of year. During the winter months or during
the summer months, if the baby happens to be
in cool climate, and digesting its food well, it
should be given, during the last few months of
its second year, a small portion of finely cut up
chicken, beef, mutton, or fresh fish.
When should a baby be given green v^eta-
bles? I usually begin to give them in small
amounts about the middle of the second year.
This is not the rule followed by many other
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INFANT FEEDING— GRAHAM
557
pediatricians. Peas, beans, spinach and car-
rots are the best They must be cooked until
soft, and pressed through a fine colander. I
believe this question of feeding fresh green
vegetables to children is one that is at present
interesting pediatricians as much as any other
problem in infant feeding, and we all know
from recent literature that many babies are
being given green vegetables during their first
year. My personal belief is that some babies
are able to digest vegetables at an age earlier
than I advise giving them, but I know positively
that many babies cannot, because these babies
are brought to me, and immediately improve
when the vegetables are discontinued and the
simple milk formulas substituted. My personal
experience is against giving fresh green vege-
tables before the baby is eighteen months old.
Moreover, I have studied the charts of those
babies fed on green vegetables, both in hospital
and private practice, and I do not believe they
develop as normally as do babies fed on prop-
erly prepared milk. Another fact which it seems
to me is important, and which has been entirely
overlooked, is that in my opinion most infants
fed so early on vegetables do not receive in
their daily food a sufficient amount of fat.
Curiously enough some of the physicians who
are enthusiastic over feedit^ vegetables early
give low fats in the small amount of milk the
baby is given. This low fat may, however, pre-
vent these babies who are given vegetables early
in life from having indigesti(3n, because if one
food element is given in excess the danger of
indigestion is lessened if the other food ele-
ments are cut down more or less.
The two great types of normal intestinal flora
are the fermentative and the putrefactive, and
while these bacteria may under certain condi-
tions produce marked symptoms, nevertheless
the bacteria are necessary for the normal
function of digestion. A carbohydrate diet
favors the development of the fermenta-
tive group, and a protein diet favors the
increase in the putrefactive group. If then
we feed too much carbohydrate or too much
protein we are apt to have a sick baby. If the
fermentative group have developed so as to
produce symptoms, carbohydrates should be
withdrawn. If the putrefactive group are in
excess, the amount of protein given should be
diminished. This in brief is what we mean by
a food injury, and it represents one of the best,
if not the best, method of feeding babies and
studying their gastro-intestinal disorders. The
fact that there is a distinct connection between
the bacteria that develop in the intestine and the
food we feed the baby is one that is important
for every physician to remember and is of great
practical importance in the feeding of well and
sick babies.
The influence of bacteria in producing dis-
turbances of nutrition is of prime importance.
The food may be infected before it is given the
baby or it may become infected in the intestine.
Alimentary intoxication produced by the ab-
sorption of toxins from the intestine and com-
ing as it does either from decomposition of
sugar, fat or protein, points strongly to the
proper feeding of sugar, fat and protein. It is
true that there is still much to learn as to just
how the toxemia is produced. The loss of salt
and water, and acidosis play their part as well
as the absorption of toxins, but their connection
with sugar, fat and protein decomposition is
certain. Finkelstein's theory as to the troubles
produced by the sugars and salts, has been
widely believed and disbelieved, but only adds
one more chapter to this whole subject of in-
fant feeding, and points to the fact that many
important questions are still in dispute. It is
necessary to bear in mind that the types of bac-
teria that develop in the intestine are the result
of the different food elements given the baby.
The question as to the amount of vitamines
contained in the different diets is important.
The diet suggested in this paper contains a lib-
eral supply of milk, and milk contains both the
fat soluble A and water soluble B vitamines.
Milk also contains the growth vitamine.
"The rapid growth of all the tissues and or-
gans of the infant, especially of the bones, ren-
ders the injestion and absorption of the mineral
salts of great importance. Potassium, sodium,
calcium, magnesium, phosphorus, and a trace
of iron are the most important mineral salts
found in milk. These salts, with the exception
of iron, are present in sufficient amounts in both
human and cow's milk to supply to the infant
all that its body requires for normal growth and
development.'"
The diet that supplies an abundance of milk
must contain an abundance of mineral salts.
Eggs and cereals also contain an abundance of
mineral salts and are in our prescribed diet.
Olive oil is a form of fat that seems to be di-
gested well by many young infants. The addi-
tion of olive oil to the diet of these infants en-
ables one to give them often an additional
amount of fat. It or cod liver oil may, of
course, be used by inunction.
REFERENCE
I. Diseases of Children, Graham, p. 157.
171S Spruce Street.
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THE PENNSYLVANIA MEDICAL JOURNAL
May, 1921
DISCUSSION -
Dr. Percival J. Eaton (Pittsburgh) : Dr. Graham
has asked me to discuss this very suggestive and very
valuable paper. Not having had it very long in my
possession and having so little time, I can only, as it
.were, hit the high spots.
What Dr. Graham said in regard to the calories' of
the child's food is the thing I think should be taught
to the student — the caloric value of the foods — ^but it
is my belief, and I think the belief of other pedia-
tricians, that to feed a baby by counting out how many
calories one thinks it ought to have and how many
calories it is going to have is not the correct way. I
believe, as some of you have heard me say before, that
the feeding of children should be based upon what the
individual child needs. Each child is an individual
human unit, and while the older rules of feeding apply
to it, and the number of calories which the average
child needs is well known to all of us, I think we
should so govern our feeding that the child gets well-
balanced rations, remembering always that it is a hu-
man unit in itself.
Dr. Graham referred to Dr. Rotch in regard to milk
and also referred to the old belief in regard to the di-
gestibility of fat and proteins. As a student of Dr.
Rotch years and years ago in Boston, I used to give
milk feeding formulas of 5^ per cent, of fat and i per
cent, of protein.
Dr. Graham referred to the giving of cereals to the
young child. I think after a child is six months old
it is a very wise plan to add cereal. We here use
either barley jelly or oat jelly instead of barley water
or oat water simply for the reason that you can make
the jelly of more uniform strength than the barley
or oat water. In this connection let me say that what
Dr. Graham had to say about bread and zweibach
seems to me to need a little further elaboration. The
starch the child needs after six months is supplied
by the barley jelly and oat jelly. It is not necessary to
have wheat starch, but to me the whole thing depends
on whether the child can get down the zweibach, toast
or bread chewed to the proper consistency. It is a
matter of personal equation — if it has the anterior
molars and can chew these foods, it is ready for them.
I tell mothers that they may try egg but if the child
develops hives or vomits its milk, do not give egg
again. Sometimes it is the albumen in the egg and
sometimes the fat, which is to blame.
The increase in the diet Dr. Graham says depends
upon ability to digest food. We add little by little the
things it can take and take care of properly. Meat and
fish come naturally as the baby grows older. Finely
cut up meat is not so good as shredded meat.
The matter of green vegetables is a most important
question. My own opinion is that there are not many
children who can stand green vegetables at a very early
age. After a year old, or perhaps ten months or
fourteen months, whatever is best for the individual
child, if you begin to give it some of the green vege-
tables thoroughly cooked they help it along. I do not
wait until a child is eighteen months before giving the
vegetables. You need to know the child well and I give a
little at a time of the green vegetables, with the excep-
tion of the highly flavored ones, such as cauliflower,
cabbage and turnip.
The results of the study of the growth of these
children is very interesting, and we find often that
some simple form of iron seems to go very well, and
seems to stimulate growth.
In conclusion, I want to thank Dr. Graham for
bringing this up and to thank him for giving me the
opportunity again to say that the success in the matter
of feeding infants for the first two or three years lies
in the fact of properly sizing up each individual child
as a human unit and giving it that which it most needs
for its growth and development
Dr. Harry Lowsnburg (Philadelphia) : We all have
to agree with Dr. Graham that individualism is the
keynote of successful infant feeding which is about
what he said in his opening statement
I am very sorry that I did not know what the sub-
ject of Dr. Graham's paper was to be or I should have
brought with me some clinical histories to illustrate
what I am about to say. I do not want to claim credit
for having given Dr. Graham the inspiration for that
part of his paper in which he refers to the feeding of
comminuted vegetables and solids but I am guilty of
having issued two publications in the New York Medi-
cal Journal on this subject
My own experience, and that is all that one can go
by, is not in keeping with Dr. Graham's conclusions as
to the harmfulness of the feeding of these commi-
nuted substances. Perhaps one man may not work
successfully with another's man's tools. I want to add
that I am not attempting to pronounce a dictum in in-
fant feeding because I have always prided myself on
the fact that I attempt to individualize, but applying
his standards as he pronounced them as to the general
weight, development, etc., by which we may judge of
the effect of a food, I can only say that from my own
experience, by early feeding of comminuted solids, the
children do as well and many times better than children
who do not receive vegetables early. I probably could
present to you the clinical histories of nearly 100
babies to whom I have fed comminuted solids as early
as six months and all evidence superior vigor and de-
velopment, and the mothers, at first doubters perhaps,
have become enthusiastic propagandists of the idea.
Bald statements do not permit of conclusions but the
time here is so limited I cannot go into details and
can take only such facts as I have found in my own
experience. These discount what Dr. Graham sajrs
with reference to the harm that children suffer by
reason of having received these things. On the con-
trary I believe that their use strengthens growth and
increases vigor and I feel that in the feeding of these
vitamin-carrying substances and mineral-carrying sub-
stances and iron-carrying substances we have a very
potent means of preventing the development of early
and late rickets, the mild and severe forms of rickets
from which very many bottle-fed babies suffer. This
is also true of babies who have been kept on breast
milk too long.
I feed cereals as early as two and three months of
age with good effect to both the breast-fed and bottle-
fed babies. I feed comminuted green vegetables, pro-
viding the child has developed normally, as early as
six months. I attempt slowly to add green vegetables
such as spinach, lima beans, potatoes, celery and peas
at this age. I have seen nothing but good develop
from their use providing the vegetables are prepared
properly, the crux of the situation being that they must
be thoroughly cooked and thoroughly comminuted.
Dr. Graham gives potato early in the second year. I
give it at six months but it must be properly baked,
properly mashed and sieved. I give chicken and meat
as early as one year, well comminuted and properly
prepared and I see good effect on the stools and gen-
eral development
I believe that the use of these vegetables some day
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INFANT FEEDING— DISCUSSION
559
will come into its own, especially in the treatment of
summer diarrluxa, to bridge that chasm between star-
vation and the return to milk. I believe that in these
substances we possess a means of maintaining nutri-
tion and not weakening the child while we are trying
to cure his diarrhcea and getting him back on milk.
Again my position is exactly the reverse of Dr. Gra-
ham's and is an outgrowth simply of my experience in
clinic and private practice.
With reference to protein and the etiological influ-
ence of protein and of fat in alimentary disturbances,
I believe the latter to be more potent but it depends
on the physical and chemical state of the protein fed.
The protein must have been properly modified, chem-
ically or mechanically, or both, to render it harmless
as well as beneficent. Then you may use protein in
larger amounts than we have been accustomed to use
it. Finkelstein feeds a finely comminuted curd but
does not feed three and four per cent, of a thick,
tough, leathery curd.
With reference to caloric feeding, I think I under-
stand Dr. Graham correctly that he is not an advocate
of caloric feeding as a method of feeding. You must
study the caloric value of foods and apply it to the
caloric requirements of the child. Unfortunately- we
cannot adopt the calory system as a standard for
judgment. No two individuals require the same num-
ber of calories. Many under-nourished children need
more calories than do the well-nourished. The caloric
system of measuring food requirements may not be
depended upon.
Dr. John F. Sincxair (Philadelphia) : Dr. Gra-
ham's paper is admirable because of its conservatism,
but perhaps it is safe to go a little further than he has
gone when discussing these cases in a meeting of those
who are especially interested in the care and feeding
of children.
As regards the caloric feedings, I must say that I
stand with Dr. Eaton exactly, and he has well voiced
my sentiments in regard to caloric feeding indications.
They are not to be taken as a complete standard, but
simply to check up our feedings. We should not feed
by calories alone.
In the matter of orange juice, I have been very
much interested in the work that has been recently
done by Byfield, University of Iowa, at Iowa City, in
which he seems to show conclusively that there is
more than an antiscorbutic in the orange juice, that
there is something that seems to be of definite value in
helping growth. He foimd that by feeding 15 cc. of
orange juice to his babies he got the antiscorbutic
value of the orange juice but frequently the baby
showed a stationary weight. He increased the orange
juice to 45 cc. and he got growth and increase in
weight, although the feeding was not changed. That
is new work, but I believe that it opens up to us a
field of usefulness for orange juice over and above
that which has been usually accorded to it
In regard to green vegetables, I should take a posi-
tion in between that advocated by Dr. Graham in his
paper and that advocated by Dr. Lowenburg. I think
that there are ways in which we can use green vege-
tables earlier than we were formerly taught to use
them, and I believe that the green vegetables must be
finely broken up and comminuted as Dr. Lowenburg
has stated, but I personally do not care to feed the
solid green vegetables to the infant child. The way I
get around it is to cook the vegetable as long as if it
were to be used as food, put it through a strainer,
comminute it absolutely, then I put it in the milk and
make a sort of puree and employ that in addition to
the bottle food, making up part of the quantity that
the baby should have. I believe that is a position in
between the two opinions that have been voiced and is
a valuable addition to our former methods of feeding.
Dr. Alfred Hand (Philadelphia) : I am afraid Dr.
Graham is in danger of having a term applied to him
that I have had hurled at me with regard to the feed-
ing of vegetables to infants of five or six months of
age — ^that of being old-fashioned. I agree with him
that some infants can get away with such a diet and
thrive, but a few of them whom I have seen later, in
their second and third years, were not good arguments
for that method of feeding. I once heard of an infant
brought up apparently successfully on white bread
dipped in coffee but we would hardly advocate that
for a second case.
Dr. Paul E. Cassidy (Philadelphia) : I should like
to ask if you prefer the use of cream of wheat over
barley or oatmeal.*
Dk. Graham (in closing) : My paper has done as I
hoped it would — brought forth a great deal of discus-
sion.
As regards calories, I quite agree with Dr. Eaton
and Dr. Lowenburg that it is simply a check-up on
the food you give the baby. In other words, you
should be able to say just how much food value there
is and how little. I do not believe in the caloric
method, but it is a valuable check.
In regard to egg, I thoroughly agree with what has
been suggested — giving half an egg and if it agrees
increasing it to a whole.
In my paper I said that some infants can digest
vegetables better than others and it is undoubtedly
true as I have seen it in my own practice. The gentle-
men who are bringing forward these arguments for
feeding green vegetables must do what I>r. Lowen-
burg is trying to do, that is, they must show us that a
baby fed in that method or according to that method,
develops just as well, if not better, than the baby fed
by older methods. It is not possible to say just when
a baby should be given green vegetables, and as Dr.
Sinclair and Dr. Lowenburg have stated they should
be cooked at least three hours, mashed, etc The
problem we have to solve and the way to do it is to
take the charts of these babies and study them to see
whether they develop as well as a normal baby. I
have taken the trouble to watch these children in pri-
vate homes and medical wards this summer and talked
to different doctors in the Middle West and I found
that a good many of them are trying this thing out
The question about which Dr. Sinclair spoke in
regard to orange juice is very interesting and is quite
true, namely, the amount of orange juice fed to babies
simply for the antiscorbutic value and the effect of
increasing the amount That is very interesting. I
simply stated in my paper that orange juice is usually
given for antiscorbutic value.
The more we study infant feeding the more we ap-
preciate the new phase of it If we go back and study
the Rotch theories and those of Czerny and Finkel-
stein and our own theories, we will simply see that
one phase leads to another and that all of these proc-
esses have been more or less helpful.
Whether Eh-. Lowenburg is right, whether others
are right in trying out the giving of vegetables early,
I do not know. I think that there are fashions in
'This question was not answered by Dr. Graham. But
he later said that he just mentioned "Cream of Wheat" as one
of the cereals.— P. E. C.
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THE PENNSYLVANIA MEDICAL JOURNAL
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medicine the same as in anything else and before we
accept this vegetable theory we, like the gentleman
from Missouri, must be shown the improvement over
the older methods.
SELECTIONS
ORIGIN OF THE PENNSYLVANIA
MEDICAL JOURNAL
C. L. STEVENS, M.D.
ATHENS, PA.
Dr. Williuam Varian, in his address as presi-
dent in 1883, speaking of the delay in the issue
of the annual volume of Transactions, said : "I
do not mean that this society could advantage-
ously establish a journal of its own, nor do I be-
lieve any such course necessary. But I think
it not impossible that an arrangement could be
made with one of the already well-established
weekly journals of the state which would prove
of advantage both to the society and to the jour-
nal." So far as the writer has observed, this is
the first published suggestion that the Transac-
tions be printed in other than in the accustomed
annual volume, and even this suggestion seems
to have been forgotten until after the death of
Dr. Varian.
In his address as president in 1894, Dr. H. G.
McCormick urged the Medical Society of the
State of Pennsylvania to secure a larger mem-
bership "in order that this society may be the
representative of the regular medical profession
in this state in fact as well as in name." At the
same meeting, on motion of Dr. W. T. Bishop,
the officers of the society were instructed to
carry out the suggestion of President McCor-
mick. A majority of the officers, including the
trustees, met in Philadelphia, November 3, 1894,
anc^ elected Dr. C. L. Stevens, chairman, and
Dr. J. H. Wilson, secretary. At the second
meeting a subcommittee, consisting of Chairman
Stevens, President John B. Roberts and Treas-
urer G. B. Dunmire, was appointed "to report
to the committee at a future meeting on the ad-
visability of publishing the Transactions in jour-
nal form. The subcommittee corresponded
with physicians in nearly every county, with
editors and printers, and with each officer of
this society, including members of the Commit-
tee on Publication and the Committee on Scien-
tific Business. (See abstracts from letters ap-
pended.) The subcommittee reported to the
committee at their third meeting that it deemed
it expedient for the society to undertake the
publication of a journal at this time but that the
question be referred to the Publication Commit-
tee for their consideration; and the committee
adopted the report of its subcommittee." This
report was adopted by the society at its meeting
in 1895.
At the meeting of the society in 1896 the
Committee on Publication, consisting of Drs.
Edward Jackson, W. B. Atkinson, G. B. Dun-
mire, H. A. Hare, G. W. Guthrie, J. H. Wilson
and D. W. Nead, reported that three members
favored a journal in place of the annual volume,
three, "while agreeing to it, feel some doubt as
to its advisability, and one is opposed. We
believe with proper economy the society could
prudently devote about $2,500 per year to the
publication of a journal. With this we could
publish, including editorial expenses, and fur-
nish directly to each member of the county so-
cieties a quarterly journal of about 125 double
column pages," etc. The report also recom-
mended an amendment to the by-laws increas-
ing the size of the Committee on Publication
and making it "the duty of this committee to
publish a journal-to be called the Pennsylvania
Medical Journal, which shall contain the min-
utes of the annual meeting, reports of commit-
tees and of county societies, addresses and sci-
entific papers with the discussions thereon, with
other matters, subject to the discretion of the
committee; provided," etc. Dr. J. B. Roberts
moved that "the recommendation of the Com-
mittee on Publication be referred to the trus-
tees with power to act." After much discussion
"with power to act" was stricken out, and the
motion was adopted as amended.
At a meeting of the trustees on October 14,
1896, the following resolution offered by Dr. C.
L. Stevens and seconded by Dr. W. T. Bishop
was unanimously passed:
"Resolved, That the board of trustees, to
whom was referred the matter of the publica-
tion of the Transactions in journal form, recom-
mended to the State Society that the Publication
Committee publish under the supervision of the
Board of Trustees, the Transactions for the
year 1897, with such other medical matter and
news items as may seem desirable, in bimonthly
parts, to be mailed directly to each member of
the county societies, as the best means of deter-
mining the advisability of the measure; pro-
vided, however, that the expense for the six
numbers, over and above the amounts received
for advertisements and subscriptions from those
not members of county societies, shall not ex-
ceed the sum of twenty-five hundred dollars."
At the meeting of the society in Pittsburgh,
May 18, 1897, the recommendation of the trus-
tees quoted above was "referred to a special
committee consisting of the Publication Com-
mittee and the Board of Trustees, with instruc-
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SELECTIONS
561
tions to report under the head of new business
at the afternoon meeting." The Committee on
Publication had already reported that "in view
of the action of the trustees recommending the
publication of the Transactions in journal form,
the committee had obtained bids and estimates
for the same, which will be turned over to the
new Committee on Publication for their con-
sideration."
At the afternoon meeting the society adopted
the report of the special committee, which was
as follows:
"Your committee recommends that the Pub-
lication Committee publish under the super-
vision of the Board of Trustees, the Transac-
ticMis for the year 1897 with such other medical
matter and news items as may seem desirable, in
monthly parts, to be mailed directly to each
member of the county societies, provided, how-
ever, that the expense over and above the
amounts received from advertisements and sub-
scriptions from those not members of county
societies, shall not exceed the sura of twenty-
five hundred dollars.
"We also recommend that Article XIII, Sec-
tion 3, be amended by inserting after the word
'Pennsylvania,' in the sixth line, the words 'or
it may at its discretion, or by direction of the
society, publish the Transactions in journal
form, under the supervision of the trustees.'
"Also amend the same section by inserting at
the end, 'The chairman of the committee, who
shall act as the editor, shall be paid an annual
salary not to exceed $300, the amount of which
shall be fixed annually by the Board of Trus-
tees.' "
At the morning meeting of the society. May
19, the publication of the Transactions was
again taken up and offers from three different
publishers were successively declined. Pending
a motion to accept an offer of Dr. Adolph
Koenig, the motion was referred to the previous
special committee with instructions to report a
form of agreement between the society and Dr.
Koenig.
The special committee reported at the morn-
ing meeting. May 20, as follows :
"The committee recommends that the trus-
tees of the society be instructed to enter into an
agreement with Dr. Adolph Koenig, with refer-
ence to the publication of the Transactions, in
which agreement shall be embodied the fol-
lowing points:
"For one year, commencing June i, the so-
ciety is to pay Dr. Koenig the sum of $200 per
month, in consideration for which he shall pub-
lish its Transactions in the form of a monthly
journal ; size seven by ten and one-half inches ;
forty-eight pages of reading matter; wire
stitched; linotype printing (size and general
style of the copy of the Pittsburgh Medical Re-
view). The reading matter for the forty-eight
pages to consist of the addresses, papers, min-
utes, communications and other transactions of
the society, tc^ether with editorials, news items,
and matters of medical interest ; the whole, ad-
vertising pages included, to be subject to the
approval of the Committee on Publication ; and
that he shall mail a copy of each number to
every member of county societies not in arrears
for dues.
"The journal shall be called The Pennsyl-
vania Medical Journal, and shall state on its
title page that it is the official organ of the Medi-
cal Society of the State of Pennsylvania. * * *
"That at the end of one year this journal
shall, at the option of the society, become the
property of the society, in the consideration of
the payment of $1.00 and the conditions that
all advertisements of secret or copyrighted me-
dicinal preparations shall be excluded forever
from its pages."
On motion of Dr. W. H. Daly, the society in-
structed the trustees to enter into a contract
with Dr. Koenig as recommended, and the first
number of the Pennsylvania Medical Journal
appeared in June, 1897, thus launching the first
of the state medical journals, which now num-
ber thirty-three publications representing forty
state societies.
Contracts with Dr. Koenig were renewed
from year to year until seven volumes had ap-
peared under his management, the size, circula-
tion and quality of the Journal gradually in-
creasing. The amount paid Dr. Koenig was
increased from time to time, but never was ade-
quate for the valuable services rendered. The
following editorial by Dr. Koenig appeared in
the last number of Volume VII, September,
1904:
"When in June, 1897, the publisher of this
Journal assumed the responsibility to publish
the transactions of the Medical Society of the
State of Pennsylvania in journal form, he had
in view the accomplishment of two special ob-
jects, namely, to prove that it could be done
without the aid of the quack medicine advertis-
ers, and also to show that the transactions of a
state society published in journal form were of
much greater value to such an organization than
when issued in book form. As this latter was
an experiment among state medical societies it
was looked upon with considerable misgivings
by many members, but the results accomplished
by the Medical Society of the State of Penn-
sylvania under this arrangement, and its adop-
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THE PENNSYLVANIA MEDICAL JOURNAL
May, 1921
tion by some ten or twelve other state societies,
also apparently with good results, prove the wis-
dom of the plan of publishing the transactions
in monthly installments. We claim for the
Medical Society of the State of Pennsylvania
the position of pioneer in establishing the merits
of this plan.
"With regard to the advertisements we feel
that the most ethical member need blush at
nothing that has appeared in this journal, and
it should not be forgotten that it was not for
lack of opportunity that unethical advertise-
ments were not abundantly represented.
"The publication of a medical journal, and
especially one representing the transactions of
a great medical society, should be as free from
commercialism as is the daily life of a physician
actuated by the highest motives of humanity,
and no one will deny that to encourage the use
of unethical remedies tends to injure the sick
and afflicted rather than to benefit them, and
the only advantage therefore that can accrue is
represented by the monetary consideration.
"Working for results believed to be of great
benefit to both the profession and the public, the
publisher has found much pleasure in his labor,
but other responsibilities devolving upon him
render it imperative that this work shall be car-
ried on by other hands, and with this issue,
therefore, the active participation in the publi-
cation of the transactions by the present pub-
lisher will come to an end."
At the meeting in Pittsburgh, in September,
1904, the Executive Council, the forerunner of
the House of Delegates, decided "that the so-
ciety itself continue the pubUcation of the Jour-
nal, subject to the approval of the trustees."
The trustees, however, decided "that the action
of the Executive Council this morning author-
izing the society to assume all responsibilities
for the publication of the Journal, be not ap-
proved on account of financial difficulties." The
trustees then decided to enter into a contract
with Dr. C. L. Stevens to publish the Journal,
the contract being practically identical with
those made with Dr. Koenig excepting that the
number of pages was increased and with a cor-
responding increase of price. Contracts with
Dr. Stevens were renewed from time to time
until sixteen volumes had appeared under his
management.
The matter of the society assuming full re-
sponsibility for the publication was discussed
from time to time, and in 1916 the trustees de-
cided that "steps be taken to prepare for the
taking over the publication by the society at the
end of two years" for which contract was then
made. It was not, however, until August, 1920,
that the society became directly responsible for
the individual bills contracted, and not until the
beginning of Voliune XXIV in October, 1920,
that the publication came fully into the hands of
the Publication Committee of the Board of
Trustees. Nevertheless the Journal was copy-
righted in the name of the Medical Society of
the State of Pennsylvania in March, 1920.
Practically from its first issue in 1897 the Jour-
nal belonged to the Society, but inasmuch as the
Society was not legally responsible for the pub-
lication, most of the officers and members failed
to take the real interest in the Journal that they
have now assumed.
Mention should be made of the fact that Dr.
Stevens, following the example of Dr. Koenig,
refused to accept unethical advertisements al-
though by doing so it would have been to his finan-
cial interest. All his offers to the trustees were on
the condition that "no advertisements were to
be inserted that are objected to by either the
Editor on the one part or by the Board of Trus-
tees on the other part." It is only just to state
that Dr. Koenig received no financial remxmera-
tion for any proprietary interest he may have
held in the Journal when it passed into the
hands of Dr. Stevens; neither did Dr. Stevens
when he relinquished any claims he may have
had in favor of the Society.
It is a matter of record that in May, 1899, a
component county society formally protested
"against the further publication of the Medical
Journal and requested that the old form of
Transactions be continued," and that in 1904
two other component county societies asked "the
officers of the society to sever whatever rela-
tions exist between it and the Pennsylvania
Medical Journal." The following excerpts
from a few of the many letters received by the
committee in 1895 will show the diversity of
opinion r^arding the advisability of establish-
ing a society journal, the negative phase of
which now seems to have been almost if not en-
tirely eliminated.
From a prominent medical professor, who
later became president of the sodety, and now
deceased:
"I consider it unwise and inexpedient for the Medi-
cal Society of the State of Pennsylvania to undertake
the publication of a medical journal of any kind. The
best reasons against such a project, it seems to me,
are given in paragraphs i and 3 of your letter. As
you say, there are too many poor journals and a suf-
ficient supply of worthy ones, and many of us now
take more journals than we can read with profit I
believe, too, you underrate the cost of a first-class
journal. A first-class journal can only be secured
through a first<lass editor of large experience and
such a person should receive a large salary which,
added to the cost of publication, will considerably in-
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563
crease the expense; and if added to this the fact that
from your own estimate, a membership of 4,000 is
necessary, instead of 2,500 as at present, the society
is likely to be.come seriously embarrassed. I believe,
however, a journal successfully carried out in the
spirit implied in paragraph 4 of your circular would
truly be valuable to those who would receive it."
From an honored professor, now deceased :
"I most earnestly hope that the subcommittee will
not report to the committee of officers in favor of the
publication of a new journal imder the auspices of the
State Medical Society. There is not the slightest
reason for supposing that if the same matter which
goes into the transactions were put into a monthly
journal it would be read any more than it is at pres-
ent. The new journal would of necessity not receive
contributions of the first class, because no man having
such a contribution to put in a journal would give it
to one whose circulation was confined to a single state.
What a horrible medical chaos this country would be
if every state association added its journalistic voice
to the hideous babel which now fills the American
continent."
From a prominent medical professor :
"I for one would regard the proposition unfavorably
for a number of reasons. In the first place it would
labor under the same difikulties which, however,
would be mag^fied, as the Journal of the American
Medical Association now labors under, for it would be
practically impossible to publish all the papers read
before the association at once or to keep good papers
for publication for many months."
From a chairman of the Committee on Scien-
tific Business, and a prominent medical editor:
"There are many and great difiiculties in the way of
publishing a medical journal under the auspices of the
State Society, but if it is attempted, you may be sure
that I shall give it my hearty support * * * I
think, in counting the cost, you ought to allow a good
salary for an editor. Work for love is uncertain and
rarely of the quality (for long at a time) of that
which is materially remunerated."
From an early president and trustee, now de-
ceased :
"I agree with you that a good journal, giving infor-
mation on all those matters which have a direct and
positive bearing on the practical duties of the prac-
titioners, avoiding all the theories which men wish to
ventilate, would be a very good thing but the great
trouble is so small a proportion of the profession
really read. Then, another matter which is very an-
noying to one who believes in the ethics is to have
a journal crowded with advertisements of proprietary
medicines which so often amoimt to nothing to the
practitioner.
"The main difficulty would be to secure a good edi-
torial staff who had the time to give to the work and
the calm judgment to decide on what was presented
for publication and the decision necessary to be exer-
cised about what should be published and what re-
jected. We have such men if they could be induced
to undertake the work and they should be well paid
too.
"The articles should be short, practical and read-
able in the full sense of that word. Such a journal
I would favor and though a very busy man with all
my time crowded with work I would do ray part to
sustain it in every way in my power."
From one who has always been an earnest
worker in the profession :
"I have great faith in the monthly or half-monthly
plan of issuing the transactions if we can afford it,
for the following reasons: they would reach us, or
begin to reach us, fresh from our meeting, while we
are yet interested, which would carry this interest
through year after year. Next, the journal would
contain carefully prepared papers, refined by discus-
sion, thus adding greatly to their value. Too many
journals print articles prepared by men without char-
acter or social or professional standing, the stories
reading well, while the fact is they are fables. Again,
this plan you suggest could encourage and stimulate
many good men throughout the state by inviting
county societies to send in good papers for publication.
"Yes, I am in favor of a state journal if it is within
our reach and we do not limit it to state transactions,
but let it contain also all the county transactions that
would be of general value and interest. I believe this
would stimulate local organizations, bring us closer
together and be worth far more to us than members.
I have talked over this journal idea with several pro-
fessional friends who all join me in the suggestions I
have made above."
From an active member and ex-president:
"I am strongly in favor of some change in the pres-
ent way of delivering the transactions. We should
have in this state a distinctly Pennsylvania journal and
I believe there is enough spirit and enterprise to main-
tain it."
From a trustee from a small society, and now
deceased :
"I most heartily concur in this effort — ^"the publica-
tion of a journal of the State Society in place of the
annual volume of Transactions,' — a volume not re-
ceived by a large number in the profession, and when
received put upon the shelf and possibly never read.
If proper interest is taken by members of the State
Medical Society the journal can be made, and no
doubt will be, most desirable and interesting. I
brought this before our society yesterday, a vote was
taken as to the issue, monthly or bimonthly, the ma-
jority favoring the monthly issue."
From a chairman of the Committee on Scien-
tific Business, now deceased :
"I decidedly approve of the State Society having a
journal of its own, or making arrangements with a
first-class journal of this state to furnish us a depart-
ment of our own in its columns. The trouble and
only objection I would have to the latter is that I am
not in favor of giving the society influence and
prestige to a questionable series of advertisements. I
am not a fanatic on that subject, but it is so evident
nowadays that medical journals are published more
for the trade than for the profession. As a whole I
think the society journal idea is the best proposition
that I have yet seen."
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THE PREVENTION OF SYPHILIS AND ITS
SANITARY MANAGEMENT*
WILLIS M. BAKER, M.D.
WARSeN, FA.
In comparing our present educational progress with
that of former years, it affords one great pleasure to
note a steady advance in the greater efficiency and
success attending every department of learning. Dur-
ing the last fifty years rapid progress has been made
in the advancement of science, law and invention and
the increasing efforts for improvement in every de-
partment of human industry and enterprise have been
crowned with success. This is an age of universal
development. Each new day brings to light some new
fact worthy the admiration of all. Seldom in the
annals of this earth has there been witnessed a time
so interesting, so remarkable as this. It is true that
we may limit our views and discover perhaps in the
histories of various nations, specific achievements more
wonderful and nearer perfection than any of which
we of to-day can boast, but we cannot go further and
say that the ages of antiquity placed humanity higher
in the scale of mental and moral progress, if we with-
draw from single achievements and isolated acts in
limited sections and look abroad upon the race and
general aspect of society. When, I ask, wercthe great
principles of truth ever at work as at the present time?
When has philosophy entertained such enlarged and
liberal views? When has the science of government
been so well understood? Our press teems with valu-
able information, conveyed to our homes in the cheap-
est and most convenient forms, volume upon volume
filled with instrviction which the wise and the good of
all ages have written is before us. The advantages
for self improvement and self culture have never been
equaled. When we see all these triumphs in human
excellence we cannot but reverence the glory of the
present and attribute to it all the greatness of our na-
tures and willing are we to compare its achievements
with those of modem times and if possible to assert
the progress and lofty superiority of our age.
While all these improvements and advancements
have been made in the various sciences, those who
work for the promotion of medical science have not
been idle. Their work during the past few years has
proved to us that some of the triumphs gained by these
efforts shall constitute lasting monuments in the his-
tory of medicine, and the good which shall accrue for
the alleviation of human misery and suffering shall
be instrumental in perpetuating the names of these
benefactors of our race. But is it not a stubborn fact
that too much valuable time has been devoted to the
cure and removal of disease? As this is true, we of
to-day experience the fact that not enough time has
been devoted to the proper consideration of this more
important subject — its prevention, and this opens to
us a new scene for activity, a new field for work. In
this direction much is to be done before we can ex-
pect to deal properly with questions which are of vast
importance to public health. Through the instrumen-
tality of our sanitariums some progress has been made
and a large amount of work laid out for future con-
sideration and for future ages to perform. At present
not all of our states have well-organized boards of
health so we must expect that a large part of this
much-needed work will go unfinished and work which
is to deal with the public at large, properly comes
'Read before the Warren County Medical Society, Dec. ao,
1930.
within the domain of our comparatively new science.
State Medicine.
Of the many questions with which the physician has
to deal, there is none at the present day of more im-
portance to us as a people than that of syphilis. In
dealing with this important subject let us lay aside
the idea of medicine for the relief of individual suf-
fering for a moment and direct attention towards in-
stituting organizations which shall have for their ob-
ject the prevention and suppression of disease from
among the masses, whose aim shall be the protection
of the public health, whether they exist as state or-
ganizations or as a sanitary bureau at the seat of gov-
ernment. Give them the power to obtain, if possible
complete control over every focus of infectious dis-
ease, every disease which has the power of transmb-
sion from one to another. It should be the duty of
every physician, and more especially of an organiza-
tion composed of medical men, to strive to enlighten
the public as far as lies within their power upon all
questions of public health and hygiene. Under that
head the subject of syphilis presents itself to us to-day
and we are bound, as intelligent and enlightened med-
ical men, so to look upon it. It remains no longer to
be asked only "What treatment shall I adopt in ref-
erence to this or that particular case?" but "In what
way can I do the most good toward arresting the
progress of this specific disease which is a poison to
the source of life?" Its seed is sown and scattered
broadcast over our land. We see its growth in all
stages of development. It is uprooting the very
foundations of moral and social life. Its poisonous
influence is experienced not only in the homes of the
popr and ill-cared for but its awful brand is stamped
upon all classes of society. We must wait no longer;
we must adopt some measures to restrain its dreadful
course. Duty calls every person enlightened upon the
subject, into the ranks of active service and with the
best interests of the- masses in mind, let us each one
aid in striking a decisive blow at the root of this dis-
ease.
Some leading minds of to-day recommend legisla-
tion to restrain its onward course, but who ever heard
of any great reform taking place unless that move had
the people to work for it, unless they understood the
nature of the proposed reform? We admit that it is
only through legislation that we can regulate proper
sanitary precautions in dealing with any question
which has to do with public health, but what can we
expect to gain, in dealing with this subject, by longer
waiting? This which of all subjects should represent
the type of precaution, whose governing sanitary
measures should be of the most strenuous nature.
In order that we may at least make an effort to do
good in dealing with this disease, what is to be done?
We know that our efforts would be in vain to try to
force upon the people laws of the nature and im-
portance of which they are totally ignorant Hence
in the beginning we ask how can the masses become
enlightened upon this subject which is so intimately
related to and upon which depends the well-being of
the human race? We answer, it can only be done
through the untiring efforts of our noble army of
physicians. It is surely within their power to diffuse
throughout our land facts concerning this disease
which will constituting living evidence. This evidence
must necessarily be presented to the people in the
form of statistics and thereby manufacture public,
sentiment. In fact, whatever light the people receive
upon this subject must emanate from these statistics
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565
as presented by the medical man, hence we see the
responsibility which is placed upon every physician
who is working for the removal of disease. It is his
duty to do all that he can for the furtherance of the
best interests of the cause for which he works. He,
like any other citizen, is not merely to occupy the
negative position, that of doing no harm, but as far
as lies within his power he has obligated himself to
do good. There is a capacity in our profession for
progress and to-day there is no question with which
the medical man has to deal of more importance to us
as a people, than the very subject under consideration.
What single scourge can count as many innocent
victims? Age, climate, sex, season, locality, tempera-
ture are none of them barriers to its progress. It is
estimated that over 8,000,000 of the population of this
country are at present infected with some form or
phase of syphilis. It is stated that there are now
nearly 500,000 women in the United Kingdom who live
solely or in part by means of prostitution. It would
indeed be difficult to overstate the amount of damage
that syphilis does yearly to our population and a care-
ful examination as to the mortality from this disease
shows it each year to be larger and larger. We have
only to search the records of the institutions where
syphilis is treated to form something of an idea as to
its relative frequency. In London, among the poor
alone, upwards of 100,000 apply yearly at the hospitals
for treatment of syphilis in some form, and this num-
ber, large as it is, must necessarily form a very small
part of the disease in that great metropolis, as at least
fifty per cent, of the cases are treated in private prac-
tice and at least twenty-five per cent, fall into the
hands of quacks or are treated by drugrgists or at
dispensaries. Other cities on the continent are rela-
tively as bad as London; however, in many cities
where reliable information cannot be obtained as to the
prevalence of this evil for they, like us, do not resort
to registration, which is the only means of bringing
out statistics. The records of syphilitic diseases will
show Dublin and Liverpool to be relatively as rotten
at London.
When we see such a large part of British blood
poisoned by this disease, is it not well to inquire, how
is it with us English-speaking Americans? Our sani-
tarians will tell you that Chicago, New York, St.
Louis, Baltimore, Buffalo, New Orleans, San Fran-
cisco and many other of our leading cities are com-
paratively as rotten as London, Dublin, Liverpool or
any of the cities on the continent. In fact, San Fran-
cisco, owing to the presence of foreigners (especially
the Chinese) has become of, necessity one of the fore-
most cities in our land, in representing to its people
the startling prevalence of this evil among them. The
larger part of the Chinese women, imported as they
have been into California, are sold and held as slaves
to be used solely for the purpose of prostitution.
Thousands of these degraded syphilized wretches are
daily breeding moral and physical pestilence among
innocent and respectable people and the brightest cities
of our Pacific coast must suffer the evil consequences
arising therefrom. If it be asked, what is the procur-
ing cause of ignorance and crime in these leading
cities, may we not justly answer that it can be traced
directly to these beings who dwell in these haunts of
filth and vice and who perpetually generate this
"jumbo" of specific disease.
The facility with which syphilis is communicated
is indeed marvelous. We know that it is daily con-
veyed from one to another by contact with infected
articles. It is not only often conveyed by the kiss
of filial affection, but authorities tell us that the secre-
tions from any syphilitic subject are capable of pro-
ducing in another a chancre of any form. It is con-
veyed by the cigar, the pipe, the tooth brush, the den-
tist's instrument, by the mouth of the suckling or the
breast of its nurse. Worse than all, it is oonveyed
by ignorant and criminal parents to unborn genera-
tions and thousands of deformed, imbecile children are
annually ushered into this world to suffer for a short
period and die. As a result we are losing an incon-
ceivable amount of national vitality.
Prof. Gross tells us of an endemic of syphilis that
occurred a few years ago in the north of France, at
which time a large number of men. women and chil-
dren were affected in rapid succession. Great excite-
ment prevailed, and it was at length ascertained that
the poison of this disease had been carried from house
to house by a midwife, who had a chancre upon one
of her fingers, contracted in the exercise of her pro-
fession.
Numerous instances are recorded of the occurrence
of syphilis in glass factories, where the saliva acts as
the vehicle of conveyance of the poison from the dis-
eased to the healthy. It is not necessary to further
quote instances of the occurrence of this disease as
they are facts long known to the medical profession
and from its ranks are numbered more innocent vic-
tims than from any other class of the community.
Therefore, as members of households as well as sani-
tarians and citizens of a country in whose prosperity
we have abiding faith, must we regard this subject,
not as one of remote importance but as one possessing
grave significance to us as individuals and protectors
of the public health.
But let us ask, why is it that this evil has existed
among us so long, why is it that the majority of our
people are so ignorant of its presence? There is only
one answer and it is this : the importance of this sub-
ject has been too long held in subjection, it has been
cast out as an improper question to be subjected to
the influence of public opinion. The members of the
press are as ignorant as men found in other walks of
life and as a result our main avenues for the diffusion
of necessary information are closed and those who are
alive to its importance have trusted it to be dealt with
entirely by the medical men.
Syphilis has long been before our profession, as a
subject of vast importance, but the time devote^ to it
has been in dealing with its treatment as regards the
individual and hot in dealing with its bearing upon
the masses. Is it not right and proper that the people
of to-day should know about this disease and know
that its evil effects are increasing and that its progress
or stay will materially influence the future genera-
tions? Must we wait until its disastrous effects shall
clog the wheels of national progress, when its indeli-
ble stamp is visible to all eyes and the knowledge of
its presence can no longer be withheld from the people,
before we even make an effort to stay its dreadful
mortality ? No I we must cease our whispers and pro-
claim the facts to the world, we must boldly scatter
the truth over the length and breadth of our land and
across our seas, we must call to our aid the press,
the pulpit, yea, the women of our country and to do
these things we roust show the world that we are in
earnest. We must issue our orders and call upon
state and county medical societies to do our bidding
and to cooperate with us ; we must keep the subject not
only before the profession but we must keepjt before j
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566
THE PENNSYLVANIA MEDICAL JOURNAL
May, 1921
the people and eventually we must appeal to legisla-
tion to give us the power to blot out this blight from
among us.
During the last century and a half our population
has increased from four to one hundred and five mil-
lions of people. We now rival the greatest nations
on the earth in commerce and manufacture. We are
beginning to make a name for ourselves in art, science
and literature and for a hundred years we have been
setting up our nation as a model for others. Shall it
be said that the representatives of the medical pro-
fession of our mighty nation, those who work to pro-
mote the health of its one hundred and five millions
of people and cognizant of these facts .shall longer
allow its people to rest in ignorance of the danger
which meets them on every hand, without an effort
to point out the danger or to lead the way of escape?
Certainly not. It is a duty placed upon every physi-
cian to guard as far as lies within his power, the
spread of this disease. It is exceedingly in keeping
with the highest interests of our profession, to secure
attention to the causes and prevention of disease.
When we stop and think how little we know of scien-
tific therapeutics and that we deal mostly with symp-
toms and not with the disease itself, we are certainly
reminded of the fact that if we are to keep pace with
the advancement being made in other sciences we must
adopt systems of sanitary inspection by which we can
at least lessen the. mortality from epidemics of con-
tagious or infectious diseases. If we aim at advancing
the boundary of our profession, how can we better
begin than by aiming a blow of unity at the root of
this evil?
This disease has been too long quietly installed
within our midst and its deteriorating effects are
facts against which we must no longer close our eyes.
We must strive to bring these facts before the people
and when they are alive to its importance there will
be a unanimous demand for protection from and re-
straint of this disease, which is now almost wholly
ignored and cast aside by our boards of health. It is
a fact that every well-organized city government has
its board of health and to this board is given the
power to protect the public against the ravages of
some of our contagious and infectious diseases, among
which we may name cholera, typhoid, smallpox, yellow
fever, scarlet fever, and diphtheria. If smallpox
makes its appearance in one of our cities, what is
done ? • The public are excited, it becomes the general
topic of conversation, measures are at once taken to
extinguish it. The board of health is at once notified
and each case must be reported as soon as found and
removed to the hospital erected for the treatment of
this branch of contagious disease. A very similar ac-
tion is taken whenever cholera or yellow fever make
themselves known. The people- are at once alive to
the necessity of the removal of these evils and prepare
the defense against their awful and speedy ravages.
Now, would it not be a wise move to give these boards
of health the same power in dealing with syphilis that
they now possess for the control of these other com-
municable diseases ? We must erect hospitals and give
this board the power of ferreting out each case (not
otherwise provided for), sending them to these hos-
pitals for treatment. Give it the power to get control
of the men and women who are likely to impart the
poison and disseminate it through a community.
The carriers of trade between our nations and great,
commercial centers are the carriers of syphilitic dis-
ease. One man may inoculate several women during
the time his ship lies in port and these women may
transmit this disease to scores of men and these men
carry it to their families and so on, until thousands
might trace the cause of their wretched existence to
these half-dozen women, who were inoculated by one
man. And this is only one of the thousand like in-
stances occurring daily. Give the board the power to
inspect these ships which daily arrive at and depart
from our ports, and if they find a case of syphilis,
cholera or smallpox, to send it to its designated hos-
pital for care and treatment Much time could here
be saved by requiring the surgeon of each vessel to
personally inspect or examine every man on board the
ship, before its arrival in port and to give to this
board the result of his examination, that they who
possess the power might deal with and thereby prevent
these subjects of syphilis from spreading the disease
through a commtmity. In some of the old countries
acts are in force which have to do with the sailor and
the soldier only, but this is not practical in this coun-
try. We have some able minds who favor licensing
prostitution, others who f^vor resorting to class
legislation, but any measures, whatever might be the
object, which have to do with fostering vice, would
be so rebelled against by the religious sentiment which
is so firmly established in our land, that any proposed
system which seemingly tolerated a supposed vice
would be sure to meet with a hearty and ignorant op-
position.
Different experiments have been tried in this coun-
try for the control of prostitution and each time the
experiment shocked the modesty of a large class of
moralists who could not rest easy until they witnessed
the downfall of the system. When we must tolerate
a necessary evil, let us deal with it tmder wise restric-
tions. All attempts at the extinction of prostitution
have in all ages and in all countries been fruitless.
The sexual impulse is sure to assert itself and as an
outcome we find that other laws are violated. Se-
duction, illegitimacy, criminal abortion and infanticide
have invariably followed. When the people know of
the danger they will not object to giving these health
boards the power of adopting a system of sanitary in-
spection to prevent the importation of syphilis from
abroad and complete control of the subjects at home.
This system is liberal, it is just and it cannot in any
way interfere with religious sentiment or with the best
interests of the syphilitic himself.
Now, what is there to prevent establishing these
boards and giving them this arbitrary power in dealing
with this disease? Nothing but the enlightenment of
the public. When the people fully appreciate these
dangers, there will be no trouble in getting the legis-
lature to amend the act concerning the power to be
exercised by our boards of health so as to give them
the same power in dealing with this disease that they
now possess over other contagious and infectious dis-
eases. This move will require not only the exertions
of boards of health in our large cities but it must
call into the field the united efforts of state and
county medical societies as well as the assistance of
every practitioner in this country. Now that a few
states have taken up the question of syphilis and had
the state legislature pass measures to ferret out the
cases not properly cared for and to find means for
their treatment, much may be done by not only saving
useful lives, but lessening the state and county expense
of caring for the thousands which are now awaiting
death in our hospitals for the insane, due to various
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May, 1921
PITTSBURGH ACADEMY OF MEDICINE
567
syphilitic lesions, which make them subjects of charity
for long periods of time.
We should devise Some means by which, when the
neglected cases are ferreted out, they can be properly
cared for at a cost within their reach. This can be
done and will be done as soon as reliable statistics of
the ravages of this disease can be placed before the
people. This plan can work no possible injustice to
the patient, but will be the means of restoring him, as
far as may be, to a useful place in society. I think the
reporting of the nature of the case to the health board
by the physician who has been consulted should be as
imperative as to report the other communicable dis-
eases. If such a course could be pursued, backed up
by the laws of the state, no patient could question or
criticize the medical man for performing his legal
duty. If in our hospitals, clinics can be established
for the care and treatment of the cases not otherwise
receiving treatment, much good can be accomplished.
When a record is kept of these syphilitics many inno-
cent people may and will escape infection, instead of
innocently and ignorantly entering into a life contract
with a diseased person, thus wrecking useful lives.
Don't feel that your duty to your syphilitic patient is
greater than your duty to humanity at large. Where
cases can and do seek proper treatment then the
physician should acquaint and enlighten the patient
of its nature and the necessity of continuing the treat-
ment until he has the disease under control as far as
it is possible to control it. Don't feel that your fee
received in treating these cases ends your duty or ob-
ligation to your profession. If our hospitals can care
for many of these cases which would otherwise not
receive proper care and treatment, who can say it is
not a proper procedure? Only the man who cares
more for a dollar than he does for a principle, who
cares more for his own interests than he does for the
Hippocratic oath.
If this disease is ever forced under control it will be
due to the efforts of the medical man to whom the
public look for guidance. Pile up statistics and sound
your klaxon till the warning is heeded and serious
consequences averted. Don't take a narrow, selfish,
ignorant view of the subject, but show the community
in which you live that God gave you gray matter to
use for the good of your fellowman. Whatever im-
perfections arise from the methods adopted, can easily
be removed as experience teaches better methods of
procedure. Get back of the movement and push — ^but
better still get ahead and pull, and lend your assistance
to a measure which promises the betterment of these
unfortunates and the protection of the innocent. Cre-
ate public sentiment until the people will demand laws
requiring registration. It is not difficult to show that
the labors of a board of health are intimately con-
nected with the' educational progress of the state, that
education is a power in arousing and manufacturing
public sentiment and developing into a state of per-
fection all matters which have to do with public health.
Every nation is interested in the progress of medical
knowledge on the simple ground of self-preservation,
even were there no higher wants of an ideal character
to be satisfied. A people which would be independent
and influential in promoting and maintaining these
principles which give life to our nation and health
to her subjects cannot afford to be behind in the race.
Look where you will, examine whatever records you
may, you will find the greatest prosperity where there
is the highest educational development. An ideal sys-
tem of education on this question of syphilis requires
organization and unity. It should culminate in a
bureau of direction and control which would be able to
infuse right principles into all measures which might
be adopted in promoting a means of blotting out this
destroyer of homes and curse to human happiness.
Our profession affords ample means of culture for
every degree of proficiency developed in any of its
several departments. The aim of tiie profession has
ever been the maintenance of an elevated standard of
excellence. How can this excellence be better sup-
ported than by educating the public mind to that point
of due appreciation on matters most concerning them,
in order to establish laws for us which shall, in time,
blot out from among us these disgraceful drawbacks
to our nation's prosperity? By a proper regard for
these enforced sanitary measures with which all
should be made familiar, we must feel justified
in the assurance that the result of a few years'
labor will establish an impetus which will insure
a success in the future fully commensurate with the
requirements of our age and which shall lay the
foundation of a broad and generous culture, tending
ever toward the advancement of our profession and
constantly towards the moral and social, as well as the
intellectual elevation of our country.
PITTSBURGH ACADEMY OF
MEDICINE
ABSTRACTS
ACUTE LEUKEMIA
Dr. J. H. Whitcraft
The recognition of acute leukemia is comparatively
recent, dating from Ebstein's work in 1887 upon the
acute lymphatic form. Since then observations show
that the acute form is more common than was for-
merly supposed. Still more recently a number of acute
cases of the myelocytic form have been described, so
that we have lymphocytic and myelocytic forms of the
acute disease. It may be stated as a general rule that
the more differentiated the cells found in the blood,
the more chronic the disease is likely to be. Thus in
chronic myeloid leukemia there are all varieties of
cells in relatively large numbers, while in acute lym-
phatic leukemia the lymphocytes are so preponderant
that it is difficult to find any other kind of cell.
In acute leukemia the disease runs a much more
rapid course than in the chronic form. Of the two
varieties of acute leukemia, the lymphatic is much the
more rapid and may be fatal in a very few weeks
from onset. The characteristics of the disease are
much the same as in the chronic form, but are exag-
gerated in degree and in rapidity of course. Rapidly
advancing pallor and weakness or severe hemorrhage
may be the first indications of the disease. Irregular
fever, often with great sweating, thirst, and anorexia,
vomiting, diarrhoea, repeated hemorrhage from nose,
gums, bowels, and subcutaneous extravasations are
among the ustial symptoms during its course. Enlarge-
ment of the lymphatic glands is sometimes well
marked, especially in the lymphatic form, and may be
one of the earliest symptoms noted by the patient.
Among the early symptoms is angina, often of an
ulcerative character involving the tonsils and pharynx.
Examination of the blood, is, of course, the most
important procedure in arriving at the diagnosis. To
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568
THE PENNSYLVANIA MEDICAL JOURNAL
May, 1921
suspect the disease is to discover its presence. The
attempt to distinguish leukemia from leukocytosis by
the number of leukocytes is unreliable. The absolute
number of leukocytes must be complemented by the
di£Ferential count to give us an insight into the va-
riety, whether lymphatic or myeloid, acute or chronic.
Splenic enlargement is usually slight in the acute form
and the spleen, as in any acute condition affecting it,
is more likely to be soft than in the chronic form.
The lymphatic glands are usually enlarged but usu-
ally moderate in extent and may even be absent. The
cervical glands are the most frequently implicated, and
the enlargement may be limited to them or may ex-
tend to axillary, inguinal and mesenteric glands.
Disturbances of the alimentary system are common, .
especially in the more acute cases. The tonsils and
lymphoid tissue may be so enlarged as to give trouble
in swallowing, especially when this is complicated by
inflanunation, which frequently occurs. In many acute
cases the chief early symptoms are related to lesions
of the mouth. These are due to swelling of the tissues
from lymphocytic deposits and also to infective proc-
esses which supervene. The gums may become much
enlarged, spongy, inflamed, and bleed easily ; the teeth
may become loosened and the proper closing of the
mouth be interfered with. There is often decomposi-
tion of blood and marked fetor. The tissues are easily
injured and necrosis and ulceration, or even gangrene
may occur. The term leukemic stomatitis has been
applied by Mosler to this condition.
Prognosis : Acute leukemia is very rapidly fatal and
is probably the most malignant of all blood diseases.
In the cases I have seen personally the duration of
life was less than a month from the time the patients
came under observation. Osier states that death has
occurred as early as the seventh day. Just how long
the disease may exist prior to coming under observa-
tion it is, of course, impossible to say.
There is no specific treatment — a number of drugs
have been tried, of which arsenic seems the most
logical. X-ray treatment directed to the bones, spleen
and lymph glands has been without success, either in
ameliorating the symptoms or checking the rapidity
of the course of the disease.
INTESTINAL AUTO-INTOXICATION
Dr. Dewitt B. NErarroN
First. — I invite your consideration of a definition of
intestinal auto-intoxication as given by Combe as fol-
lows : "Intestinal auto-intoxication is a toxemia
caused by substances which are formed through the
influence of the vital processes of the organism."
This at once limits the size of the subject and
throws out of consideration all toxemias caused by
toxic substances which have been produced outside
the body and also those in which the toxemias have
been produced in the body, but under the influence of
microbes introduced accidentally from without.
The food toxemias resulting from tainted meats,
sausage, canned goods, milks, etc., are not to be re-
garded as auto-intoxication because the intoxication is
caused by the flesh of diseased animals or by the
pathological microbes or their toxins accidentally de-
veloping in healthy foods. It is also wrong to de-
scribe the symptoms presented by those who are af-
fected by one or another of the proteins, as those
symptoms due to anaphylaxis. Again, hyperthyroid-
ism, which may be regarded as an auto-intnxication,
is not under discussion because it is probably not of
intestinal origin; the same holds true of myxedema
and Addison's disease.
If we are to study intestinal auto-intoxication it
will be necessary to agree upon the definition and then
agree to the dual digestion in the intestinal tract, for
upon the putrefaction of the albuminous molecule
after it has been broken down as far as the amino
acids by the action, of enzymes or microbes, or by a
combination of these two, depends the development
of the toxic substances.
Now, if practically all civilized people eat too much
protein why do they not all exhibit symptoms of in-
testinal auto-intoxication. It is because of very elab-
orate defenses against the escape of these substances
from the intestinal tube into the blood. The gastric
juice disposes of some, the diastase of others, the
mucous of the small intestines and the cells of the
intestinal mucous membrane of others. The bile helps
to destroy the toxins and probably also some of the
microbes; also a part of the function of the liver cells
is to withdraw from the portal vein the toxic sub-
stances which have escaped the action of the detoxi-
cating substances in the intestine. It is probable that
toxins escaping into the blood are modified by the
action of some of the glands of internal secretions,
but their mode of action is apparently not clear. The
mode of escape from the body is through the stools,
the urine, the sweat, the expired air, and possibly
through the saliva. The symptoms are so varied that
it is difficult to say what part of the body may not
exhibit them. At the same time this very fact should
warn of a general cause; one that is capable of op-
erating in all parts of the liody and should tend to
an examination of the urine, the stools, and the body
of the patient before deciding on the nature of the
malady.
Symptomatology: To fairly describe the symptoms
is diffictalt. The manifestations are many and affect
almost the whole body. Among the most prominent
symptoms are fatigue, anemia, anorexia, insomnia,
skin irritations, neurasthenia, asthma, myocarditis,
arthritis, hyperacidity and hy{>ersecretions, muscular
atony, colitis, adhesions, ptosis, gall bladder conditions,
and chronic appendicitis.
Fatigue : This resembles greatly the fatigue of neu-
rasthenia. The patient is exhausted by a small amount
of work and loses the capacity for physical or mental
effort early in the day, has cold hands and feet and
sweating palms.
The anemia is of moderate d^ree and may be due
to absorbed H. S. from the intestine.
Annorexia is common, though many auto-intoxi-
cated have enormous ap{>etites and are large eaters.
Insomnia characterizes mostly the indolic forms and
while the patient sleeps badly at night, he is hard to
rouse in the morning and lies in a half-awake condi-
tion for an appreciable time.
The skin is the site of eczema, erythema and urti-
carial rashes ; acne and lichen planus may also be due
— ^at least partly — to intoxication.
Neurasthenia is frequently complicated by auto-
intoxication and in some cases it is possibly primary
as a cause; at any rate, these neurasthenics will dear
up more quickly if they are treated for their intestinal
condition than they will if treated neurologically alone,
and relapses will not be so frequent.
Eye symptoms include chroiditis and iritis and some
functional disturbances.
Asthma may be caused by putrefaction and absorp-
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May, 1921
WILLS HOSPITAL OPHTHALMIC SOCIETY
569
tion, but of course heredity, renid and cardiac condi-
tion roust first be excluded.
So with myocarditis; syphilis, alcohol and other
sources should first be excluded. Among the arthri-
tides, arthritis deformans is the most important, and
here Bassler claims most striking results from vaccine
treatment. It is not illogical to regard chronic ap-
pendicitis as the result of the bacteriology of the in-
testinal canal, and even in acute cases this may be
true. Almost anyone can think of patients who have
failed of lasting benefit after appendectomy and in
these cases it is probably the result of a bad intestinal
condition instead of a cause. The other intestinal con-
ditions mentioned, colitis, adhesions, ptosis and gall
bladder conditions, can be regarded as effects also.
It is only necessary to remember that bacteria may
reach the general circulation from the intestinal canal
to appreciate the possibility of this effecting the for-
mation of adhesions, cholecystitis and colitis by the
exercise of the same quality.
Any plan of treatment must take into account the
length and contents of the intestinal tube, its flora,
the fact that all the elements favorable to bacterial
growth and especially to the growth of anaerobes
are present These facts render the antiseptic treat-
ment futile, so far as drugs are concerned, although
it is probable that some reduction in the number of
bacteria can be secured by the use of beta naphthol,
creosote and formaldehyde. It is also impossible to
secure antiseptis by means of enemata and irriga-
tions, though eneraata will give relief from symptoms.
The best results are to be expected from a carefully
supervised diet which is to be determined from the
results of the bacteriology of the stools. If a saccharo-
butyric fermentation is responsible, then a high pro-
tein diet is indicated; while in the case of protein
putrefaction or the indol producing type, the lacto-
farinaceous diet should be followed. Teeth and mouth
should be rendered free from the possibility of re-
infecting the digestive tract, by careful attention to
the condition of the teeth and gums, and the frequent
use of the tooth brush. The food should be well
chewed and small meals taken; appetite should be
stimulated by bitter tonics if necessary. Adequate
motor activity should be induced by means of nux
vomica or strychnia; the blood improved by hema-
turic tonics, acid deficiency supplemented by HCL,
general bodily and mental vigor stimulated by rest,
baths or exercise according to individual needs. In
ordering carbohydrates it should be remembered that
all starches are not the same, that rice, macaroni, sago,
arrowroot and tapioca are not so likely to give rise to
the formation of organic acids and gases as are po-
tato, bread, sugar and the legumes. High meats,
game and fish, made dishes, broths, stews, pork and
veal are especially bad because of the high putrefac-
tion content. Frbderick B. Utlev, Reporter.
WILLS HOSPITAL OPHTHALMIC
SOCIETY
MEETING HELD AT THE WILLS HOSPITAL,
PHILADELPHIA, JANUARY 4, 1921.
Dr. Bxjrton Chance, Chairman
burns op the conjunctiva
Dr. p. N. K. Schwenk presented a young man show-
ing two kinds of burns, one a superficial burn of the
left eye and the other a deep burn of the right eye.
In this case both the palpebral and bulbar conjunctivae
were excoriated. The ordinary treatment of such a
case is olive oil but, in the opinion of Dr. Schwenk,
a vegetable oil should not be used, a mineral oil such
as cosmaline being preferable if one would use an
oil. Dr. Schwenk prefers to treat these .cases with
irrigations of cold sterile water repeated frequently,
no other medication being used. He wishes to em-
phasize the fact that he thinks dionin is contraindi-
cated in these cases. ■
Discussion: Dr. McCluney Radcliffe agrees with
Dr. Schwenk as regards the use of dionin, thinking
that it should not be used in the acute stages but
should be withheld for use in old cicatrices, etc.
Dr. Burton Chance: "Dionin should be used in old
cases but not in the acute stages."
Dr. L. F. Appleman stated that in cases such as the
above he uses a one per cent, solution of holocain in
an oily base, principally on account of the antiseptic
properties of this drug as well as its analgesic action.
RETAINED POREICN BODY IN THE GI^OBG
Dr. Schwenk also presented a man aged thirty who
had a penetrating wound of the globe, the x-rays
showing a foreign body to be present The magnet
had been used unsuccessfully upon two occasions.
The patient now has a retained foreign body, full
visual acuity and a comparatively quiet eye. The case
was presented on account of the question of treatment
BILATERAL TRAUMATIC CATARACT
Dr. McCluney Radcliflfe presented a boy who, while
driving cattle, accidentally struck himself across the
face with the lash. Following the blow double cataract
developed. Under general anesthesia Dr. Radcliffe
operated the right eye with a keratome, the left
eye being operated by the same method at a later date
under local anesthetic. The right eye healed well and
there was no subsequent operation while the left still
shows some slight reaction subsequent to a capsulot-
omy. Vision O. D. 6/6 O. S. 6/9. The operation
performed was the one of Dr. Risley: The keratome
is entered at the limbus, the capsule opened with the
point of the knife and the cortex milked over the
blade of the instrument, especial care being taken on
withdrawing the knife to proceed slowly in order to
prevent any possibility of iris prolapse.
Discussion: Dr. Schwenk — "After entering the
keratome make gentle pressure backward, this being
the secret of the operation."
Dr. Chance stated that Dr. Radcliife's case is but a
second instance of simultaneous bilateral cataracts
from moderate force which he has seen. In the past
twelve months he has operated upon a man in whose
eyes were complete cataracts which had been produced
by a flying leather belt
Dr. William Campbell Posey said that he could not
remember having seen a similar case of bilateral trau-
matic cataracts caused by blunt force. He supposed
there must be some rupture of the lens capsule, prob-
ably posteriorly.
CATARACT SHOWING HEREDITARY TENDENCY
Dr. Radcliffe showed a case of a young woman,
aged thirty-four, with a cataract first noticed six years
ago, shortly after a miscarriage. A combined ex-
traction was done. The patient has three aunts on
her father's side of the house who have cataracts
which appeared about the third decade of life.
Discussion : Dr. Posey agreed with Dr. Radcliffe
that soft cataracts which affect the comparatively
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THE PENNSYLVANIA MEDICAL JOURNAL
May. 1921
young are often hereditary and cited several cases in
his own practice. He dwelt especially on one case,
that of a young man who lost his mind coincidently
with his sight and recovered his sanity upon the
successful removal of his cataracts by operation.
PEBFORATING WOUND OF THB GLOBB AT THB UMBUS WITH
SeCOVERY
Dr. J. Milton Griscom exhibited a case illustrating
the conservative treatment of a severely injured eye.
The patient, a male aged 25, was struck in the right
eye on November 30, 1920, by a flying piece of wood.
When admitted to the Wills Hospital a few hours
later there was a gaping wound at the limbus up and
in with prolapse of the iris and vitreous. Under rest
in bed, atropine and ice compresses, in two weeks the
wound had healed with an anterior synechia and a cyst
had developed in the sclera at the site of the injury.
This grew rapidly in size until it was three by four
millimeters. A compress bandage was applied and a
solution of alum, eserine and adrenalin instilled twice
daily with the result that at the time the case was ex-
hibited the cyst had entirely disappeared, the eye was
quiet and the tension was normal. Dr. Griscom
thought the case was of interest because it illustrated
the value of postponing enucleation, in what at first
may seem a hopeless condition, until the case has been
under treatment and observation a few days.
Discussion: Dr. Schwenk mentioned a case in this
hospital a number of years ago who had several iris
cysts and stated that the case resembled the present
one very much.
DISTENSION OF THE CltlARY SEGMENT OF THE GLOBE
Dr. Burton Chance exhibited a case of distension of
the ciliary segment of the globe in a young man who
had had bilateral cataracts which had been extracted
two years ago. When discharged in 1919 there was
nothing abnormal noted in either eye. To-day the
patient returned to the hospital because of impaired
sight in his left eye and swelling of the globe in the
anterior segment A huge bladder-like swelling of
the entire superior aspect of the segment was present,
in the nasal third of which were two or three purplish
elevations resembling uveal tissue seen in staphylo-
matous ectases. The distension extended for some
distance below the external angle of the extraction
cicatrix which was well within the cornea and seemed
to be free Of iris tissue. Chance was inclined to re-
gard the case as one of cystic distension of the ciliary
body caused by a disturbance of the body and probable
inclusion of the lacerated tissues during the healing
of the wound after the extraction of the cataractous
lens.
PUCHS'S SUPERFICIAL MARGINAL KERATITIS
Dr. L. W. Hughes presented for Dr. William Zent-
mayer a case of Fuchs's superficial marginal keratitis.
The. patient was a colored man 25 years of age, with
a history of inflammation in his left eye of seven
months' duration and in the right eye of two
month's standing. The patient admitted that he had
gonorrhea ten months ago, also an inguinal adenitis
seven months ago. In the right eye there was a waxy,
concentric, superficial infiltrate invading the cornea
from the periphery except on the nasal side, the width
of this zone of infiltrate varying from two to three
millimeters. The line of extension was sinuous,
slightly denser than the other parts and presented fine
granular-like elevations which stained faintly.
CONGENITAL HYPERTROPIA
Dr. William Campbell Posey exhibited a case of
congenital hypertropia in a young man with marked
facial asymmetry, the left side of the face being under-
developed. With the left eye fixed in the horizontal
plane, the right eye deviated strongly upward. Down-
ward and outward motion in the right eye was
abolished but the eye could be moved downward and
inward to a certain extent by the superior oblique.
All other movements of both eyes normaL On ac-
count of the absence of action of the inferior rectus,
transplantation of muscle fibers from the internal and
external recti upon the inferior rectus was decided
upon. A curvilinear incision parallel to the corneal
limbus was made, laying bare the insertions of these
three muscles. The inferior rectus was found to be
absent, except for a very rudimentary portion of
muscle fibres found at the site of the usual insertion
of this muscle into the globe. The lower halves of
the externus and internus were sewed into position
through this stump. A free tenotomy of the superior
rectus was done. Care was taken to bring the cap-
sule of Tenon forward below as much as possible by
double single, stitch sutures. Healing was prompt At
the end of two weeks the eyes were on the same hori-
zontal plane, left hyperphoria of ten degrees, esophoria
of twenty degrees at five meters (no measurements
could be made prior to operation on account of the
high degree of the deviations). Refractions:
O. D. — S. 1.00 D. = -f-C. 2.2s D. ax. 85 = 5/6
O. S. +S. 0.50 D. = -f-C. 0.75 D. ax. 120 = 5/S
Discussion: Dr. William Zentraayer stated that he
had seen a similar case at the Polyclinic Hospital last
year.
ZON(n,AR KERATITIS
Dr. J. Milton Griscom presented a colored woman,
aged 60, who came to the hospital three weeks ago
complaining of failing vision in both eyes. The left
eye had been useless for a number of years and on ad-
mission vision equalled light perception. There was
a dense white band composed of somewhat irregular
masses of calcareous material located just beneath the
epithelium, this band being about five millimeters in
width and placed horizontally across the cornea. The
cornea above and below was clear but no view of the
media was obtained.
The patient stated that vision in the right eye began
to fail following an attack of influenza two years aga
On admission there was a thin band of homogeneous
infiltrate occupying a zone five millimeters wide at
axis 180 degrees in which, however, there were a
number of dear spaces. Vision 20/200. No view of
the media or fundus was obtained. Dr. Griscom had
planned to do an iridectomy in this eye but was forced
to postpone it on account of an attack of bronchitis in
the patient
Discussion: Dr. P. N. K. Schwenk stated that he
would be inclined to do an upward iridectomy for
optical purposes.
INTANTILE GLAUCOMA
Dr. L. W. Hughes presented for Dr. Burton Chance
a child, aged five, who was brought to the Wills Hos-
pital clinic about two years ago with a history of hav-
ing had an enlarged right eye since birth. The mother
stated that at the age of three weeks the child was
taken to the Episcopal Hospital in this city where a
growth (described as a membrane) was taken off the
eye.
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May, 1921
ABSTRACTS FROM MEDICAL JOURNALS
571
Two years ago examination showed the right eye
to be markedly enlarged, the external angle and tem-
poral zygoma had an aperture-like incompleteness,
upper lid margins thickened and drooping, entropion
of the upper lid, cornea almost twice the size of that
in the fellow eye and presented a number of blebs,
media otherwise clear and view of the fundus unob-
tainable. Left eye normal as far as could be deter-
mined.
At the time the patient was presented the right eye
showed marked enlargement, wide palpebral fissure,
lids swollen with entropion and trichiasis of the lower.
The cornea very much enlarged but clear. There was
a thinning of the sclera above. The anterior chamber
was of normal depth, pupil somewhat irregular and
did not react to light. The child counted fingers at
two feet. Media were clear. There was a deep, patho-
logical cupping of the disk which was quite pale.
Blood vessels normal calibre. No discreet lesions of
fundus seen except the glaucomatous cupping. Left
eye normal.
Discussion: Dr. Zentmayer thought the eye should
be enucleated soon on account of the danger of rup-
ture. He did not think an iridectomy was indicated. .
Many fine straight vessels invaded the affected area
from the limbus. The centre of the cornea was clear
and there was slight ciliary injection. In the left eye
the condition was similar to that in the right except
that the infiltrate was denser and there were some foci
near the centre of the cornea and in this eye the vas-
cularization was less marked. The Wassermann was
negative and the vonPirquet positive. Under small
doses of old tuberculin there has been a gradual im-
provement in the eye condition, also in the patient's
general health. Dr. Zentmayer wished to have stated
that he had been aided in reaching this diagnosis by
Dr. C. S. O'Brien.
Discussion: Dr. Posey thought the case one of
hyperplasia of the epithelial element of the cornea
and vascularization not unlike that of the salmon patch
in interstitial keratitis. He thought the case would
probably prove to be specific
Dr. Schwenk thought that an enucleation in the near
future would tend to equalize the development of the
two sides of the face.
Dr. Posey stated that he would do an iridectomy
first and if this were unsuccessful he would enucleate.
CONGENITAL PTOSIS
Dr. Burton Chance exhibited the following cases :
1. A case of congenital ptosis in a young negro who
has, in addition to the drooping of the lids, an inability
to look upward, all such e£Forts bringing about sharp
convergence of the axes, although involuntary con-
vergence cannot be attained until fixing object is car-
ried upwards.
2. An instance of high myopia in a woman and her
son.
3. A case showing highly glistening, numerous opaci-
ties in the vitreous, of the so-called snow-ball type.
The woman came to the clinic on the day on which -
a man was present in whose eyes exactly similar bodies
were noticed.
4. The young woman from whose left orbit an an-
gioma was removed several years ago, which case Dr.
Chance had reported before the Ophthalmologrical So-
ciety. The patient cannot elevate her brow nor raise
her eye. Chance intends to pursue a plan of operative
procedure which shall comprise the transplanting of
bundles from the frontalis.
INTKAOCULAR BLOOD FKESSURE
Dr. Pierre Gaudissart read a paper reviewing the
recent work of French and Belgian ophthalmologists
on the above subject. C. S. O'Brien, Secretary.
ABSTRACTS FROM AMERICAN
JOURNAL OF MEDICAL
SCIENCES
FRANK P. D. RECKORD, M.D.
Assistant Editor
ACUTE EPIDEMIC ENCEPHALITIS
Charles H. Mines, M.D., and Stanley L. Freeman,
M.D.
The clinical phenomena or symptoms of the disease
are caused by an acute infiltrative inflammation of the
central nervous system — especially about the optic
thalmus, the floor of the fourth ventricle and in the
white matter of the brain and cord.
The disease usually begins with symptoms that re-
semble and have frequently been mistaken for influ-
enza. Catarrhal manifestations of the mucous mem-
branes, of the upper respiratory tract with malaise,
headache, general pains (mild or very severe) and
frequently nausea, vomiting and constipation. The
prodromal period is from three to seven days plus.
In studying a group of twenty cases the average dura-
tion of fever was seven days, in mild cases 99 to loi
or 102, in fulminating cases as high as 107. Age,
nine to seventy-eight. Double vision was present in
seventeen cases, lasting two to four days. Third
cranial nerve paralysis occurred in eighteen cases;
bilateral ptosis was the most constant and striking
cranial nerve symptom. Fifth nerve paralysis was
present in nine cases with dropping of the lower jaw
and difficulty in chewing. Sixth nerve: six cases had
internal squint. Seventh nerve: next in frequency to
the third narve paralysis — ^usually unilateral and usu-
ally the right side. Eighth nerve not involved in this
series. The ninth nerve was affected and produced
dysphagia in seven cases. Tachycardia was present in
five cases. This is probably due to the tenth. The
eleventh was affected in three cases, involving the
trapezius and stenocleido mastoid muscle. A tremor
of the tongue and slurring speech such as is seen in
general paresis was often noted. This is probably the
effect upon the twelfth.
The most striking symptom seen in this series was a
disturbance of consciousness, progressive in character,
varying from apathy to coma and usually developed by
the end of the first week. The lethargy is at first mild,
so that the patient will arouse when spoken to and
answer questions. Later, as the lethargy increased it
was much more difficult to elicit responses. Some of
the patients were very restless and excited with mut-
tering delirium, yet apparently lethargic.
In the early stages of the lethargy, catatonia was a
symptom. The lethargy lasted from two weeks to
three months. Other notable objective symptoms were
ataxia — arms and legs, chloreiform movements, mus-
cular fibrillation — muscles and muscle groups and a
very important Parkinson mask resembling that of
paralysis agitans, the two latter symptoms being ex-
tremely common. Herpetic eruptions and purpura
were sometimes present with gangrene later. Severe
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THE PENNSYLVANIA MEDICAL JOURNAL
May. 1921
polyneuritis and paralysis sometimes ensued but as
fast as the neuritis ceased the paralysis disappeared.
Partial wrist drop and foot drop occasionally de-
veloped. Euphoria, a sense of well being, was fre-
quently present. Asthenia was often very pronounced,
the patient very often being difficult to move in bed.
The reflexes were exaggerated in thirteen cases, nor-
mal in four and decreased in three. Early in the
disease they are increased, and as the lethargy devel-
oped gradually decreased and returned to the normal
late in the disease. Kernig's sign did not appear con-
stant and very often at first was absent. This was
later increased during early lethargy and decreased as
the patient recovered. Babinski's sign was negative.
Muscular atrophy appeared only in those cases that
developed polyneuritis or paralysis. Spinal fluid re-
ports differ in this respect. Barker and Strauss report
an increased cell count and inceased globulin content.
Others found a clear fluid, no sediment and no in-
crease in globulin, the counts differing materially.
W. B. C. cotut of the blood usually a slight leucocy-
tosis.
Conclusions: In any case presenting fever, cranial
nerve paralysis, particularly the third and seventh ac-
companied by stupor or lethargy, with muscular fibril-
lation and tremor together with a mask-like face, a
diagnosis of epidemic encephalitis should be seri-
ously considered. A spinal puncture should be made
to exclude cerebrospinal and tuberculous meningitis,
anterior poliomyelitis and cerebrospinal syphilis.
January, 1921.
DIAGNOSIS OF MYXEDEMA
J. M. Ander, M.D., LL.D.
Myxedema is insidious in its onset. The importance
of recognizing this disease is shown in that first, there
is a sovereign remedy for its treatment ; second, seri-
ous physical and mental developments ensue in long-
overlooked cases ; eventually there is an unsatisfactory
response to appropriate measures.
It must be remembered that an infiltration of all the
anatomic systems of the body occur leading to an in-
crease in the general bulk of the individual. The most
characteristic sign is a firm inelastic thickening of the
skin and subcutaneous fibrous tissue and connective
tissue which does not pit on pressure. The dry,
swollen skin of the face obliterates more or less com-
pletely the natural facial lines, so that in well-marked
cases the patient seems to be wearing a mask with
broad coarse immobile features. The same dry, firm,
inelastic myxedematous infiltration of the skin of the
extremities and notably in the supraclavicular region
is to be observed. The mucous membranes are also
infiltrated and the teeth may become loosened. A solid
appearance of the conjunctiva has been emphasized
as an early sign. The tongue, lips and nose are thick-
ened and the voice is peculiarly monotonous and has
a leathery tone with curious nasal explosions at short
intervals during speaking. Thought and movement
are slow and heavy. Retardation of psychomotor ac-
tion is to be regarded as being quite characteristic.
The patient may have headache and irritability of
temper, hallucinations and delusions tending toward
dementia, trophic changes of hair and teeth and de-
struction of the masticating apparatus. Baldness is
common with special distribution — the hair of the
frontal region, nape of the neck and eyebrows. Al-
bumin is commonly found in the urine and occasion-
ally tube casts as well. Temperature is usually sub-
normal. Thyroid is not palpable. It is a disease in
itself and can be recognized as readily as flowers of
the field or the faces of friends when these are seen
often enough.
Commonly chronic nephritis is mistaken for this dis-
ease. Recognition is based mainly on observation of
skin and mucous membranes and the fact that myx-
edematous infiltration of the face and legs is harsh,
and inelastic. Stiff edema does not pit on pressure as
is true of cardiac and renal dropsy. Myxedema,
acromegaly and tuberculosis may be associated.
Another endocrine disease intimately related to
myxedema along metabolic lines and not infrequently
associated with it is exopthalmic goiter. Similar
metabolic disturbances may be present in both hyper-
thyroid and hypothyroid states and also the blood
picture in exophthalmic goiter is practically identical
with that of myxedema.
Another group of cases of so-called myxedema
fruste or incomplete myxedema is characterized by
irritability of temper, malarflush, apathy, neuralgia,
headache, impairment of memory, tinnitus (especially
when lying down), slight deafness, slowness of the
mental processes, undue susceptibility to cold, weak
digestion, constipation, swelling of the nasal mucosa,
slight thickening of the skin and subcutaneous tissues
(often confined to certain regions of the body), early
fatigue on exertion and a moderate degree of anemia.
The thyroid is usually smaller than normal. Eczema,
psoriasis and urticaria are often present
In all suspicious cases make a cautious trial with
thyroid preparations as a diagnostic aid.
December, igso. .
COMMUNICATIONS
Dear Edtor:
From the time of the organization of the Medical
Society of the State of Pennsylvania in 1848 until
August, 1920, it had no fixed "home." In the above
month rooms were rented and occupied, at 212 North
Third Street, Harrisburg, and the first step in the
direction of a permanent place of business was taken.
Under present conditions the Society is, however,
"locum tenens" subject to the whims of a landlord,
either for an increased rental or a notice jto vacate
For an organization of so great a number and of
so much importance to the medical profession of our
State, it is imperative that a permanent home or office
must be maintained. As no business can expect to
succeed with the possibility of an ever-changing ofiice,
no less can our Society properly perform its functions
unless it shall be permanently located. With this per-
manent location must come that concrete working
organization which is essential to every enterprise.
We are a growing and prosperous body; and if the
present rate of increase continues it will not be long
before our membership will reach the eight thousand
mark. To a very great extent we must throw off
that one predominating idea, altruism, and realize that
. as a profession we must embrace modem methods of
business. We can no longer go along in a slipshod
manner as individual practitioners and no more can
we as a corporate body hope to exist if we do not
change our methods to correspond with those of other
business concerns.
Might it be considered premature at this early date,
to speak of acquiring a building of our own? Is it
too soon after opening our present office, and is the
venture only experimental? We hope not. We be-
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May, 1921
COMMUNICATIONS
573
lieve there is no time like the present to launch a cam-
paign, or at least to place the proposition before the
Society with the hope that it shall merit the considera-
tion it deserves and eventually make such a project
possible.
The Society is paying an annual rental of $840.00, or
the interest of an investment of $14,000.00 at 6 per
cent., and that for two rooms, the only concession being
heat. All repairs must be made by the tenant, which
though it may not mean a large sum annually, is
nevertheless an added fixed charge. Looking the
proposition squarely in the face, is it good business to
go on in this manner year after year? Would it be a
better policy for the Society to pay this amount for its
own use or to a landlord who has no future interest
in us whatsoever.
Think it over ! What say you ?
Ira G. Shoemaker, M.D.
Af>ril 20, 1921.
THE PHYSIATRIC INSTITUTE
MORRISTOWN, NEW JERSEY
The attention of the medical profession is
called to this newly-established institution for
the treatment and investigation of metabolic
disorders, especially diabetes, obesity, nephritis
and high blood pressure. The purposes of the
institute are scientific and philanthropic, and
treatment is offered to suitable patients in all
degrees of financial circumstances.
The benefits of the newer dietetic treatment
of diabetes are now generally recognized. Less
information has as yet been disseminated con-
cerning the full possibilities of accurate diets
for renal and vascular troubles, especially ar-
terial hypertension. The modern developments
in diagnoses and therapy have made the field
of metabolism a distinct specialty. It no longer
suffices, for example, to treat a case of high blood
pressure with random prohibition of red meats,
or milk diet, bed rest or drugs of any kind, when
exact chemical studies can show specifically
what kind of food material is at fault and the
dietary modifications necessary for relief.
Under these methods high blood pressure is no
longer a hopeless condition. Marked and last-
ing benefit is obtainable in nearly all the earlier
or milder cases and also in a high proportion of
the older or more severe forms, sometimes even
in the presence of advanced arteriosclerosis. In
so far as arteriosclerosis may be secondary to
hypertension, its advance may perhaps some-
times be checked by the control of the latter.
The general principle of the management of this
entire group of disorders is thus the same;
namely, the diagnosis of a specific deficiency of
a bodily function, and a rest treatment provided
by an accurate diet which spares the weakened
function as completely as possible.
The problem involved is a very large one.
According to Joslin's estimate over five hundred
thousand persons in this country to-day have
diabetes. The number of renal and hyperten-
sion cases is far greater, and undobutedly totals
several millions. This group of disorders rank
among the commonest causes of rejection for
life insurance. Probably a majority of the en-
tire population may expect to suffer from some
of them either in themselves or in their fami-
lies. Disability, suffering and death on the
large scale represented in these chronic dis-
eases offer a challenge to medical attention.
An inefficient or half-way treatment of these
troubles is no longer excusable. Conscientious
physicians are divided broadly into two classes,
namely, those who take a special interest in
these conditions and provide themselves with
the necessary special training and facilities for
treating them; and those whose interest and
training lie in other directions and who are glad
to be rid of these chronic cases by sending them
elsewhere for treatment.
In former years thousands of patients, either
on their own volition or the advice of their
physicians, flocked yearly to famous resorts or
watering places in Europe. Thousands more
congregated at various mineral springs in this
country, or sought the supposed advantages of
change of climate. The medical profession
should face squarely the fact that the disorders
in question are the result of damage of organs,
which continues even after the original infec-
tious or toxic cause has been removed, and that
the old belief in the curative value of mineral
waters for such troubles is a superstition. The
war put a stop to the pilgrimages of Americans
to the European spas, and they will probably
never be resumed, since the American develop-
ments in therapy have made the former treat-
ment obsolete.
All these circumstances combined have cre-
ated a pressing need for American institutions,
equipped with the necessary laboratories and
diet kitchens, together with a properly trained
staff, for the study and treatment of such cases
by up-to-date scientific methods. General hos-
pitals have notoriously served chiefly for sur-
gical and acute medical cases, and have made
very inadequate provisions for chronic and
metabolic cases. Some of them are now meet-
ing the new need by the establishment of meta-
bolic wards, with the requisite laboratory and
kitchen attachments. This is a movement which
will doubtless grow. Nevertheless the rest and
pleasant surroundings, which were the most im-
portant feature of the old-time resorts, are best
obtained in a special institution, which also
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THE PENNSYLVANIA MEDICAL JOURNAL
May, 1921
oflFers other advantages for both treatment and
investigation. The founding of such an institu-
tion is a needed philanthropy for the rich, as
may be testified by physicians who realize how
seldom those who can pay the highest prices ob-
tain the most efficient treatment; and this need
is obviously magnified in the case of the poor.
The Physiatric Institute, under Dr. Frederick
M. Allen as director, has been organized as one
attempt to meet this need. For the site was ob-
tained the former coimtry estate of Otto H.
Kahn, comprising some two hundred acres of
woodland, lawns, gardens and farm land. This
environment, and the pleasant and healthful all-
year climate of Morristown were chosen as ideal
for the comfort and welfare of the sick. Never-
theless they are not stressed as the main
features, and emphasis is placed solely upon ac-
curacy and thoroughness of the dietetic treat-
ment. Only those patients are invited who will
seriously cooperate toward their own improve-
ment, and the purpose is to provide the proper
treatment for such, irrespective of their financial
circumstances. The accommodations offered,
therefore, must range from those which are
within the reach of the poor to those which are
suitable to please the rich. Also, in the absence
of any important endowment, the institution
must be essentially self-supporting.
This financial problem is met by considering
first the basic cost of treatment. The diet treat-
ment is expensive, especially as accuracy re-
quires individual study of each patient, the
separate weighing of every article of food by
trained dietitians, and the best, quality and
preparation of each article in order to make the
restricted ration appetizing and satisfying. The
regular ward rate is therefore fixed at thirty
dollars per week, with an additional charge of
fifteen dollars per week for medical and labora-
tory services. A reduction below these rates
means charity, as it is a reduction below cost.
Such reductions are made for any worthy pa-
tient, who may be called upon to pay thirty,
twenty or ten dollars per week, or nothing, ac-
cording to circumstances. Both self-respect and
appreciation are cultivated by the payment of
some amount if possible. When feasible, cer-
tain patients may perform labor in part payment
for treatment, but the general experience with
such attempts at labor has been disappointing.
Abuses such as are common in free clinics are
for the most part avoided by requiring a repu-
table physician's recommendation for the ad-
mission of such patients. The strict require-
ments concerning personal character, fidelity to
treatment in the institute and ability to con-
tinue it at home exclude a type of patient iq)on
whom exact treatment would be wasted and
who can best be managed in public hospitals.
By the same rule the wards are kept as a fit en-
vironment for the treatment of respectable pa-
tients, either paying or nonpaying.
Rooms for one, two or three patients are of-
fered at graded prices, ranging from a slight
increase above ward rates to the higher tenns
which the rich may pay for the best accommoda-
tions. No reduced or charity rates are made for
the private rooms. The same strict fidelity to
treatment is required of the highest paying pa-
tients as of charity patients.
One of the most important purposes of the
institute is scientific investigation of the dis-
orders in question. From one aspect, research
is indispensable for the best treatment, since the
best medical workers necessarily approach their
tasks from the standpoint of research. A spe-
cial institution of this character should afford
an exceptional collection of clinical material,
with corresponding facilities for study. Animal
experimentation is not yet in progress, but is
planned as an important phase of the work. It
is expected that the principal development of
the institute will lie along the lines of research.
With the possibilities open for clinical and ex-
perimental study, and with the training which
may be offered to physicians, nurses and dieti-
tians in this special field, the founding of such
an institute may be hoped to mark an epoch in
the development of the subject in this country.
Granted the proper scientific guidance, the
success of such an undertaking depends essen-
tially upon securing funds. The fact is im-
pressed upon patients that the problem of
metabolic disease is primarily a problem of
those who suffer from them ; that the aggr^ate
wealth of the afflicted individuals and families
is many times that of any single philanthropist;
that they have heretofore been dependent upon
somebody's chance charity for providing means
for treatment and investigation of their trou-
bles ; but that by' cooperation they are abun-
dantly able to provide these means for them-
selves, and ought not to remain thus dependent
upon the charity of others. Some support for
the charitable and scientific work has thus been
obtained, but an appeal is made to all persons
interested for more funds to place the new in-
stitute on a safe basis and aid in the develop-
ment of a branch of medicine in which the
possibility of important therapeutic advance has
already been demonstrated. — Advt.
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ELEVENTH CONFERENCE OF INDUSTRIAL PHYSICIANS AND SURGEONS
HELD UNDER THE DIRECTION OF THE DEPARTMENT OF LABOR AND IN-
DUSTRY OF THE COMMONWEALTH OF PENNSYLVANIA
BELLEVUE-STRATFORD HOTEL, PHILADELPHIA, DECEMBER 17, 1920
MORNING SESSION
The meeting was called to order at lo a. m. by the
chairman, Dr. Francis D. Patterson, Chief, Division
of Industrial Hygiene and Engineering, Pennsylvania
Department of Labor and Industry, Harrisburg, Pa.
D«. Patterson: The meeting will come to order.
This is, as you know, our eleventh conference of State
Industrial Physicians and Surgeons; and at this time
it gives roe very great pleasure to introduce to you the
Honorable Clifford B. Connelley, Commissioner, De-
partment of Labor and Industry, who will give us a
few words of welcome. Commissioner Connelley.
ADDRESS OF WELCOME
DR. CLIFFORD B. CONNELLEY
Commissioner, Pennsylvania Department of Labor and
Industry
HAKKISBURG
The doctor has a way of presenting to his col-
leagues the subjects which he would like to have
presented, and especially the people who are go-
ing to present them ; and you notice that every
time he presents a person, he ends as he starts
out, and in many cases he carries his audience
with him. In this case, however, the department
has others than the audience. If you will bear
with me, I will read this Address of Welcome,
which was written by another person in the
office.
We have been disturbed a great deal in the
past months over the high cost of living; it
might help us considerably if we would &ink a
little more of the high cost of life. Human life
is the costliest thing in the world;. We are born
in bitter pain and suffering of others. We are
nurtured by the destruction of other forms of
life — ^the plant and the animal. We are kept
warm by the sunless toil in the mine. We are
clothed by the patient weaving of the worm, by
the sheep yielding his coat of white, and by the
weary toiling of millions in shop and factory.
Even our luxuries and pleasures are only pos-
sible through toil and the sacrifice of some form
of life. Life that is so dearly bought should be
safeguarded by every possible means.
The original "safety man," when we consider
the conservation of human life, is the physician.
It is your profession that deals most directly
with the whole problem of safety, which in the
final analysis means keeping man fit to live and
to do his work in the world. It was inevitable
that when it was pointed out that industry was
the cause of much of the injury to htunan life
that the physician should specialize and apply his
skill to making our industries a safe place in
which men may work. It is a real pleasure,
therefore, to have this opportunity again to wel-
come to this conference you who safeguard the
health of our workers, who treat their injuries
when our mechanical safeguards and standards
have failed, or have not been installed, or have not
been used, and who labor to restore them back
to health and to their jobs. Pennsylvania owes
much to the industrial physicians and surgeons
who gather with us year after year to confer on
how best to conserve the life and health of work-
ers in our industries.
In studying the program of this conference
one discovers three major topics of compelling
interest in the matter of the preservation of hu-
man life:
1. There is the problem of the injured worker
— the transportation, the treatment of his
wounds, and the rehabilitation of the industrial
cripple.
2. There is the distressing fact of infant mor-
tality due to our industrial conditions, and the
difficult problem of the child in industry,
3. I am particularly glad to note this subject,
"Our L^slative Program."
If I may I would like to discuss these three
topics in a general way, keeping in mind their
relation to the high cost of life.
THE INJURED IN INDUSTRY
The cost of industrial accidents can never be
adequately met. We set an arbitrary sum of
money for the loss of a foot, or a hand, or an
eye, or a life, but in no real sense can money
ever compensate for such losses. It is, of
course, a big step in advance that the injured or
his dependents might secure some financial as-
sistance under the compensation law. The law
also is effective in that it makes the employer
careful to prevent accidents as a matter of busi-
ness. In Pennsylvania, with a safety program
that compares favorably with that of any other
state or commonwealth, and with the enforce-
ment of the most favorable laws pertaining to
safety we can only report that for the.past six j
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THE PENNSYLVANIA MEDICAL JOURNAL
May, 1921
years industrial accidents have been reduced
forty per cent, in the commonwealth.
While we are greatly concerned in our safety
campaigns in preventing accidents, we have too
often forgotten the man who was the victim of
the accident. Most of our programs and discus-
sions in the past have ignored the wounded man.
The consideration of the wounded man seems to
me to be one of the very great services that such
a body as this has done towards the conserva-
tion of human life. While some of us have been
busy theorizing, making laws, conducting cam-
paigns, outlining safety organizations, the phy-
sician and surgeon have taken the injured man
"as is," and by knowledge and skill, have re-
stored him to health and usefulness to industry.
The practical nature of the discussions, as out-
lined for to-day: "The Transportation of the
Injured," "The Treatment of Wounds," "The
Rehabilitation of the Industrial Cripple," is im-
pressive by reason of their simplicity. Much is
being written and discussed to-day of the mar-
vels, almost miracles, that are being accomplished
by physicians and surgeons. In this connection
the following interesting editorial from one of
our Philadelphia newspapers has come to my at-
tention :
SURGERY AND CHARACTER
"The theory of which physicians are more and
more taking cognizance, that character or men-
tal traits can be influenced by certain kinds of
surgical operations, holds out fascinating possi-
bilities. If it can be established that by remov-
ing pressure on the brain a defect of the mind
can be remedied, or that mental growth can be
stimulated by transplantation of glands, the way
will be paved for a vast improvement in the hu-
man race.
"Cases in which there is expectation of realiz-
ing these results in the manner indicated are re-
ported from Philadelphia and Chicago. In the
former city there is a boy, otherwise of unusu-
ally great intelligence, who seems to have no per-
ception of what is right and what is wrong, and
who is repeatedly getting into trouble by com-
mitting robberies. It is thought his mind is af-
fected by the conformation of his skull, and pos-
sibly by other physical defects, and it is proposed
to perform an operation in the hope that a
healthy brain and normal mind will result. The
theory that his criminal propensities are a form
of mental trouble does not seem far-fetched
when it is borne in mind that there are recog-
nized forms of insanity, such as kleptomania,
and pyromania, in which the victims show no
other symptoms of derangement, except the com-
mission of the deeds from which the diseases de-
rive their names and which in normal persons
would be crimes.
"In the Chicago case a thyroid gland from a
monkey (chosen only because a human gland
was not available) is to be transplanted to a 19-
year-old girl who has been locked up in a cellar
since she was a baby, and consequently is no
more developed intellectually than a baby. If
the operation has the desired result, the question
arises if it will not suggest ways of treating
other cases of arrested mental development.
"It "is no wonder, in view of the hope of relief
that success in these operations would hold out
to thousands of other persons defective or other-
wise abnormal mentally, that the cases have
aroused extraordinary interest."
Of course, we all understand that there re-
mains much to be done before the medical pro-
fession can achieve definite results along such
lines. It is of practical moment however, to
know that much of what we considered impos-
sible years ago is now becoming within the realm
of possibility. My plea is that some of the study
and skill that is applied to the relief of the men-
tally defective, if applied to the physically in-
jured in industry, would accomplish results of
inestimable value to industry itself as well as the
placing of proper emphasis upon the value 0!
human life. Industry figures its losses through
industrial accidents and diseases at a half billion
lion dollars ($500,000,000) annually ; by throw-
ing out of employment 250,000 persons per year.
It is highly gratifying to note that the matter
of the rehabilitation of industrial cripples is to
be discussed at this meeting. We recognize in
Pennsylvania that it is not enough to restore a
man to health after he has met with an industrial
accident or suffered from an occupational dis-
ease, but it is our job also to restore him back to
industry as a productive worker. We believe
that the type of rehabilitation service that is be-
ing done in this commonwealth, of which you
will hear, is good business.
THE CHILD AND INDUSTRY
We speak of industrial injuries as accidents;
we are rapidly coming to the point where some
accidents must be called by their proper names —
crimes. As soon as the public conscience can be
aroused to this point there will be less accidents
in industry. I wonder if the day has not ar-
rived when we should speak more frankly on the
matters of infant mortality and of child labor.
We are told that "every year from a quarter to
a third million little children and approximately
20,000 mothers in childbirth, die from prevent-
able causes." In studying causes this chdienging
fact has been stated again and again with good
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May, 1921
CONFERENCE OF INDUSTRIAL PHYSICIANS
577
authority, "in certain industrial centers the in-
fant mortality rate is twice as high as in similar
towns without factories and overcrowding." In
1917, Erie, Pennsylvania, with 2494 births, or
a birth rate of 32.6 per 1,000 estimated popula-
tion, had a mortality of 87 infants under one
year of age per 1,000 births. Johnstown, with
2,246 births, a birth rate of 31.9 per 1,000 of
population, had a mortality record of 130 in-
fants under one year of age per 1,000 births.
The following gives the deaths of infants under
one year of age per 1,000 births in a few of our
important cities of the commonwealth for 191 7,
from which we may deduce our own conclusions :
Allentown 144
Altoona 89
Harrisburg 81
Lancaster 92
Philadelphia 108
Pittsburgh 120
Reading 104
Scranton 148
(Note: These figures were taken from the
American Year Book of 1919.)
We believe that the greatest need of any city
or commonwealth or of any country is a stable
birth rate and a low rate of mortality among in-
fants. It is forever true that the mother is the
greatest factor in saving the baby. This brings
us to a condition of women employment which
^^e must face. Women cannot work in factories
and raise babies. No woman should be per-
mitted to work at a dangerous trade. Women
are not physically capable of doing the same
work as men, if we are to consider the future of
the race. Women in any industrial establish-
ment should be provided with seats.
The other side to the high cost of life in con-
nection with the child and industry, is permit-
ting the child to enter industry before he has
been properly matured mentally and physically.
It will be a great thing for America when there
shall be uniform minimum physical standards
for the child laborer. Pennsylvania needs to co-
ordinate its efforts in enforcing its child labor
laws. The responsibility for enforcement is now
divided among the State Department of Public
Instruction, the police authorities of the local
community, and the Department of Labor and
Industry, and it must be confessed that the en-
forcement is far from satisfactory. We are
hopeful that the next legislature will create a
Bureau of Women in Industry and Child Wel-
fare, in the Department of Labor and Industry,
that will supervise the cooperative administration
of the laws now on the statute books.
LSGISLATION
This brings us to the important matter of leg-
islation with its bearing on the high cost of life.
Whatever your legislation program might be, I
trust that it will be pitched on the idea that the
state government exists to help industry and not
to hinder it. The old conception that legislative
enactment means interference and prohibitions
must be relegated to the scrap heap. A desire
for really constructive legislation will meet with
a ready response on the part of the governor and
the members of the coming legislature.
Now, ladies and gentlemen, I wish that you
would follow what the department is trying to
do, and especially the Bureau of Hygiene and
Engineering. It is your help that we are seek-
ing. I certainly, as the executive of this De-
partment of Labor and Industry, under whose
auspices this meeting is held, wish to greet you
here to-day.
Dr. Patterson: I am sure that we are most appre-
ciative of this address of welcome by the commis-
sioner of this department.
The next paper is "The Obligation of Industry in
Relation to Infant Mortality." I am sure it is unnec-
essary for me to point out to you at this time the re-
sponsibility which industry owes to the heahh of these
children, who will eventually become the wage earners
of the commonwealth; and it gives me great pleasure
to call on Dr. Potter, who is the Chief of the Division
of Child Health, Pennsylvania Department of Health,
who will address us upon this subject.
THE OBLIGATION OF INDUSTRY IN
RELATION TO INFANT
MORTALITY
DR. ELLEN C. POTTER
Chief, Division of Child Health, Pennsylvania State Depart-
ment of Health
HARRISBURG
The field in industrial medicine, or better, of
industrial health conservation, is in process of
delimiting the sphere of its activities. Are these
activities to be limited to the confines of the
plant and to those persons actively engaged in
industry or are they to reach outside of the plant
into the community and to concern themselves
with the welfare of the individuals who compose
the families of the workers and even to concern
themselves with the friends and neighbors of the
plant employees?
If the health conservation activities of the
plant are to reach out into the community what
is to be their purpose and what advantage will
it be to the plant which so enlarges the scope of
the activities of the industrial physician and
nurse ?
What I shall say to-day is for the purpose of j
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THE PENNSYLVANIA MEDICAL JOURNAL
May, 1921
ascertaining what cooperation and coordination,
if any, can be secured between industry and the
State Department of Health particularly in rela-
tion to its child conservation program.
In the old, old days there was a period in the
development of industrial relationships when
"master" and "man" were friends; the master
knew the problems in the individual homes of
his workers and the wife of the master was the
home visitor and the lady bountiful in the more
or less crude type of social service then estab-
lished. Where these relations obtained there
was steady employment, maximum production,
reasonable profit and loyalty.
At a later period with industry grown large
and impersonal, the man in industry became
only a "hand"; personal relations ceased; the
"hands" were driven to the maximum and were
scrapped when they were worn out; the wives
and children were left to shift for themselves or
were cared for by charitable agencies, not expres-
sive of any good will on the part of the employer.
This made for industrial war, economic waste
and human degredation.
At a still later period society, as represented by
organized government, began to set up standards
to safeguard those employed in industry, as to
hours of labor, conditions under which labor is
performed, minimum age for employment, edu-
cational qualifications, physical condition of
those entering industrial employment, and so on.
Society did these things for the protection of it-
self, for it was not expedient that men and
women should be relegated to the scrap heap at
a time when they ought to be at the maximum of
productivity and unregulated employers ab-
sorbed in the thought of profits were not con-
sidering human welfare.
Organized society now faces another prob-
lem ; it has made its attempt to place safeguards
about the workers of the present day, it must
now conserve and safeguard the potential workr
ers of to-morrow, the babies of to-day, the group
which until recently has been left to die without
thought of the great economic waste involved.
The mortality which occurs among infants
under one year represents approximately one-
fifth of our annual toll of death and the loss can
never be replaced. The factors which make for
this high infant mortality have some of them
been pointed out by Commissioner Connelley in
his address, and to them I want to call your espe-
cial attention.
He has said that the mother is the most im-
portant factor in the cause and also in the pre-
vention of infant mortality. Will you note par-
ticularly these facts, that if the mother is em-
ployed in industry too late in the months of her
pregnancy, her child has a diminished chance of
survival and she herself runs a much greater
risk of death. Figures submitted by English ob-
servers indicate that of women employed in in-
dustry one dies out of every 1 16 who are deliv-
ered, while of women who are not so employed
only one dies out of 293 delivered ; for one still-
birth among women who are not employed in in-
dustry there are 8 stillbirths among those who
are employed. They also report that during a
period of great industrial depression and unem-
ployment in one of the mill towns, during which
great hardship was experienced by adults, there
was a marked diminution in the infant mortality
rate undoubtedly due to the fact that mothers
were at home and babies received maternal care
and breast feeding for a longer period.
You are in a strategic position to see that the
lives of mothers and babies are not needlessly
sacrificed from this cause. The Department of
Health would be glad to be assured that every
pregnant woman was relieved of industrial bur-
dens at least three months before her confine-
ment and that for six months following her con-
finement she should be free to remain at home to
nurse her child, which is after all her greatest
contribution to public welfare.
We recognize that such a program implies cer-
tain economic and social adjustments not en-
tirely within the province of industrial em-
ployers, nor yet within the province of a State
Health Department, but we are nevertheless re-
sponsible for an attempt to arrive at such an
ideal.
The ignorance of the mother as to the care of
herself and as to the care of her child is another
contributing factor to a high infant mortality
rate. Here we meet a group recruited largely
from among the wives of the men employed in
the plant but not themselves subject to the haz-
ards of industry.
Pennsylvania shows an infant mortality rate
of 100 as contrasted with a rate of 87 for the
United States in the registration area. Our
higher rate is in large measure due to our large
foreign and ignorant industrial population. The
ignorant mother is, however, not recruited alone
from our foreign population but from our
American-bom girls who have completed but a
part of their education in a system which offers
nothing in the way of preparation for home-
making and child-bearing.
We can remedy this deficiency in their educa-
tion only through the activity of the public
health nurse. Throughout Pennsylvania there
are scores upon scores of industrial nurses,
capable, keenly alive to the need and with a de-
sire to serve in an attempt to reduce these high
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May. 1921
CONFERENCE OF INDUSTRIAL PHYSICIANS
579
maternal and infant death rates, but who are un-
able to do so because the routine of their work
confines them so closely to the four walls of the
plant or to activity outside the plant concerned
chiefly with illness of adult employees.
If this great potential force could be diverted
for part of its time to constructive service in the
prenatal and postnatal field, in maternity centers
and child health stations and in field visits, we
should be able to show within a very few years
a reduction in maternal mortality of possibly 75
per cent., of stillbirths of 25 per cent., and of in-
fant deaths under one month of approximately
40 per cent. — surely a saving worth while. This
is the aim of the State Health Department.
A third factor which makes for high infant
mortality and maternal ill health is venereal dis-
ease. You do not need to be told of the high
incidence of the venereal diseases among the
men employed in your plants. You know the
resultant inefficiency of the men and the eco-
nomic loss entailed. You probably do not stop
to recall how large a proportion of abortions,
stillbirths, early infant deaths, sterility and sur-
gical operations upon women are directly at-
tributable to these diseases. Industry has not
been accustomed to calculate these things on its
cost sheets — but they are there under one guise
or another and the time has come for a reckon-
ing.
The State Department of Health is making a
determined drive to eradicate venereal disease.
The law, while not perfect, is adequate to con-
trol the situation. If you in your plants would
bring to the attention of the management the
extreme importance, from the point of view of
economic efficiency alone, of the diagnosis of
these diseases, then of their treatment and of the
continued follow-up in the community you
would have gone a long way with us in our pro-
gram. If you will go a step further and in the
community outside of the plant will insist upon
the suppression of the red light district and the
prostitute, you will have enabled us to eliminate
the breeding places of the disease.
The third step in which we ask your coop-
eration is in the establishment of clinics for the
treatment of the men, women and children in-
fected. Let these be maintained by the com-
munity, the plant, the state or a combination of
these agencies but let the facilities be available
for diagnosis and treatment for all who need it.
A fourth factor, which is the last that I shall
mention, as contributing to a high infant mor-
tality rate is a low family income. In these days
of abnormal prices and wages it is somewhat
difficult to determine exactly what constitutes an
adequate income. However, an adequate income
frequently becomes inadequate in the face of bad
management on the part of the housewife.
The public health nurse and the industrial
nurse should receive as part of her training in-
struction in family budget making. Such infor-
mation passed on to the wives of industrial em-
ployees will make for economy in the home;
will result in improved nutrition for the entire
family; will minimize the constant demand for
increased wages because "ends do not meet";
and will make for increased efficiency in the
plant and contentment of the workers.
The health and welfare movement in industry
must show a financial return upon the investment
involved to make it worth while in the eyes of
the cost accountant. Such activities do show a
substantial return but there is something even
better to be realized, and that is that at last
through the industrial physician and the indus-
trial nurse the "human" touch between master
and man is being restored. Through the coor-
dination of the activities- of the health staff of
the plant with the health activities outside the
plant we shall be able speedily to develop a work-
ing force to adequately safeguard the lives of
our children.
Ds. Pattekson: Before commencing the discussion
of Dr. Potter's interesting paper, at the request of Dr.
Roberts, chairman of the Commission of Industry of
the College of Physicians, I extend an invitation to
you to attend the meeting of the Section on Industrial
Medicine and Public Health, to be held at the College
of Physicians Building, Twenty-second Street, above
Chestnut, to-night at 8: 15. At this meeting, various
problems in industrial medicine will be discussed. You
are all cordially invited to be present.
I am sure that every industrial surgeon will extend
his cooperation to the very fine piece of work that Dr.
Potter is doing. It is my great pleasure to announce
that our State Department of Labor and Industry and
our State Department of Health are working in close
harmony and cooperation ; and that this year we have
had the great privilege of having Dr. Edward Martin,
the Commissioner of Health in this commonwealth,
accept the appointment as the consultant of the Divi-
sion of Industrial Hygiene and Engineering of the De-
partment of Labor and Industry. So the two depart-
ments are closely tied together so that there wiU al-
ways be cooperation and not conflict or overlapping
of activities. It gives me great pleasure to introduce
Colonel Martin, who will open the discussion on Dr.
Potter's paper.
DISCUSSION
CotoNSt Edward Martin, M.D., Commissioner of
Health, State of Pennsylvania, Harrisburg: Dr. Pot-
ter has formulated the relations which should exist be-
tween capital and labor; the driver and the driven;
the men whow ork others and the men who work
themselves. The effort to-day is to humanize some-
times inhuman corporations ; to civilize sometimes un-
civil labor organizations.
A corporation wants results so keenly that it may
forget or submerge the human element. A labor or-
ganization may be equally inhuman, and being less in-
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580
THE PENNSYLVANIA MEDICAL JOURNAL
May. 1921
felligent, may show its inhumanity in explosive and
destructive ways.
The industrial surgeon should be the correlator be-
tween the corporation and the labor organization; for
the employer, a means of saving money; for the em-
ployed, a means of saving health ; for both, an under-
standing, each of the other. The real industrial sur-
geon is the friend — ^the trusted friend — of every indi-
vidual in the force.
Specifically, what we need, as told by Doctor Potter,
is an extension of that human totich toward the con-
servation of human life — a better fitting of the men
for their work by relieving them of the anxieties in-
cident to illness or death in their homes. Anxiety is
a distinct factor in diminishing efficiency and favoring
accidents.
We are asking you, the men who are most experi-
enced in the problems of the working man, to use your
great influence with the corporations, that they will
go a little farther than they are now going, and
through you or by your direction inaugurate a cam-
paign of conservation which will begin with the baby
before it is bom and shall follow it through its in-
fancy and early childhood.
This is a happy combination of both business and
humanity — indeed the two are inseparable. The
shortest route to a man's heart is by way of his chil-
dren.
The larger the industry, the more receptive it is to
a concept of the profits accruing from altruism.
Dr. Patterson: The subject is now open for gen-
eral discussion, and we shall be glad to hear how the
industrial surgeons may best carry out this conserva-
tion of maternal and infant life.
Dr. Chas. J. Steim, Philadelphia Company, Pitts-
burgh : Both Dr. Potter and Dr. Martin have stressed
one thing in this discussion ; that is, the attenuation of
the personal relation between employer and employee,
and have asked for — or at least implied that they
would like to know how the Department of Health can
help to lessen that attenuation.
I think that everybody present to-day will bear me
out in saying that the employer at this time is in a re-
ceptive mood in regard to reestablishing that old — one
hundred years ago — relation.
There are a great many factors involved in the mat-
ter, and I think that the greatest one is, that the em-
ployer fears that he might be misunderstood and be
accused of paternalism. I can see this one way that
the State Department of Health can help, and that is,
by using the authority given it by law to bring the
lesson home directly to the family and to the em-
ployee, and do this as much as possible without the
intervention of the employer and his organization.
The employer can and will use his organization to co-
operate afterwards.
I have reference especially to such efforts as were
started by the health lessons issued by the State De-
partment of Health. More of this kind of education
brought directly into the family is what is needed and
afterwards the employer will be able to use all the
facilities he possesses to cooperate with the depart-
ment in driving the lesson home.
The employee and his family are prone to resent in-
terference with what they choose to term their per-
sonal liberty, but if such things were started and
backed by the authority vested in the Department of
Health, I am sure that every employer would be glad
to use all of his facilities in bringing about the de-
sired result. Backing a movement with the authority
of the state has special force in communities largely
made up of aliens, since they are accustomed by gen-
erations of training to respect that authority.
Dr. Patterson: We have had to rearrange our
program and I am now going to call for a paper whose
scope is so closely related to the subject of Dr. Pot-
ter's paper that they can be grouped together and dis-
cussed at the same time. It gives me great pleasure to
present to you one who has done an immense amount
of work in the standardization of the requirements
that should be imposed, so that the proper protecting
cloak of the law may be thrown around the child la-
borer. We have children in industry; and if these
children are to work with safety to themselves, and so
that they may in future become healthy citizens of the
state in which they reside, it is essential that safe-
guards should be placed around their employment So
it affords me much pleasure at this time to introduce
to you Dr. S. Josephine Baker, Director of the Bureau
of Child Hygiene of the Department of Health of
New York City, who will speak to us on the subject
of "Minimum Physical Standards for the Child La-
borer." Dr. Baker.
MINIMUM PHYSICAL STANDARDS
FOR THE CHILD LABORER
S. JOSEPHINE BAKER, M.D., D.P.H.
Director, Bureau of Child Hygiene, Department of Health
NEW YORK CITY
I am afraid that I am not going to speak ex-
actly on the subject of the protection of the
child after it enters industry, because what we
have done has been largely devoted to prevent-
ing things, as well as to curing things after they
have occurred.
The National Child Labor Committee has
called attention to an existing condition that is
wrorthy of the deep consideration of all who are
interested in the welfare of the child and its ef-
fect upon future generations. In The American
Child for November, 1920, this committee states
that:
1. There are at least five and a half million
illiterates in the United States.
2. Nearly one fifth of all American children
between the ages of ten and fifteen are out of
school, earning their own living.
3. Illinois, Iowa, Kansas, Maryland, Minne-
sota, New York, Pennsylvania, Texas and Wis-
consin all report a startling increase in the num-
ber of children leaving school to go to work in
the year 1920.
Investigations would also seem to show that
only four per cent, of the children in the ele-
mentary schools enter high school, and only
about one per cent, of all children finally enter
college.
In the United States there are approximately
eleven million children between the ages of ten
and fifteen years. According to the statements
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CONFERENCE OF INDUSTRIAL PHYSICIANS
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just given, therefore, we have approximately
two million, two hundred thousand children at
the vitally potential ages of from ten to fifteen
years, engaged in some form of industrial occu-
pation.
It would seem that the time has gone by for
any argument as to the need of protecting our
children against exploitation. Whatever may be
our conception of a world in which social jus-
tice will be the rule for all, we must consider one
fact as basic: social justice for children is es-
sential. (This is still denied because, in my opin-
ion, people have not yet been sufficiently aroused
both to the extent to which it is denied and to
the importance of measures which will mean full
protection for every phase of child life and
progress.)
During the latter years of the war, children
were apparently needed in industry to a greater
extent than ever before. It is probable that
many doubtful arguments were put forward as
to the extent of the need of children in indus-
trial occupations even during that period. With
the ending of the war, however, such an emer-
gency may be considered to have ceased. Ac-
cording to the authority quoted above, however,
the tendency for children to leave school and go
to work is on the increase instead of on the
decline. The committee states: "More children
have left school to go to work in 1920 in many
industrial centers than in 1919. Fourteen states
report an increase in child labor during the first
six or eight months of 1920 as compared with
the same period last year. In New York City
5,283 more children applied for work permits in
the first six months of 1920 than in the same
period last year, but in the last three months
there has been a decrease in applications, so that
the total increase is only 2,353. I" Baltimore
County, Maryland, there were 4,064 more appli-
cations for work permits up to October 31, 1920,
than in 1919, while during the summer the Chi-
cago authorities reported an increase of 13,000
in that city, and in Minnesota there has been an
increase of 193 per cent, since 1915." The fur-
ther statement is made: "The place for every
American child up to sixteen, at least, is in
school, and we have proved that by mothers' pen-
sions, child labor scholarships and other devices
for public aid, even poor children may be kept in
school. The child who goes to work at four-
teen has an earning capacity at twenty-five just
half as great as the child who stays in school
until he is eighteen; and the child who goes to
work at fourteen is twice as liable to sickness
and disability as the child who stays in school.
In fact, the loss 'to the nation in health, efficiency
and happiness, created by premature employment.
is incalculable. As Mr. Hoover puts it, child
labor is 'poisoning the springs of the nation at
their source.' " The present time offers un-
equalled opportunities for the protection of the
child. The war taught us the value of human
life and the United States is now following the
example of Europe in devising and putting into
effect many forms of child welfare work. Never
before has so much attention been given to the
essential needs of childhood.
At the present time, industrial conditions, par-
ticularly those pertaining to employment, are
reverting to their prewar status. Whatever the
needs of industry for children may have been in
war time, we may be sure the conditions of adult
employment at present, and increasingly in the
near future, will make the employment of chil-
dren less and less essential. It will probably be
true, for the next few years at least, that where
children are employed to any extent it will not
b^ because of the need of them in industry but
because they can be employed at a wage far be-
low that for the adult worker. Such a course
can only result in harmful exploitation of the
child, without any benefit to a sound industrial
policy. There is another point of view from
which we must consider the relation of the child
to industry, and that is that even when industry
shows an apparent, even if dubious, need of child
labor, only the minor premise of the argument is
stated. The main point to be kept in mind is not
industry and the child, but the child and in-
dustry. ! 1
We are not arguing with regard to the present
alone when we consider our attitude towards
child labor. There is a later aspect to the mat-
ter, as has already been shown ; that is, the pro-
ductive capacity of children who have been well
prepared is greater than for those who have
spent less time in school, but the immediate eco-
nomic question relative to the use of child labor
should not be considered as worthy of discussion
when compared with the need of a sound policy
for the protection of children.
It seems to me futile to discuss the results of
gainful occupation upon children when the fact
is so clear that children should not be employed
at all. The action of the Supreme Court in de-
claring unconstitutional the Child Labor Law re-
cently passed by the United States Congress is,
of course, a sound legal action, but the purpose
of the law marks a milestone in the right direc-
tion. If the United States government, by Fed-
eral enactment, cannot settle the question of child
labor, the individual states have it well within
their power to do so, and in one way at least the
United States government has now taken steps
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THE PENNSYLVANIA MEDICAL JOURNAL
May, 1921
to suggest standards for the normal development
and physical fitness of working children.
Early this year the Children's Bureau of the
United States Department of Labor called to-
gether a committee of specialists in child welfare
to formulate a set of standards which would
serve as a basis for those to be adopted by the
various states, as the minimum health require-
ments for all children who expect to enter indus-
try. It is true that such standards have no direct
administrative or legal authority, as they are
promulgated by the Federal government, but
their normal force is strong and they point the
way for enlightened state action. While the
committee as a whole has not reported, and while
it is too early to give definite information about
the form of their report, I think it is possible at
this time to mention some of the physical stand-
ards which are considered the minimum that
should apply to children entering industry.
These conclusions should in no sense be consid-
ered as reflecting the views of or as coming from
the committee in question. The majority of the
standards outlined are those of New York City
and have been proved to be entirely feasible and
of the greatest importance to the welfare of the
child.
Age: There is practically no state in the Union
that requires a child to be over fifteen years of
age when it first enters industry. The ages at
which a child may go to work range from ten to
fifteen years.
I think we may dismiss without comment the
deplorable condition of affairs that would allow
any child between the ages of ten and fourteen
years to be employed in a gainful occupation.
Such laws are barbarous, and a decent and en-
lightened public sentiment should demand their
repeal. It is also questionable whether any child
under sixteen years of age should be allowed to
enter the industrial field. No one can reason-
ably expect that children under sixteen years of
age can be entirely kept away from home occu-
pations or the minor forms of helpfulness which
every boy and girl enjoys. There are many
kinds of employment which cannot have any
serious effect upon the health of children, when
they are under family supervision, when only a
few hours a day are devoted to the employment
and when the work is liberally interspersed with
play. The difficulty, however, is that there are
no laws which would limit occupation at these
ages in this manner.
When a child is once allowed to go to work,
there is very little control over the type of in-
dustry which it enters. It may be an industry
requiring an amount of strength and endurance
far beyond the physical ability of the child to
supply, or it may be one which, from its very
nature, is injurious to the health of the child.
Any form of industrial employment may be
harmful to children during adolescence. It may
not be essential to afford the same protection to
boys during this critical period of life as it is
to girls, but certainly the boy between fourteen
and sixteen years of age should not be subjected
to any unusual strain, and the girl between four-
teen and sixteen years of age should not be al-
lowed to have any physical strain at all. When
one remembers that in the United States thirty-
five per cent, of all infant deaths occur during
the first month of life, and that this large pro-
portion— one third of all baby deaths — are due
to conditions affecting the health of the mother
before the baby is bom, it will be realized that
the effect of industry upon girls during the pe-
riod of puberty has not yet been fully measured.
There can be no doubt whatever that many
types of employment to which the adolescent girl
is subjected can have such serious and far-
reaching effects that they may be shown not only
in chronic invalidism to the girl in question but
may seriously interfere with the possibility of
motherhood in her case and may even be detri-
mental to the health of the next generation.
There can be nothing clearer, to my mind, than
that it is the duty of the state to protect the
health of children and women, therefore it would
be desirable if a minimum standard age of six-
teen years could be established in all states for
the entrance of children into industry.
From a physiological point of view, these
children should be kept under observation until
they are eighteen years of age and repeated
physical examinations should be made of them
at stated intervals during the two years in order
to determine the effect industry has had on their
physical well-being. If any deleterious efifect
can be shown, provision should be made in the
law that such child be barred from industry for
a period of time necessary to regain health.
Character of Occupation: The type of work
the child performs may have a most important
bearing upon its health. For that reason, the
employment certificate should always be issued
for a particular job, and should be issued in the
name of the employer. No new certificate
should be issued unless the child has had a
physical examination and is shown to be in
sound health, and physically fit to perform the
work it intends to do. Repeated physical ex-
aminations of this type will, in time, show the
effects of various industries upon the health of
children and will, in the meanlime, protect the
child to a very great extent from entering an in-
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May, 1921
CONFERENCE OF INDUSTRIAL PHYSICIANS
583
dustry that may have a serious effect upon its
physical well-being.
Physical Bxteminations While in Industry:
When children are continuously employed in any
position for more than one year, provision
should be made for yearly physical examination
of each child. Such examinations might well
take place in the industrial plants or at the office
of the official who issued the original employ-
ment certificate. If carried on in the industrial
plant, it might easily be part of a general pro-
gram for industrial hygiene and as such offers
an opportunity in a field which has hitherto been
neglected.
Minimum Standards of Physicd Fitness and
Normal Development for Children Entering In-
dustry: No child should be allowed to go to
work unless it is in sound physical health and
physically fitted to perform the work it intends
to do. "Sound physical health" should here be
interpreted in a literal manner. Deviations from
the physically normal may not seem to be either
a symptom or a cause of ill-health but the future
consequence of such physical defects may easily
be serious enough to form a definite handicap to
proper physical development.
The tjrpe of defects for which men were re-
jected in the draft were those which are com-
monly encountered in children applying for em-
ployment certificates. If thirty-nine per cent, of
our young men between twenty-one and thirty-
one years of age were rejected in the draft be-
cause of these preventable and easily remediable
physical defects, it is a clear indication that the
ultimate injury resulting from such defects war-
rant more serious consideration during the pe-
riod of childhood than any we have ever given
before. Practically all these defects begin in
early childhood. If neglected during the school
age, they may establish abnormal physical con-
ditions which will be permanently harmful. If
they still exist at the time the child reaches the
stage of adolescence and wishes to go to work,
the final opportunity is presented for correcting
them before they do definite harm. For these
reasons, every child who wishes to go to work
should be subjected to a thorough physical ex-
amination. It is probable that the Committee on
Standards of the Children's Bureau will recom-
mend a definite form of examination, standard-
ized so that there can be no question as to its
thoroughness. At this time it is sufficient to say
that any examination of the child before it en-
ters industry should cover the following points :
height, weight, general physical conditions, con-
dition of nutrition, maturity, examination of the
skin, eyes, ears, mouth, nasopharynx, glands,
heart, lungs and abdomen. Orthopedic defects
should be noted, and diseases of the nervous sys-
tem and disturbance of the menses are also of
importance.
The standards of height and weight which
have been used by the Department of Health of
New York City for a number of years are :
Fourteen years 58 inches 80 pounds
Fifteen years 58 inches 85 pounds
Sixteen years 59 inches 90 pounds
No difference has been made in the require-
ments for height and weight of boys and girls
because it has been felt that while boys may be
noticeably taller and heavier than girls, the lat-
ter are entitled to greater protection. Their
standards, therefore, have been made as high as
those for boys.
When a child is found to be ten per cent, be-
low the proper weight for its height, it should
be examined by two physicians to determine
whether this underweight is the result of imder-
nourishment or other bodily defect or whether
it is a racial or family characteristic. In the lat-
ter case, of course, there may be no physical dis-
ability and if the child is found to be otherwise
in good condition, the employment certificate
may be issued.
It has been found that certain types of physi-
cal defects may be easily remedied, and if we are
to issue employment certificates at all, it hardly
seems fair to definitely refuse a certificate to a
child who could be put in sound health with a
reasonable amount of care. Such cases, there-
fore, are classed as having the certificates "tem-
porarily withheld" and only where treatment is
not obtained after a reasonable length of time is
the certificate refused permanently.
The opportunity for affording proper health
supervision and adequate treatment to the chil-
dren who are found to be physically defective is
one of the most important results of physical ex-
amination. The standards and methods carried
out in New York City may be taken to indicate
what may be considered the minimum for any
state that wishes to prevent the employment of
any child who is physically unfit. The standards
brought out by New York City have recently
been adopted by the rest of New York State.
Physical Defects Which Justify Permanent
Refusal:
1. Cardiac disease.
2. Tuberculosis or other evidence of serious
pulmonary disease.
3. Tuberculous or syphilitic disease of joints
and bones.
4. Irremediable defective vision.
5. Trachoma.
6. Serious orthopedic defects.
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THE PENNSYLVANIA MEDICAL JOURNAL
May, 1921
7. Malnutritipn, equivalent to Grade 4 of the
Dunfermline scale.
8. Chorea.
9. Total deafness.
Every effort is made to see that children who
are refused employment certificates because of
physical defects are referred to some appropriate
person or agency for whatever medical or other
assistance is needed.
Physical Defects Which Justify Temporary
Refusal:
1. Defective vision subject to correction by
lenses.
2. Contagious eye and skin diseases.
3. Defective teeth: extraction or treatment
needed.
4. Malnutrition, equivalent to Grade 3 of the
Dunfermline scale.
5. Untreated hernia.
6. Hypertrophied tonsils, where there is evi-
dence of serious obstruction or diseased condi-
tion.
7. Defective nasal breathing, causing complete
occlusion of the nostrils.
8. Tubercular glands.
All children who are temporarily refused em-
ployment certificates because of the existence of
physical defects which may be curable under
proper treatment, are referred to the care of the
school nurse of the Bureau of Child Hygiene,
who assumes responsibility for the case and
makes every effort to see that the necessary
medical treatment or other care is secured for
the child. When such care or treatment has been
provided and the physical defect has been cor-
rected, the employment certificate is issued.
In diagnosing malnutrition, weight in relation
to height, and both in relation to age, are taken
into consideration as one of the factors. The
same qualifications noted under "minimum
standards of height and weight" are applied in
this connection. Children who are ten per cent,
below the minimum weight for their height and
age must be examined by two physicians to de-
termine whether or not the underweight is the
result of individual or racial characteristics or
whether it is due to some undernourished condi-
tion. It is realized that undernourishment ex-
ists in varying degrees. The Department of
Health of the City of New York has for many
years classified cases of undernourishment ac-
cording to the Dunfermline scale.
This scale recognizes that there are certain in-
dications of undernourishment other than in-
sufficient weight in relation to height. The facial
expression of a child, the presence of dark cir-
cles under the eyes, look of extreme fatigue, evi-
dences of anemia, flabby muscles, slouchy posi-
tion, hollow chest, winged scapulae and other in-
dications of a loss of physical tone, are all taken
into consideration. The degree of undernour-
ishment is indicated by using the Dunfermline
scale, as follows:
(i) Excellent. Indicates that the child is in
splendid physical condition and absolutely sound
health.
(2) Good. Indicates that the child falls be-
low the standard of "excellent" yet does not
show any definite signs of undernourishment.
(3) Needing health supervision. Indicates
that the child shows definite signs of undernour-
ishment and needs health supervision.
(4) Needing medical care. A child in this
grade is in an advanced stage of undernourish-
ment and should be under medical care.
The application of such standards to New York
City has resulted in the year 1919, in the abso-
lute refusal of 3.17 per cent, of all children who
applied for employment certificates, on the
ground of physical defects. During the first
three quarters of 1920 of the total number of
children who applied for employment certifi-
cates, 3.15 per cent, were refused because of
physical defects. These figures, of course, refer
only to children who have defects which cannot
be corrected. The children who have defects
which may be easily remedied are, in most in-
stances, given their employment certificates even-
tually and do not enter into this calculation.
In this connection it may be of interest to
state that during 1919, 49,294 employment cer-
tificates were granted and 2,306 were refused.
By far the greater number of these were refused
because of physical incapacity (1,668). The
other classifications were insufficient tuition 44,
insufficient education 10, under age 27, over age
557. An analysis of the causes of rejection for
physical incapacity shows the following:
Malnutrition 9.65 per cent.
Cardiac disease 20.26 " "
Pulmonary disease 1.08 " "
Defective teeth 30.50 " "
Defective vision 16.42 " "
Adenoids and enlarged tonsils 9.60 " "
Miscellaneous defects 12. 39 " "
100.00
In determining the physical status of the child,
certain other items must be taken into account.
Race and nationality, age and sex, as well as
family history, have a marked bearing upon the
matter. For the purpose of determining the
child's fitness to be employed, the intended occu-
pation should always be ascertained.
While future study is necessary, if we widi to
determine whether children who are only par-
tially physically disabled may go into certain
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May, 1921
CONFERENCE OF INDUSTRIAL PHYSICIANS
585
types of industry, for the present at least, if we
are to afford full protection to our children we
must consider that no child who is physically ab-
normal should engage in any gainful occupation
whatsoever. Such a standard is not impossible
of achievement. It has been successfully main-
tained in New York City for a number of years.
Even this, however, is not the goal towards
which we should be working. From the point
of view of the economic status of adult labor,
the serious" effects of lack of education or illiter-
acy and the lasting harm that may result from
industrial employment of children during the pe-
riod of adolescence, it seems that, in this country
at least, the arguments against the employment
of children far outweigh any advantages that
have been mentioned in its favor. The ex-
perience of twenty years in close relation to this
subject has convinced me that child labor is
niether necessary nor desirable, that it may have
an exceedingly harmful effect upon the physical
development of children and that the employ-
ment of any child under sixteen years of age
should be prohibited. Surely, this great and rich
nation does not need to live on the earnings of
its young.
Dk. Pattekson : I am sure that we shall profit very
much from this valuable paper and from the discussion
which will follow. I am going to call on Dr. Mary R.
Noble, Assistant Chief of the Division of Child
Health of the Pennsylvania State Department of
Health, to open the discussion on Dr. Baker's paper
and the paper of Dr. Potter.
DISCUSSION
Dr. Mary R. Noble, Assistant Chief, Division of
Child Health, Pennsylvania State Department of
Health, Harrisburg: I have only a few words to say,
because I think that Dr. Baker has done the subject
such adequate justice that little remains to be said. I
think she might have been a little harder on the roc-
tors. It is no time for us to sit down complacently
and feel that we know enough to make us able to go
over the child in the industrial plant and state our
judgment in such a way that we consider that nothing
more could be said. I believe that Dr. Baker would
probably agree with the idea that doctors have to re-
ceive a special training to make them fit for this kind
of work. It is probably axiomatic in our minds that
this is so, and that we can get a sufficient amotint of
experience only with time. We can expect no newly
graduated physician to step into an industrial plant
and do the thing as it should be done. He or she
needs a special training to make him or her fit to do
the thing properly in the plant. It is not only expe-
rience in going over heart and lungs to discover the
things that the doctor gave us a list of, that is neces-
sary. It is not only that we must be skilled in any-
thing that eyes and ears and a trained mind can bring
to it ; but we must be willing to admit that there are
things that we do not know and cannot learn until
more research work has been done.
For example, one question on which more research
work must be done is the question of fatigue. We do
not know just where fatigue begins to show itself.
and people have to be told how the child will be less
and less profitable in industry from the moment when
fatigue begins to show itself.
If Dr. Baker had been taking up the mentally defec-
tive children, I think she would have given us much
that would have been most illuminating. The Penn-
sylvania laws provide that all mentally defective chil-
dren shall be sorted out and put into special institu-
tions. We have the law, but not the machinery to
carry it out nor the institutions in which to put the
children, with the possibility of making them good
citizens. The New York laws are even better than the
Pennsylvania laws, I understand ; but in this state we
have not the machinery to carry them into effect. Now
we must create a desire among ourselves to take the
thing in both hands; moreover we are not to do the
thing in our own little group of doctors alone, but
share oui* responsibility with the lay community; we
must make it seem useful to the lay mind as well.
Dr. Patterson : The discussion will be continued by
Dr. Taliferro Clark, of the United States Public
Health Service.
Dr. Taiiapebro Clark, United States Public Health
Service, Washington, D. C. : Those of you who know
Dr. Baker as well as I do and have heard her paper
to-day can appreciate how difficult it is for me to add
anything new to what she has said. The tendency to
restrict the child in industry according to age is sound.
No one will dispute the bad effect of certain forms of
stress on the vital resistance and physical and mental
stamina. The younger the child, and therefore the
more immature, the gfreater will be the ill effect of
stress on the body and mind. The safe standard to
govern us in permitting the child to enter industry is
whether or not the child is mature enough. It is for
this reason I wish to emphasize the effects made to
raise the age limit at which the child may enter in-
dustry to prevent young and immature children from
engaging in injurious occupations.
Physical measurements made by myself and others
show that a certain age period, that is, at the begin-
ning of pubescence, there is a slowing up in the rate
of growth as indicated by height and weight, and by
lowered response to other physical tests. This empha-
sizes the lack of "pep" at this period of life when
children are undergoing such wonderful and important
physiological readjustments, during which the child
should be carefully guarded from undue stress of both
mind and body.
In speaking of standards of physical measurements
one naturally thinks of these in terms of height and
weight measurements. Such standards are extremely
difficult to determine with accuracy because of the
wide individual variations of height, and of weight in
relation to height. However, a number of standards
based on the correlation of height and weight at given
age periods have been widely adopted and are in gen-
eral use. At best they are largely approximations. In
connection with such standards it must be emphasized
that, owing to the great individual variations, the in-
fluence of race and heredity, the effect of physical dis-
abilities, the role of an endocrine imbalance and many
other instances, it is extremely difficult to devise a
standard applicable to the country as a whole.
Recently Georges Dreyer, Patholog^ist at Oxford
University, made some remarkable studies of physical
development based on the assumption that as weight is
a function of body surface so is vital capacity. Work-
ing from this premise and by the use of four physical
measurements, namely, the circumference of the chest
at restt the vital capacity, the length of the body stem j
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586
THE PENNSYLVANIA MEDICAL JOURNAL
May, 1921
(sitting height), and the weight, he has calculated con-
stants that are applicable to all ages. The Public
Health Service has long been interested in the estab-
lishment of standards from the standpoint of the sit-
ting height and has been making and is continuing to
make on a nation-wide basis, examinations of se-
lected groups of normal children for this purpose.
We hope to apply Dreyer's formulae and determine
whether we can arrive at some physical standard that
will be applicable to all classes of children, if not to
the country as a whole, at least to certain sections ac-
cording to geographical location and race distribution.
If I may be permitted, I should like briefly to dis-
cuss certain phases of Dr. Potter's paper. I think she
has brought out in a very fine way the intimate inter-
relationship which obtains between all forms of health
work. For example, after doing everything possible
from the standpoint of care and instruction of the
mother or the child, you must go back to the com-
munity and improve local conditions such as sanita-
tion, facilities for medical care and service, control of
communicable diseases, measures for safeguarding
milk and water supplies and the like, to attain the best
results. The maximum protection to the child in in-
dustry can only be secured by the proper coordination
of the activities of the Division of Child Health of the
State Department of Health with those of the Division
of Hygiene and Engineering of the Department of
Labor and Industry.
I wish to emphasize specially Dr. Potter's remarks
on infant mortality associated with the employment of
the mother in industry. An analysis of the census sta-
tistics of cities classified into cities of over 100,000
population, between 50,000 and 100,000^ and under
50,000 shows that the infant mortality is less in the
first and third class cities and higher in cities of mid-
dle population, due to the fact that these for the most
part are centers of great industrial activities where the
incentive is great for the mother to engage in gainful
occupation rather than remain at home and care for
her newly bom infant.
A great English expert on nutrition reports an in-
teresting comparison in infant mortality rate in an in-
dustrial city in England where large sums of money
were expended for child health work and the infant
mortality rate of one of the poorest and most illiterate
communities in Ireland where nothing was spent for
health work, by which the mortality rate was shown
to be four times higher in the former than in the lat-
ter. In other words, in the industrial city of England
the mothers largely returned to work shortly after the
birth of the child with a high infant mortality, whereas
in the unenlightened community where nothing was
spent for health work the mothers nursed their chil-
dren— the great factor in keeping down the infant mor-
tality rate. Industry must take cognizance of this fact
and the effort of Dr. Potter to coordinate the child
hygiene work of the Department of Health with the
work of the Division of Hygiene and Engineering of
the Department of Labor and Industry is greatly to be
commended.
Dr. Patterson: The subject is now open for gen-
eral discussion. Please come to the front of the room
and give your name and address to the stenographer.
We shall be glad to hear from all that are present.
Miss A. EsTette Lauder, Executive Secretary, Con-
sumers' League of Eastern Pennsylvania, Philadel-
phia : I wish to say something from the standpoint of
the Consumers' League in relation to the subject of the
cooperation of the doctors with people who are trying
to enforce an age standard. I have had cases referred
to roe in regard to their medical aspect in which doc-
tors have had a hand, and in which the doctors have
hesitated to take the uncomfortable, but necessary
step, so now I ask for the cooperation of the physi-
cians in soch cases. I was called to one section of the
state where children strip tobacco. I have seen chil-
dren as young as five years of age doing this work.
They sat on boxes, without backs, and they bent their
bodies over all day long to strip the tobacco. From
long experience they strip very quickly, just like clock-
work. I could not do it The children laughed when
I attempted it They can strip the midrib from the
leaf without breaking the leaf except into the two
natural parts. They sit there all day long; and those
that make an attempt to go to school at all, miss over
half the school. days. The doctors report that these
children have a yellow complexion, due to the to-
bacco, and different sorts of trouble from the same
cause. In the tobacco factories, we do not allow the
employment of children; yet they can work in the
same way in their homes from the age of five years on.
When the doctors in a community find out that a cer-
tain industrial process is harming the children, why
don't they see that the industry is forbidden to the
children? Why does the Parent-Teachers' Associa-
tion have to come to the Consumers' League and say,
"We are concerned that these children do not stay in
the schools ; and that when they do go to school, they
are so affected by the health hazard that they do not
make good scholars"? Why don't the doctors talk to
the employers? Again — I had a case turned over to
me the other day by a principal of a school, who said
that a factory had given out tags to be strung in the
homes of the workers. The pay was ten cents for
stringing a thousand. (You can talk of wages going
up, but this does not look like it) They string these
tags on wire, and you can imagine what it means to
string a thousand. A man who had been crippled in
industry before the days of workmen's compensation,
and who had not been taken care of by his employer,
was unable to do any regular work, so he had taken
these tags to string; and he got his children, before
and after school to string tags with him, so that the
family income might be increased. What was the re-
sult? I need not tell you that you cannot bridle a
child's spirit without bad results. The school authori-
ties faced with the situation and trying to combat the
evil, called upon the Consumers' League for advice
and assistance, saying "Why does the child run away
nights, and stay out with little boys during school
hours?" I was interested that they should come to
the Consumers' League, for they must know that the
spirit of play in the child will find an outlet One
child in ^e family already had a municipal court
record.
I do not blame the family so much as the doctor
connected with the- school or the industry. I have an-
other case from the Social Service Department of a
hospital. "Our doctor says that the Consumers'
League should look into the fact that there are chil-
dren working in a process in a factory in which the
material seems to be affecting their health. What shall
we do about it?" said the Social Service worker. In
such a case, the Consumers' League has to engage a
physician to investigate; while here are the doctors
that are in a position to know these things.
Then there is the old subject of the textile indus-
try, shoddy and the large amount of tuberculosis con-
nected with it. The league has recently published an
article in the Journal of Industrial Hygiene on the
subject There is the subject of the large sums of
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CONFERENCE OF INDUSTRIAL PHYSICIANS
587
money collected yearly by tuberculosis societies, that
are taking care of cases of tuberculosis, after it has
developed; but what are you doing to prevent its de-
velopment ? Even the shoddy and wool men say to us,
"You are right so far as conditions in the industry are
concerned." They are rotten. Some of the plants
have industrial physicians, but we go in and find that
there are no blowers to carry the dust off. Sometimes
the workers are breathing the dust from old rags.
You should say to the employer, "Remedy this, or I
shall give up my job." Why is it left to the Con-
sumers' League to stop these health hazards? Why
was it necessary for a worker in a nonmedical organi-
zation to make the study of fatigue in connection with
industry that has been recognized as an authority? I
refer to Fatigue and Efficiency, written by Josephine
Goldsmith,of the National Consumers' League. She had
to use the works of doctors in doing this; therefore,
I make a plea that you recognize these conditions as
far as possible. Our organizations proposed the child
labor laws to protect the health of children, yet you
knew the conditions resulting from child labor.
I hope that there will be a reconstruction ; and that
the doctors, recognizing these troubles, will get to the
bottom of them and help us lots more than they have
helped up to the present time. There is a good deal
more that I could say along these lines because I have
lived for years in settlements, and have seen the re-
sults of industries on the health of the workers. You
see it every day, but now that I no longer live near
the workers I see it only as the cases are reported
to me.
Dr. Patterson : I am^sure that the industrial physi-
cians will cooperate in every way with the Consumers'
League in its wonderful work. The subject is open
for further discussion.
If there is no further discussion, we will again
make a change in our program, due to the fact that
one of the speakers has to be in Washington, and dis-
cuss the important subject of "The Rehabilitation of
the Industrial Cripple." It needs no words of mine to
emphasize to you the need on the part of the state to
care for those who have had the misfortune to meet
with crippling injuries; and with pride, I point out
the fact that the state of Pennsylvania was the first
commonwealth in the Union to clearly recognize this
need and take advantage of the experience gained
abroad by surgeons in the care of the war cripples. We
have, as a part of our Department of Labor and In-
dustry, a Bureau of Rehabilitation; and it gives me
pleasure to call on Mr. S. S. Riddle, Chief of that
bureau, to speak on this subject.
(To be continued in June issue.)
THE VALUE OF PRENATAL AND INFANT
WELFARE CLINICS
By C. V. Rice, M.D.
Muskogee, Oklahoma
The value of the prenatal and infant welfare clinic
is as follows:
First: To guide our maternity cases safely through
their journey to motherhood, with the least possible
harm or injury.
Second: The teaching of the proper feeding of in-
fants and children with the importance of maternal
nursing.
Third: The value of fresh air, sunshine and cloth-
ing.
Fourth : The early recognition of abnormal and de-
fected children. That these conditions may be recti-
fied before there is a permanent impression.
Fifth : The awakening of general interest in the
prenatal and infant welfare work. — From the Journal
of the Oklahoma State Medical Association, December,
1920.
GOITER— OBSERVATION ON APPROXIMATE-
LY TWO THOUSAND CASES
By Samuel Orr Black, M.D.
Spartansburg, S. C.
The treatment of exopthalmic goiter readily divides
itself into four headings:
First : Very early treatment.
Second : Treatment of an acute attack.
Third : Operative treatment.
Fourth : Postoperative treatment.
When detected early, rest in bed, light diet, quanti-
ties of water and moderate doses of neutral quinine
hydrobromide may stay the disease. Adrenalin, sup-
plemented by x-ray therapy and sufficient codeine or
morphine will be of assistance.
An acute attack or exacerbation of symptoms is to
be nursed along until they subside — absolute rest in
bed, visitors, magazines, newspapers and alcohol of
any kind are prohibited. The ice bag to the precor-
dium, elevation of the feet, with quantities of morphia
and fluids yrill usually induce the desired effect.
These remedies will check the heart's actions, quiet
the nervousness, stop the diarrhoea and return the pa-
tient to a condition more normal at which time the
case becomes an operative one.
From the general condition of the patient depends
the nature of the primary operation. Ligations, hot
water injections, quinine and urea hypodermically into
the gland itself, or a resection of part of the gland are
all appropriate and have their special indications.
Sharp knife dissection is of prime importance. Pick
up all tissues parallel to the larynx and trachea.
Adjacent nerves and blood vessels are not to be in-
jured. Maintain as bloodless an operating field as
possible. Avoid the posterior capsule of the gland so
as not to disturb the parthyroids. Ether is the pref-
erable anesthetic, but if secondary changes of an ag-
gravated nature exist in the heart or kidneys cocaine
is to be preferred.
The postoperative treatment is almost as important
as the operation itself. Keep the patient free from
physical and mental strain. Child bearing, club meet-
ings, crowded stores, theatre and church sociables
should be dispensed with for a varying length of time.
The diet should be plain and easily digested. The
bowels should be mildly evacuated daily and never
purged.
Certain hours of each morning and afternoon should
be spent in bed. Graduated exercises, especially walk-
ing, should be prescribed, gradually increasing the dis-
tance each week.
In other words, in order to secure a prompt and
more permanent recovery, the patient's environment
should be made pleasant and quiet and all personal
cares and worries should be removed. — From the Jour-
nal of the South Carolina Medical Association, Octo-
ber, 1920.
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THE PENNSYLVANIA MEDICAL JOURNAL
May. 1921
THE PENNSYLVANIA
Medical Journal
Published monthly under the supervision of the Publication
Committee of the Trustees of the Medical Society of the State
of Pennsylvania.
Editor
FREDERICK L. VAN SICKLE, M.D Harrisburg
Auiitent Editor
FRANK F. D. RECKORD Harrisburg
AnocUte Editors
JosiPK McFakland, M.D Philadelphia
GiOKGC E. ?FAHi.E«, M.D Philadelphia
Lawuhcs Litchfield, M.D Pituburgh
GloKCK C. Johnston, M.D Pittsburgh
T. Stiwart Roduan, M.D., Philadelphia
John B. McAlistck, M.D Harrisburg
BlKNAiD J. Mykks, Esq., l,ancaster
Publication Oommitto*
InA G. Sboehake«, M.D., Chairman, Reading
Theodore B. Appel, M.D Lancaster
Fran it C. Hammond, M.D Philadelphia
All communications relative to exchanges, books for review,
manuscripts, news, advertising and subscriptions are to be ad-
dressed to Frederick L. Van Sickle, M.D., Editor, aia N.
Third St., Harrisburg, Pa.
The Society does not hold itself responsible for opinions ex-
pressed in original papers, discussions, communications or ad-
vertisements.
Subscription Price — $3.00 per year, in advance.
May, 1921
EDITORIALS
MEDICAL EDUCATIONAL REQUIRE-
MENTS—ARE THEY BEST FOR
PRESENT-DAY CONDITIONS ?
It is axiomatic that our educational standards
can never be too high, but we must be sure that
they are practical and that they meet with the
needs of the public and the business conditions
of the country. Medicine is too serious a pro-
fession to be lightly dealt with; but are seven
years of education necessary for obtaining a
medical certificate? Social conditions through-
out the world have changed. The people of to-
day should have just as high a degree of medical
attention as ever; but is medical education
keeping pace with concentration in other di-
rections? Not as an educator or as one
versed in curriculum, but as a general prac-
titioner and observer of medical needs, it seems
to me that medical studies might be condensed
and the less practical and less important sub-
jects eliminated in order to make the whole
course intensely practical, so that the medical
course might be cut down to at least six years,
without lowering the standard of medical edu-
cation. The average graduate might then be
just as well prepared, be a year younger in be-
ginning his life's work, at a more enthusiastic
age, and save a year of expense in his education.
In all business lines the effort is to readi
greater efficiency with less expenditure of time
and money. In medicine the effort has been to
attain greater efficiency through the expenditure
of more time, more money and increasing legis-
lative restrictions. The practice of medicine is
a business as well as a profession. Could not
greater concentration and more practical courses
make it possible for a young man or woman to
become a physician in six instead of seven
years ? The study of medicine means business,
not merry-making. It is to the credit of our
pioneers, who after much struggling placed the
profession on a high plane, that war in earnest
has been carried on against the lax standards
formerly existing in this country for the mak-
ing of doctors, and rapid steps have been taken
to raise the standards of the profession. There
is always danger even of any well-meant attempts
to lessen the curriculum, for there are always ex-
tremists to deal with. But the constructive
brains of our profession can certainly arrange
the course to get the men into the profession at
an earlier age than is now possible, and conse-
quently lessen the prohibitive expense to so
many prospective students.
Why are so many communities in all of our
states begging for and even offering induce-
ments for a physician to settle in their midst?
A doctor is a crying need in many places. The
shortage of doctors is becoming serious. The
number in the United States has decreased rela-
tively to the population, and the number of
students in our medical colleges is constantly
growing smaller. May it not be that the hard-
ships and length of time necessary to obtain a
medical education, are responsible for the
growth of so many cults which are to-day thriv-
ing and receiving the confidence of the public?
Many a young man, ambitious to be a doctor,
who seeing seven long years of preparation and
the attendant expense ahead, and in the end the
possibility of failure to pass final examinations
or state board examinations, and noticing that
some successful neighbor is an osteopath or
chiropractor or one of a dozen other cults, is
supported by his family and friends in his de-
cision that it pays better to be a member of the
cult. We in the profession may talk the higher
ethics of the profession, but when the boy
begins his course it is a matter of making a liv-
ing that concerns him.
What is the most practical and most effectual
means to encourage him to study true medicine,
and thus help to supply the medical needs of the
public? It must be remembered that in medi-
cine, as in every other phase of human activity,
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May, 1921
EDITORIALS
589
economic considerations play an important part.
No profession will attract to itself men of high
abilities unless there is a reasonable prospect
that a long and tedious course of study and hard
work will be rewarded with a suitable recom-
pense. The doctor of the future could well give
better service and charge more for it. This ef-
ficient age for which we are striving may see to
it that our doctors acquire the maximum amount
of training in the minimum amount of time, and
that the family doctor, educated to know the
human body but who will also know that he has
his limitations, and recognize when he needs
special medicine and surgery, will not vanish
from a land which needs his ministrations.
J. B. McA.
BASAL METABOLISM AN APPRECIA-
TION AND A WARNING
The determination of the basal metabolism by
indirect calorimetry has become routine practice
in certain cases in all the leading clinics. The
development of accurate methods of making
this test practicable for clinical work is one of
the most important contributions of the research
laboratory to the clinical laboratory.
It has already found application in the diag-
nosis of hyperthyroidism and hypothyroidism
and in the differentiation of these conditions,
which is sometimes difficult, and in determining
which factor predominates when these two syn-
dromes are combined — a not unusual occur-
rence. It gives us for the first time an accurate
method of following the treatment of these con-
ditions, estimating its efficiency and adapting
the dosage and duration of the treatment to
the needs of each case. This applies particu-
larly to the treatment of hyperthyroidism by the
x-ray and to the treatment of hypothyroidism
with thyroid gland. It is also useful in guiding
preliminary thyroid treatment preparatory to
operations for other conditions. It opens up the
problems of the effects of the different anes-
thetics on patients who are to be operated on
for other conditions but who have at the same
time thyroid disturbances of metabolism, and
also the problem of the effect of the rate of
metabolism on the reparative processes after
surgical operations.
It will undoubtedly find a wider and wider
range of usefulness as it becomes more and
more generally employed. Many of the prob-
lems of nutrition invite the application of this
method of study.
The more the laboratory has to offer to the
clinician, the greater the tendency to expect too
much from the laboratory technician. It is not
his sphere to make the diagnosis. He is called
upon to furnish certain facts which the clinician
can combine with other facts which he must ob-
tain from the patient's history, the family his-
tory, the physical examination, and the correla-
tion of similar cases in his experience.
There are many pitfalls for one who wishes
to take advantage of the evidence offered by in-
direct calorimetry. It is timely to call attention
to some of these, while the advertising columns
of all of our journals are proclaiming the sim-
plicity of the various outfits, and the ease with
which accurate results may be obtained.
To get dependable results by the use of any
apparatus for the determination of the basal
metabolism requires a certain amount of train-
ing in laboratory technique, a thorough knowl-
edge of the principles involved, an abundance of
patience and tact in handling nervous individu-
als and sensitive instruments, a most painstak-
ing attention to many more or less annoying
details with quick judgment for their evaluation,
and an ability and willingness to sacrifice as
much time to each determination as it may re-
quire.
If you are such a person you can make your
own basal metabolism determinations; other-
wise do not undertake them, and do not entrust
them to a technician who does not fulfill all
these requirements. You cannot draw depend-
able conclusions from any quantitative estima-
tions unless you know the person that made
them.
A single determination should not be accepted
until checked by one or two repetitions. You
should not be satisfied with a method or an
apparatus until it has been found to check with
another, preferably by another method. For
example, there are two types — the "closed"
type, in which the subject rebreathes into an
excess of oxygen for a certain time with the
absorption of the exhaled carbon dioxide by
soda lime, the shrinkage in volume representing
oxygen consumed (exemplified by the Bene-
dict apparatus) and the gasometer type (the
Tissot) in which outside air is inhaled while
the expired air goes into a gasometer where it
is measured and from which samples are taken
and analyzed by a Haldane gas apparatus. Cor-
rections are made for the thermometric and
barometric conditions. The patient breathes
into the apparatus either through a rubber
mouthpiece, in which case the nose is closed by
a "nose clip," or through a half mask covering
both the nose and mouth. In either case adjust-
ment of the mouthpiece and nose clip, or of the
half mask requires care and patience, as leaks
are very apt to occur, and such leaks are often
not evident unless carefully looked for by an
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THE PENNSYLVANIA MEDICAL JOURNAL
May, 1921
experienced operator. Leakage is also apt to
occur in the joints and connections of the appa-
ratus. Such a leak, if not recognized and cor-
rected, results in an error in the estimation of
the volume of oxygen consumed. It takes tact
and patience to get a nervous man or woman to
breathe normally under these conditions and
sometimes it is impossible. If both these types
of apparatus are used on the same patient errors
due to leakage are apt to balance each other, as
leakage about the mouth or nose is most apt to
occur during expiration, which increases the
final result in the Benedict and diminishes it in
the Tissot. Of course, leakage during inspira-
tion would have the opposite effect:
Another very important point is that the soda
lime in the Benedict must be watched and fre-
quently checked as it may go dead and fail to
absorb the carbon dioxide, in which case the
volume of carbon dioxide not absorbed will be
added to the volume of unused oxygen and di-
minish the reading for oxygen consumed by just
the amount of carbon dioxide not absorbed.
The reaction of the patient to these pro-
cedures, especially the nervous hyperthyroid
case, must be taken into consideration. The
fear of the unknown, the imposing array of ap-
paratus, the buzzing of the electric fan, the dis-
comfort of the mouthpiece, nose clip, or mask,
all are apt to cause physical restlessness, appre-
hension, fear of suffocation and inability to
cooperate, as shown by great variation in the
rate and depth of respiration, making it very
difficult to determine the proper readings for the
beginning and end of the test. Judgment and
experience are required to determine when a
patient is in a suitable condition for the test as
well as in the selection of the moment at which
to start and stop the stop-watch, marking the
duration of the test.
The method with the Tissot gasometer and
the Haldane gas analysis requires about twice
as much time, but offers much less liability to
error. In hospitals it is desirable to have both
types. The quicker can be used as routine and
frequently checked by the other, which is also
available for determinations of the respiratory
coefficient.
The value to clinical medicine of the ability
to measure the rate of metabolism quickly and
accurately cannot be overestimated, but any
portable apparatus should be closely scanned
and the results carefully checked by other meth-
ods and other types. The same caution applies
to a new operator. The watchword at present
in all basal metabolism determinations is
"check." Check the apparatus. Check the
method. Check the man. L. L.
STATE TUBERCULOSIS CLINICS
At a recent meeting of one of our count)' so-
cieties, Dr. Francine, chief of the Tuberculosis
Department of the State Bureau of Health.
made an announcement which is far-reaching
in its possibilities. In effect he said, "that the
state tubercular clinics were to be regarded as
at the disposal of the profession. In the event
of not being able to diagnose a given case, by
sending it to the clinic, those in charge would
if possible make a diagnosis or assist in arriving
at some conclusion, and return the patient to the
physician with a complete record of the case."
May this be looked upon as a step in the di-
rection of state group medicine? If so, what
shall be the attitude of the profession toward
this scheme? That it will be a great help in
combating disease, in that it will materially aid
in diagnosing obscure conditions not necessarily
tubercular, cannot be denied.
Group practice of medicine has many advo-
cates, possibly more opponents. The study of
obscure conditions by a group of specialists may
solve a knotty problem, but in the routine and
regular practice of submitting every case to such
a procedure undoubtedly tends towards lower-
ing the efficiency of the internist and may
eventually, to a very great extent, eliminate him
altogether.
We doubt whether any other motive than the
promotion of better health conditions has
prompted the action of the Department of
Health. The question of the ages, "Am I my
brother's keeper?" is being answered by every
agency having the health of the people under its
charge. As the medical profession is the most
actively concerned in the promotion of every
means toward this end, we should undoubtedly
accept the invitation and profit by it. Every
agency which will assist in diagnosing obscure
conditions can only tend to make better doctors.
At the same time it assures the patient that he is
getting the best care and attention possible and
if not a cure, at least the satisfaction of knowing
from what disease he is suffering.
The department is to be commended for its
activities and the broad construction it puts
upon the different avenues at its command for
the betterment of health conditions. The pro-
fession of the state should, and we believe will,
cooperate in every manner possible. Thus with
the state authorities on one hand and the pro-
fession on the other, a mighty force is provided
which should and eventually will raise our
health standard above that of any other state.
I. G. S.
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EDITORIALS
591
"SOCRATES REDUX"
SAVING THE BABIES
You don't believe in saving the babies?
"I decline to commit myself upon so gen-
eral a statement."
Do you mean to say that you can harden your
heart to so pitiful an appeal as that which has to
do with the needs and sufferings of helpless in-
fants ?
"Well, before I answer your question, I at
least have a right to know what babies are to be
saved and what they are to be saved for."
What difference does it make? As an ab-
stract proposition if there are anywhere babies
to be saved, and it is in our power to save them,
are not we obligated to save them ?
Without answering the question our friend
took from his pocket a package of envelopes
held together by a rubber band, and gravely
handed it to me. I have a feeling that I may
have looked somewhat savage as I took it, for
I was certainly intensely irritated by the recep-
tion my pet philanthropy had met at the hands
of onein whose good sense I had heretofore felt
some confidence, although I knew him rather
given to unexpected differences of opinion.
The first envelope contained an appeal for
funds to aid in the Saving of the children of
Austria and Vienna from starvation, the sec-
ond a similar one in aid of the German children,
the third in aid of the Armenian children, the
fourth told that three cents a day would save a
Chinese baby from starvation, and the last
urged the reader to give a liberal donation to the
fund being raised to enable a well-known chari-
table enterprise to save the babies of one of our
own large cities. Having looked them over I re-
placed the rubber band and returned them.
■ "Will you contribute to all ?"
That would be impossible. I only wish that I
could.
"To which then?"
You know very well that I have my own
charity of this kind to support; of course, I
shall give my contributions to it.
"Very good, and wisely answered."
Well, if you agree with me, give me a liberal
donation ; you can easily afford it.
"First, I must know what the babies are being
saved for."
Did you ever read the life of Pasteur? He
loved children, and said that in their presence
he always felt a certain reverence because he
never could tell what that child might later be-
come. We never can tell but that the most un-
promising child for whom we give our mite may
some day become the President of the United
States.
"True enough, our country has been unfor-
tunate in some of its presidents. But all joking
aside, do you ever ask yourself whither we are
tending with all our modem life-saving devices?
If no women any longer die in childbirth be-
cause of modem methods in obstetrics; if no
babies are allowed to die because of our "baby-
saving" enterprises ; if all people are prevented
from dying in the good old-fashioned way from
smallpox because they are all vaccinated; if
the Public Health Department keeps everybody
from epidemic disease through its various vac-
cinations, its water purifications, its food inspec-
tions and dairy regulations ; if all of the indus-
tries are made safe from injurj' from poisons
and accidents ; if the surgeons cure all the in-
testinal obstructions, remove all the appendices
and gall bladders, excise all the precancerous
conditions, and patch up all the injured parts;
if the studies in dietetics and the enforcement
of prohibition stamp out all of the dissipation
disorders, and if the hundred other measures
for improving the people are successfully main-
tained, what is to become of all the people? The
world will shortly be so overpopulated that
there will only be standing room. We'll all be
hanging onto straps as in the Philadelphia street
cars. Why in my lifetime the population of this
country has doubled. If it doubles again where
are the people to go? We used always to com-
fort ourselves with the thought that there was
the great "West" with plenty of room, but
where is it now ? I was out there a while ago,
and if there was much worth having that some
fellow hadn't got, I couldn't find it."
The old gentleman had become so heated over
what he said that we could not help laughing;
but as he seemed to be offended, we sobered
enough to hasten to -say, "But these matters do
not concern us. Our duty is very clear ; it is to
save life."
"Even if the end result be such an excess of
population that there will soon be no coal, no
trees, no oil, no meat, no milk, no anything, ex-
cept for the favored and wealthy few? Even if
the general condition of th§ world becomes as
it is in China where about half of the popula-
tion lives from hand to mouth, and in times of
famine, such as they are having now, is threat-
ened with starvation?'
But, my dear friend, we do not nCed to worry
about that. With the steady improvement in
the transportation facilities it will be easy for
those in famine districts to get food from the
more fortunate regions.
"Will it ? Can China get anything to eat from
Digitized by VjOOQIC
592
THE PENNSYLVANIA MEDICAL JOURNAL
May, 1921
England? Why? Because England has not
enough to eat herself. Why? Because she is so
overpopulated that if her transportation were
interrupted for only a few weeks, starvation
would be staring her in the face. From Aus-
tria ? No, people are starving there as well as in
China. In France? Scarcely, for things there
are on a very close margin. In fact, if there is
scarcity of food anywhere in the world, where
do the people turn except to America? Why?
Only because America is the only place where
the supply of food exceeds the demand. As
soon as we produce only as much as we con-
sume, we will be in exactly the same position as
these older countries, and will have to cry for
help in times of need. And to whom shall we
turn? Nobody will be in a position to help us.
It will be our turn to die."
Then you would let the babies die? Would
that not be a crime committed in the present to
prevent a disaster so far in the future as to be
a mere chimera?
"How much do you pay for beefsteak now ?"
Forty-five cents a pound.
"It used to be twenty-five."
Do you know why it costs more now? It is
because those western ranges over which the
cattle used to graze in great herds have disap-
peared— been fenced in to make farms. Why,
cattle used to be so numerous in California that
they used to kill them for their hides ; later they
killed them for their meat ; now there are very
few cattle in California. It is not a meat state.
The same .thing is true in all parts of the
country. With the cultivation of the land go
the ranges, and with them the cattle, and with
that up go the prices of meat, never to come
down. At present wheat is raised on great
farms in the northwest ; it scarcely pays to raise
it in the east. As the population grows and the
farms are divided into smaller and smaller ones,
there will be other things than wheat needed and
everybody will raise only a fraction of the
present great crop, and wheat will go up, then
bread will go up, then poor bread will be sold,
and so poverty will have to eat it and its ill-
eflfects will be seen. The great boast of our
country has always been and still is that we are
the best-fed nation on earth. How long will we
remain so if we go on as at present, and as you
baby-savers want to?"
The clock pointed to closing time, and as we
looked at it he followed our eyes and under-
stood that the interview must come to an end.
"What do I mean when I say I want to know
tvhat babies, when I am asked whether I favor
baby-saving? I'll tell you. If I want to save
babies, I want to save good babies. I want
them to be of a kind that hold out some definite
hope of being worth saving."
But no one can ever know what a child may
become, to use the words of Pasteur. (We
were very anxious to bring Pasteur into the
matter because we knew the old man to be a
particular admirer of his.)
"No, you cannot tell what a child may be-
come, but you may be able to tell somethii^
about what averages of children may become.
The weak offspring of weak-bodied and weak-
minded parents are apt to have children like
themselves; strong-bodied and strong-minded
parents, children like themselves."
Ah, now you are taking about eugenics.
"Yes, and something more than eugenics;
something more useful in the present state of
society in our country. Birth control! I want
fewer children, and better children. I want
them bred by fathers and mothers of sound
bodies and intelligent minds. I want them so
regulated in coming into the world that there
will be no increase in the number but a great
improvement in the quality of our population. I
want my countrymen of the future to be the
world's best, strongest, wisest people, and I
want them to have plenty to eat and plenty to
drink to make them strong and happy."
My dear sir, you are an idealist !
"I know I am," he said.' as we went down tne
stairs together. "By the way, here is another
envelope that I forgot to show you. Look over
its contents when you get home."
It contained a check for one himdred dollars,
made out in the name of "The Campaign foe
Better Babies" — our own organization !
PROPAGANDA FOR REFORM
Helmito, Omitted from N. N. R. — Helmitol is
hcxamethylenamin methylencitrate. It was introdiKed
with the claim that it was superior to hexamethyl-
enamin (which acts in acid fluids only) in that it is
equally efficient whether the urine is alkaline or acid.
In 1918 the Bayer Co., which then marketed the product
in the United States, was notified that the Council on
Pharmacy and Chemistry questioned the claims and
desired evidence for their substantiation. In 1919 the
same notification was sent the Winthrop Chemical Co,
which in the meantime had secured control of the
product. Pending the submission of evidence, the
Council continued Helmitol in New and Nonof&ial
Remedies with the statement that the action and uses
were those of hexamethylenamin. Now the Council
on Pharmacy and Chemistry announces that Helmitol
has been omitted from New and Nonofficial Remedies
for the reason that the claims under which it was in-
troduced have been disproved by P. J. Hanzlik, who
demonstrated that the alkalinity required to split off
formaldehyd from helmitol is greater than exists in
urine, even in the advanced ammoniacal fermentation
(Jour. A. M. A., Jan. 22, 1921, p. 260).
Digitized by
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The Medical Society of the State of Pennsylvania
OFFICERS' DEPARTMENT
WALTER F. DONALDSON, M.D.
Secretary
8014 Jenkins Arcade BIdg., Pittsburgh, Pa.
EDUCATING THE PUBLIC
We quote the following from an editorial ap-
pearing in the April 2, 1921, number of the
Pittsburgh Medical Bulletin:
"The Sayre (Pa.) Times of March 9, 1921,
contained a full-page advertisement by chiro-
practors made up of misinformation regarding
the history of the Mariam Rubin "talking sick-
ness" case, and a number of false statements
about the child's condition subsequent to a series
of "adjustments" by a chiropractor. The same
paper of March 10 contained a full-page state-
ment composed of the special article and edi-
torial that appeared in the Journal of the A. M.
A., giving the facts in the above-mentioned case
of encephalitis.
"We were so impressed by the outstanding
efficiency of this unique procedure that we in-
vestigated and learned to our gratification that
the copy and payment for this article of March
10 had been furnished individually by an ex-
president of the Medical Society of the State of
Pennsylvania. The enterprise thus manifested
may point out the only way by which public
opinion may be molded against the aims of the
propaganda of this healing cult, which is based
on abysmal ignorance of the etiology and treat-
ment of disease.
"Of one thing we are sure, and that is that
our conservative methods of ignoring the blatant
claims of various healing cults has not stayed to
any appreciable extent the apparently endless
procession of fads of healing. May it not be
time for medical organizations to pay full ad-
vertising rates, if necessary, in order to place
before the public facts regarding the cause and
cure of sickness, in contradistinction to the lying
claims of those whose interests in sickness are
absolutely selfish, and who have no interest
whatever in its prevention. Has the time not
also arrived in Pennsylvania for medical organi-
zations to provide the necessary funds for the
detection and prosecution of illegal practitioners
of the healing art ? Our statute books are filled
with laws regulating the practice of medicine,
the practice of osteopathy, the practice of vari-
ous of the drugless cults, but the state makes no
provision for the necessary funds to enforce
these laws. At the risk of being considered
selfish and of belonging to a "medical trust,"
let us provide, for a few years at least, the nec-
essary funds to protect the people of this com-
monwealth from the machinations of boastful
pretenders to healing skill."
Why not from time to time pay for publicity
expressed in facts properly arranged ? We ten-
tatively suggest the following:
REPLACED VERTEBRAE
"One of your vertebrae was out of place. I
have replaced it and you will be relieved of your
complaint."
The above falsehood represents the stock-in-
trade of the average manipulator healing the
sick under the guise of most of the drugless
cults. The next time such brainless chatter is
repeated in your hearing, you should challenge
the miracle worker to obtain from a meat dealer
the spinal column of a calf (veal) and in your
presence actually displace with his finger one-
thirty-second of an inch the body of one ver-
tebrae upon another. It can't be done.
The actual dsiplacem^nt by crushing weight
of the vertebrae of a human being results in a
"broken back" or a "broken neck," and gen-
erally results in death, in spite of the efforts of
the most skilled surgeons, with the aid of anes-
thesia and powerful instruments to overcome
the strength of the muscles, ligaments and in-
terlocking bony structures concerned. It can't
be done.
Actual displacement of vertebrae invariably
results in complete paralysis of the body below
the point of injury.
If it were not for the element of time and the
tendency of half of our ailments toward recov-
ery without any treatment, fads in the healing
art would fail utterly.
THE 1921 MEETING OF THE A. M. A.
All the duly elected delegates from our So-
ciety to the Boston meeting have formally signi-
fied their intention to attend.' Many problems
will confront the A. M. A. House of Delegates
this year, most important of which will include
recommendations for change and advancement
of standards and ideas regarding the slowly
changing relations between the urban physician
Digitized by VjOOQIC
594
THE PENNSYLVANIA MEDICAL JOURNAL
May, 1921
and his clientele on the one hand and the rural
practitioner with his following on the other.
A defense against the continuous and monot-
onous attacks of the various healing cults and
their supporters upon the medical profession
should also receive careful consideration by the
House.
We recommend to the nine delegates from
Pennsylvania a study of the hearing reviewed
on pages 510, 511 and 512 of the April Penn-
sylvania Medical Journal.
Members of the Medical Society of the State
of Pennsylvania planning to visit Boston June
6-10 should make hotel reservations and also
obtain identification certificate entitling them to
the reduced railroad rates. (See page 517 of
the April Pennsylvania Medical Journal.)
RESULTS
The enterprise manifested in most oi our component
societies during the current year is remarkable. The
scientific and economic phases of medical practice have
been emphasized in well planned programs, and the re-
sponse to the financial obligation of membership has
been magnificent. Note the following:
/p^o Per Capita
ifHi Per Capita
County
Tax Paid
Tax Paid
(April i3, 192 j)
Per Cent.
Elk
22
26
1181
Greene
22
■ 25
1 136
Montgomery
138
144
1044
Lehigh
83
100
1039
Berks
127
130
1023
Lycoming
102
104
1019
Chester
75
76
1013
York
118
121
1002
Crawford
55
55
1000
Huntingdon
36
36
1000
Juniata
It
11
1000
Mercer
73
73
1000
Sullivan
8
8
1000
Wyoming
13
13
1000
Allegheny
"35
1134
999
Dauphin
147
145
985
Philadelphia
2046
2016
^J
Erie
"7
115
982
Bucks
84
82
976
Cumberland
41
40
975
Tioga
34
33
970
Armstrong
62
60
966
Beaver
59
57
966
Bradford
52
SO
961
Lancaster
131
126
961
Adams
25
24
960
Butler
40
48
960
Washington
127
123
960
Fayette
121
"5
958
Montour
20
19
955
Northampton
133
127
954
Indiana
63
60
952
Lawrence
58
55
948
Union
18
17
944
Columbia
48
45
934
Carbon
30
28
933
Center
30
28
933
Westmoreland
150
140
933
McKean
44
41
931
Snyder
13
12
923
1920 Per Capita
1921 Per Capita
County Tax Paid
Tax Paid
Per Cent.
(April 23, 1921)
Mifllin
27
25
922
Blair
89
82
921
Northumberland
64
59
921
Jefferson
49
45
918
Lackawanna
184
169
913
Luzerne
234
213
910
Clearfield
63
57
904
Venango
62
55
886
Delaware
96
85
88s
Cambria
128
112
875
Potter
16
14
875
Somerset
46
40
869
Clarian
36
31
86t
Lebanon
36
31
861
Perry
16
16
844
Schuylkill
118
99
838
Wayne
29
24
827
Franklin
59
47
Monroe
14
II
785
Clinton
27
21
773
Bedford
21
16
761
Warren
50
37
740
Susquehanna
22
14
636
Total 7198 6957 968
That our members prize their State Society mem-
bership is well illustrated in the following incident:
In one of our component counties, lack of hard roads
and the bad weather have to date prevented an organi-
zation meeting. Shortly before March 31 this oflice
volunteered to receive direct the State Society per
capita tax of the nineteen members. Forty-eight hours
subsequent to the date of the offer, fifteen members
had remitted.
To our component societies located in counties
where the above mentioned conditions of roads and
weather are likely to obtain from November to May,
we respectfully suggest a fiscal year ending in June.
Such an arrangement would assure the functioning of
the society officers so essential to a year-round or-
ganization, even if actual meetings are possible only
during the summer and fall months.
It is a yearly experience for this office to receive in
reply to our April notices a delinquency to those whose
per capita tax is unpaid March 31st, a statement to
the effect that the delinquent member has not been
notified that his 1921 dues were due or overdue. We
would respectfully suggest to the secretaries of all
component societies that on March 15th of each year,
statements be sent by registered mail to each member
whose dues for the current year remain unpaid and
that as far as possible, a telephone message be sent to
all members whose dues for the current year remain
unpaid March 28th.
CHANGES IN MEMBERSHIP OF COUNTY
SOCIETIES
The following changes have been reported to .April
15:
Adams : Death — Charles E. Smith, of Center Mills.
March 14.
Allegheny : .\'ew Members — Harry S. Midgley, At-
wood and Forbes Sts. ; Charles M. Swindler, 1027
Carnegie BIdg. ; Annie Schuyler, 525 Woodboume
Ave., S. S., Pittsburgh; Francis M. S. Bowers, 814
Braddock Ave., Braddock. Reinstated Members—
Abraham L. Barbrow, 705 Sandusky St., N. S.; Cort-
landt W. W. Elkin, 519 N. Hiland Ave.; Charles A.
Hauck, 316 Lowell St.; John F. McGrath, 1434 Fifth
.\ve. ; Charles S. Burns, 7435 Washington St. ; Simon
Sigman, 81 12 Jenkins Arcade; Charles P. Leininger,
Digitized by
Cnoogle
May, 1921
OFFICERS' DEPARTMENT
595
Fulton Bldg. ; Morris A. Goodstone, 302 Washington
Bank Bldg.; Samuel C. McCorkle, 3301 Brighton
Road, N. S., Pittsburgh; James W. Harper, 186
Promenade St., Crafton.
Blair: Reinstated Members — William H. Robinson,
Roaring Springs; Charles S. Hendricks, 508 Second
St., Juniata.
Carbon : New Member — John J. Quinn, Lansford.
Cambria : New Members — Melvin E. Cowen, Sani-
tarium, Cresson ; William F. Mayer, 228 Market St.,
Johnstown ; Death — Louis H. Mayer, Sr. (Jeff. Med.
Coll., '87), of Johnstown, May 21, 1920, aged 59.
Center: Transfer — George T. Yearick of Centre
Hall from Cambria Co.
Chester : New Members — Frederick B. West, Kem-
blesville; William Greenfield, Chester County Hos-
pital, West Chester; Charles D. Diettrich, R. D. 3,
Pottstown. Reinstated Members — Ellwood Patrick,
West Chester; Fred L. Baker, New Cumberland; C.
H. Ehringer, West Chester. Transfer — James S.
Hammers of Embreeville from Montour Co. Death
—Frank D. Emack (Univ. of Md., Sch. of Med., '75),
of Phoenixville, Nov. 17, 1920, aged 71.
Clarion : Dtro/A— James A. Brown of New Ken-
sington, Oct. II, 1920, aged 77.
Clearfield: Removal — Samuel Stalberg from Glen
Richey to Boardman ; Isaac Stalberg from Boardman to
Furnace Run (Armstrong Co.). Tronj/c/— Joseph W.
Harshberger, of Lamar to Clinton Co. Death-— WaI-
lace H. Dale (Coll. Phys. & Surg., Baltimore, '95), in
Houtzdale, Mar. 11, from embolism following septi-
cemia and Bright's disease, aged 60.
Cumberland: New Member — Alexander Stewart,
Shippensburg.
Dauphin: Reinstated Member — George R. Moffitt,
200 Pine St., Harrisburg.
Erie: Transfer — A. Girard Cranch of Lakewood,
O., to Cuyahoga Co. Med. Society, Ohio.
Fayette: Reinstated Members — Albion J. Marston,
Belle Vernon; Don D. Brooks, Connellsville ; Her-
man A. Heise, Frank X. Merrick. Uniontown.
Greene: Reinstated Member— James A. Knox,
Waynesburg.
Jefferson: Reinstated Member— E. W. Jaquish,
Punxsutawney.
Lackawanna : Reinstated Members — Robert V.
White, Brooks Bldg. ; Patrick J. Heston, 325 Pittston
St., Scranton; Harry Jones, Dickson City.
Lawrence: Reinstated Member— Chirles E. Train-
or, IIS E. North St., New Castle.
Lebanon: Reinstated Member— Paul D. Reich,
Jonestown.
Lehigh: Death— Vred C. Sieberling (N. Y. Univ.
Med. Coll., '62), of Allentown, April 4, aged 81.
Luzerne: Death — James Reid Thompson (Univ. of
Penna., '94), of Forty Fort, Mar. 19, from acute
nephritis, aged S3-
Lycoming: New Member— BiTton Brown, Linden.
(Temporary address. Quarantine Station, Savannah,
Ga.)
McKean: New Member — Guy S. Vogan, Marien-
ville.
Mo.NiTGOMERY : New Member— Herhtrt W. Taylor,
Haverford.
Northampton: New Member— C\»Tence D. Hum-
mel, 2339 Hay St., Easton. Death — Sterling D.
Shimer (Univ. of Penna., '9s), of Easton, Aug. 28,
1920, aged SI-
Northumberland : Reinstated Member— l^renzo B.
Zimmerman, 23 N. Oak St., Mount Carmel.
Somerset: New Member— Elmer E. Geissler, Je-
rome.
York : Reinstated Member— Jeremiah F. Lutz, Glen
Rock.
PAYMENT OF PER CAPITA ASSESSMENT
The following payment of per capita assessment has
been received since March 14th. Figures in the first
column indicate county socie^ numbers; second col-
umn, state society numbers :
1920
Mar. 21
1921
Mar. 14
16
17
18
19
22
23
24
25
28
Fayette
Wayne
Lycoming
Somerset
Lehigh
Adams
Venango
Luzerne
Washington
Allegheny
Mercer
Centre
Franklin
Westmore-
land
Cumberland
Adams
Elk
Somerset
Cambria
Wyoming
Dauphin
Somerset
Columbia
Mercer
Bradford
McKean
Venango
Franklin
123-124 7197-7198 $10.00
24
81-94
23-27
66-89
23
43
104-134
68-108
641-866
68-69
20-22,24,25,35
31-32
114-116
21-32
24
27
28-29
53-92
12
I 14-124
30-33
38-39
70
36-39
30-31
44
33-38
Lackawanna 84,105-123
Fayette 1-83
Cumberland 33
Delaware 78-80
Westmore-
land 117-119
Butler 18-24
Montgomery 120-130
Northampton 97-112
Clearfield
Luzerne
Union
Venango
Mercer
Somerset
Blair
Montour
Dauphin
Carbon
Perry
Blair
Cumberland
Lawrence
Franklin
Lancaster
Chester
Lancaster
Lycoming
Perry
Somerset
Armstrong
Luzerne
Mifflin
Chester
Mercer
Washington
Lancaster
Bucks
McKean
Venango
Northumber'
land
24-44
135-158
17-18
45-46
71
34
54-72
17-18
125-130
1-23
1-2
73
34-35
40-54
39
82-1 19
1-65
120-121
95-100
3
35-36
41—47
159-162
23
66-68
72
109-116
122
65-75
32-37
47
46-56
2987
2988-3001
3002-3006
3007-3030
3031
3032
3033-3063
3064-3104
3105-3330
3331-3332
3333-3338
3339-3340
3341-3343
3344-3345
3346
3347
3348-3349
3350-3389
3390
3391-3401
3402-3405
3406-3407
3408
3409-3412
3413-3414
3415
3416-3421
3422-3441
3442-3524
3525
3526-3528
3529-3531
3532-3538
3539-3549
3550-3565
3566-3586
3587-3610
3611-3612
3613-3614
3615
3616
3617-3635
3636-3637
3638-3643
3644-3666
3667-3668
3669
3670-3671
3672-3686
3687
368S-372S
3726-3790
3791-3792-
3793-3798
3799
3800-3801
3802-3808
3809-3812
3813
3814-3816
3817
3818-3825
3826
3827-3837
383^3843
3844
3845-3855
digitized by
S-oo
70.00
25.00
120.00
S-oo
5.00
155-00
205.00
1,130.00
10.00
30.00
10.00
'1500
10.00
5.00
5.00
10.00
200.00
5-00
55-00
20.00
10.00
5.00
20.00
10.00
5.00
30.00
100.00
415-00
S-oo
15-00
15-00
35 -po
SS-00
80.00
105.00
120.00
10.00
10.00
5.00
5.00
95.00
10.00
30.00
115.00
10.00
S-OO
10.00
75-00
5.00
190.00
325.00
10.00
30.00
S-OO
10.00
35 00
20.00
5.00
1500
5.00
40.00
5.00
55-00
30.00
5. 00
C.d^gle
596
THE PENNSYLVANIA MEDICAL JOURNAL
May, 1921
Mar. 28 Indiana
1-59
3856-3914
$295.00
29 Carbon
24-25
3915-3916
10.00
Berks
122-129
3917-3924
40.00
Jefferson
28-34
3952-3931
35-00
Columbia
40-41
3932-3933
10.00
Montour
19
3934
5.00
Dauphin
131-143
3935-3947
65.00
Erie 93-0, 9^-109
3948-3963
80.00
Washington
117-118
3964-3965
10.00
30 York
4-6,52-118
3966-4035
350.00
Fayette
84-103
4036-4055
100.00
Bucks
76-82
4056-4062
35.00
Mercer
73
4063
5.00
McKean
39-39
4064-4065
10.00
Blair
74
4066
5.00
Delaware
81-83
4067-4069
15-00
Washington
119-120
4070-4071
10.00
Huntingdon
31-36
4072-4077
30.00
Lancaster
123-125
4078-4080
15-00
Venango
48
4081
5.00
Lycoming
101-103
4082-40R4
1500
Beaver
35-42„
4085-4092
40.00
Montgomery
131-138
4093-4100
40.00
• Perry
4-7
4101-4104
20.00
31 Clearfield
45-54
4105-4114
50.00
Montgomery
139
4115
5-00
Indiana
60
4116
5.00
Cumberland
36
4117
5-00
Juniata
10
41 18
5.00
Blair
75
4119
5-00
Westmore-
land
I20-I2S
4120-4125
30.00
Columbia
42-43
4126-4127
10.00
Bradford
40-45
4128-4133
30.00
Berks
130
4134
5.00
McKean
40
4135
5.00
Cumberland
Z7
4136
5.00
Perry
8-13 .
4137-4142
30.00
Butler 25-45, 47-48
4143-4165
115.00
Bedford
4-8
4166-4170
25.00
Luzerne
163-176
4171-4184
70.00
Westmore-
land
126-127
4185-4186
10.00
Cumberland
38-39
4187-4188
10.00
Perry
14
4189
5-00
Erie
IIO-III
4190-4191
10.00
Carbon
26-27
4192-4193
10.00
Blair
76-77
4194-4195
10.00
McKean
41
4196
5-00
Somerset
37-38
4197-4198
10.00
Schuylkill 42-65,67-96
4199-4252
270.00
Lackawanna
124-147
4253-4276
120.00
Clearfield
55-56
4277-4278
10.00
Perry
15
4279
5-00
Clinton
19
4280
5.00
Columbia
44
4281
5-00
Crawford
15-55
4282-4322
205.00
Carbon
28
4323
5.00
Bradford
46-47
4324-4325
10.00
Westmore-
land
128-130
4326-4328
15.00
Washington
121
4329
5-00
Allegheny
159,601,602
610, 867-1076
4330-4543
1,070.00
Bradford
48
4544
5.00
York
119
4545 .
5.00
Snyder
10
4546
5-00
Venango
49
4547
5-00
Chester
69-72
4548-4551
20.00
Lebanon
1 5-3 1
4552-4568
85.00
Snyder
II
4569
s-oo
Dauphin
144
4570
5.0O
Tioga
1-31
4571-4601
155-00
Montgomery
140-141
4602-4603
10.00
Bradford
49
4604
5.00
Westmore-
land
131-134
4606-4608
20.00
Armstrong
48-54
4609-4615
35-00
Mar. 31
Schuylkill
97-99
4616-4618
$15-00
Philadelphia
1-2013
4619-6631
10,065 -00
Luzerne
177-204
6632-6659
140.00
Somerset
39
6660
5-00
Juniata
11
6661
5-00
Blair
78
6662
5-00
Tioga
32
^3_
5-00
Venango
50-51
6664-6665
10.00
Montgomery
142-143
6666-6667
10.00
Luzerne
205-207
6668-6670
15.00
Lancaster
126
6671
5-00
York
120
6672
5.00
Beaver
43-48
6673-6678
30.00
Armstrong
55
6679
5-00
Columbia
45
6680
5-00
Cambria
93-105
6681-6693
65.00
Bradford
50
6694
5-00
Cambria
106
6695
5-00
Erie
112-113
6696-6697
10.00
Beaver
49-53
6698-6702
25.00
Bedford
9-14
6703-6708
30.00
Somerset
40
6709
5-00
Armstrong
56-60
6710-6714
25.00
Allegheny
1077-1116
6715-6754
200.00
Lackawanna
148-150,
152-160
6755-6766
60.00
Snyder
12
6767
5-00
Gretne
24-25
6787-6769
10.00
Perry
16
6770
5-00
Blair
79^
6771-6772
10.00
Lycoming
104
6773
5.00
Erie
97
6774
500
Northumber-
land
57-59
6775-6777
15.00
Jefferson
35-37
6778-6780
1500
Delaware
84
6781
5.00
Clearfield
57
6782
5-00
Chester
73-75
6783-^5
15.00
Dauphin
145
6786
5-00
Venango
52
6787
5-00
Clarion
31
§§
5-00
Lawrence
55
5-00
Delaware
85
6790
5-00
Mifflin
25
6791
5-00
Cambria
107-109
6792-6794
15-00
Bedford
15-16
6795-<5796
10.00
FREDERICK L. VAN SICKLE. M.D.
Executive Secretary
212 North Third St.,
Harrisburg
REPORT OF THE HEALTH INSURANCE
COMMISSION
It is with pleasure that we publish the ma-
jority report of the Health Insurance Commis-
sion, as submitted to the Legislature in the ses-
sion of 1921. It will be noted that this report
does not emphasize the need of compulsory
health insurance in Pennsylvania at this time.
We believe that the medical profession may
have no little satisfaction in knowing that the
arguments presented before this Commission
carried sufficient weight to have the effect of
demonstrating to the Commission the conditions
of medical service to the people of this Com-
monwealth and the inadvisability of changing
the plan of medical practice which has proved
as satisfactory as any other plan could.
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May, 1921
OFFICERS' DEPARTMENT
597
REPORT OF THE HEALTH INSURANCE
COMMISSION
TO THE 1921 SESSION OF THE GENERAL
ASSEMBLY OF THE COMMONWEALTH
OF PENNSYLVANIA
Harrisburg, Pa., April 18, 1921.
Gentlemen:
Your Commission was appointed under the
provisions of the Act approved the i8th day
of July, A. D. 1919, reading as follows :
Session of 1919
No. 392-A
AN ACT
To establish a commission to continue the in-
vestigation made by the Commission appoint-
ed under the Act approved the twenty-fifth
day of July, one thousand nine hundred and
seventeen (Pamphlet Laws, one thousand one
hundred and ninety-nine), entitled "An Act
to establish a commission to investigate sick-
ness and accident, not compensated under the
> Workmen's Compensation Act of one thou-
sand nine hundred and fifteen, of employed
persons and their families, and to make an ap-
propriation for such commission."
Section i. Be it enacted, &c., That a com-
mission is hereby created to be known as the
Health Insurance Commission, which shall :
1. Continue the investigation begun and car-
ried on by the commission appointed under the
Act approved the twenty-fifth day of July, one
thousand nine hundred and seventeen (Pam-
phlet Laws, one thousand one hundred and
ninety-nine), entitled "An act to establish a com-
mission to investigate sickness and accident, not
compensated under the Workmen's Compensa-
tion Act of one thousand nine hundred and fif-
teen, of employed persons and their families,
and to make an appropriation for such commis-
sion.
2. Make a study of proposed and existing
systems of health insurance in this and other
countries.
3. Make a careful study of possible remedial
legislation which shall provide adequate medical
care for employes and their families during
sickness, afford a means of meeting the wage
loss suffered by employes during such periods
of sickness, and stimulate statewide interest and
active work in sickness prevention.
Section 2. The commission shall hold public
meetings in different parts of the Common-
wealth, and shall submit to the general assem-
bly of one thousand nine hundred and tw»nty-
one a full final report, including such recom-
mendations for legislation by bill or otherwise
as in its judgment may seem proper.
Section 3. The commission shall consist of
three Senators, to be appointed by the president
pro tempore of the Senate, three representa-
tives, to be appointed by the speaker of the
House of Representatives; and five other per-
sons, not members of the general assembly, to be
appointed by the governor.
Section 4. The commission shall have power
to elect its chairman and other officers, to ex-
amine witnesses, books and papers respecting all
matters to be investigated, to issue subpoenas to
compel the attendance of witnesses, and the
production of books and papers, to administer
oaths, to employ a secretary, experts in the
matters to be investigated, and all necessary
clerical and other assistance, to purchase books
and all necessary supplies, and to rent halls for
hearings. If the commission shall appoint from
its members subcommittees to make an inquiry,
the subcommittees shall have the same powers
for the examination of persons and papers and
to administer oaths as are herein conferred upon
the commission. Salaries and other expenses
of the commission shall be paid upon vouchers
approved by the chairman of the commission,
up to the amount appropriated by the general
asembly.
Section 5. The Commissioner of Health and
the Commissioner of Labor and Industry are
hereby directed to cooperate with the commission
and to render it any such proper aid and assist-
ance as in their judgment may not interfere with
the proper conduct of their respective depart-
ments; and, as far as possible, rooms in build-
ings owned or leased by the Commonwealth shall
be assigned to the commission for hearings or
other purposes.
Section 6. The sum of fifteen thousand dol-
lars ($15,000) or as much thereof as may be
necessary is hereby specifically appropriated
for the actual and necessary expenses of the
commission in carrying out the provisions of
this act. Payment of the money shall be on
order of the chairman of the commission and on
warrant of the auditor general.
Approved — ^The 18th day of July, A. D. 1919.
Wm. C. Sproul.
In pursuance of this act, the following mem-
bers of the commission were appointed:
Members named by the Governor : Mr. Wil-
liam Flinn, Pittsburgh, Pa.; Mr. William
Draper Lewis, Philadelphia; Dr. Francis D.
Patterson, Philadelphia; Dr. G. Oram Ring,
Philadelphia; Mr. William H. Kingsley, Phila-
delphia. . J
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598
THE PENNSYLVANIA MEDICAL JOURNAL
May, 1921
Members named by the president pro tem. of
the Senate: Senator S. J. Miller, Clearfield,
Pa. ; Senator Morris Einstein, Allegheny ; Sen-
ator Charles W. Sones, Lycoming.
Members named by the speaker of the House :
Mr. Wililam T. Ramsey, Delaware; Mr. John
M. Flynn, Elk ; Mr. Theodore Campbell, Phila-
delphia,.
On March ii, 1920, the commission organ-
ized with the election of the following officers:
Mr. William T. Ramsey, chairman ; Mr. Theo-
dore Campbell, treasurer; Dr. Francis D. Pat-
terson, secretary.
In order to facilitate the work of the com-
mission a committee on "plan of work" was ap-
pointed by the chairman, which committee con-
sisted of the following members: Mr. William
Draper Lewis, Mr. William H. Kingsley, Mr.
Charles W. Sones, Mr. William T. Ramsey, ex-
officio; Mr. Theodore Campbell, ex-officio; Dr.
Francis D. Patterson, ex-officio.
The committee on plan of work determined
that it was essential that the commission have
the benefit and cooperation of various agencies,
and accordingly the following associations were
requested to appoint committees to cooperate
with the commission and we had the coopera-
tion of the following :
Committee representing the Pennsylvania
Manufacturers' Association: Col. John P.
Wood, Pequea Mills, 22A and Spring Garden
Sts., Philadelphia; Mr. Justus H. Schwacke,
Wm. Sellers & Co., i6th and Hamilton Sts.,
Philadelphia; Mr. Robert H. Anderson, Keas-
by & Mattison, Ambler, Pa..; Mr. Arthur N.
Blum, Henry Disston & Sons, Inc., Tacony,
Philadelphia ; Mr. J. W. Rawle, J. G. Brill Co.,
62d and Woodland Ave., Philadelphia; Mr.
B. R. Lichty, Otto Eisenlohr & Bros., Inc.,
Philadelphia; Mr. Francis Curtis, editor. Bulle-
tin of Pennsylvanisi Manufacturers' Association,
Finance Bldg., Philadelphia.
Committee representing the Pennsylvania
Federation of Labor: Mr. John A. Phillips, 131
N. 15th St., Philadelphia; Mr. James H.
Maurer, Commonwealth Trust Co. Bldg., Har-
risburg. Pa.; Mr. A. P. Bower, in N. 6th St.,
Reading, Pa.
Committee representing the Medical Legisla-
tive Conference of Pennsylvania: Dr. G. A.
Knowles, 4812 Baltimore Ave., Philadelphia;
Dr. F. L. Van Sickle, 212 N. 3d St., Harrisburg,
Pa.; Dr. Jos. G. Steedle, McKees Rocks. Pa.;
Dr. L. Webster Fox, 17th & Spruce Sts., Phila-
delphia ; Dr. Frank Hartman, 136 N. Duke St.,
Lancaster, Pa. ; Dr. B. A. Krusen, Norristovvn,
Pa. ; Dr. J. Ross Swartz, 236 N. 3d St., Harris-
burg, Pa.; Dr. G. Harlan Wells, 1807 Chest-
nut St., Philadelphia; Dr. W. Steele, 1825
Chestnut St., Philadelphia; Dr. Wm. Hillegas,
1807 Chestnut St., Philadelphia; Dr. M. V.
Hazen, 211 Locust St., Harrisburg, Pa.; Dr.
E. F. Shaulis, Indiana, Pa. ; Wr. W. S. Glenn,
State College, Pa.; Dr. W. O. Keffer, Frugal-
ity, Pa. ; Dr. R. E. Holmes, i8th and State Sts.,
Harrisburg, Pa.
Committee representing the Industrial Phy-
sicians: Dr. Drury Hinton, 3500 Grays Ferry
Road, Philadelphia; Dr. A. W. Colcord, Car-
negie Steel Co., Clairton, Pa.; Dr. Loyal
Shoudy, Bethlehem Steel Co., Bethlehem, Pa.
Committee representing the Emergency Aid
of Pennsylvania : Mrs. John C. Groome, Rose-
mont. Pa. ; Mrs. Barclay H. Warburton, Jen-
kintown. Pa.; Mrs. Thomas Robins, Philadel-
phia, Pa.
Committee representing the American Red
Cross: Mrs. H. C. Boyer.
Committee representing the Visiting Nurse
Society : Miss Tucker.
Committee representing the Pennsylvania
State Chamber of Commerce: Mr. Robert,
Haight, Harrisburg, Pa.
The commission at this point desires to make
public expression of its deep appreciation of the
cooperation and help it has received from all
the members of these committees.
The commission has also had the very great
advantage of the advice and cooperation of
Miss Edith Hilles, who was executive secretary
of the commission appointed in 1919, and de-
sires at this time to publicly express its appre-
ciation of her efforts in behalf of the commis-
sion.
With a view of gathering knowledge, the
commission has held a number of public meet-
ings, the first of which was held in Philadelphia,
May 24, 1920, at which time addresses were de-
livered by the following: Dr. Edward Martin,
Commissioner of Health of Pennsylvania; Mr.
John A. Lapp, Secretary, Ohio Health Insur-
ance Commission ; Dr. F. L. Van Sickle, Exec-
utive Secretary, Pennsylvania State Medical
Society; Dr. Lee K. Frankel, Vice-president,
Metropolitan Life Insurance Company ; Dr. A.
W. Colcord, Chief Surgeon, Carnegie Steel Co.
A joint session of the commission with the
Homeopathic Medical Society of Pennsylvania
was held at Harrisburg, Pa., September 21,
1920. Chairman of the meeting. Dr. R. L.
Piper, Tyrone, Pa., which meeting was devoted
to the subject of "What Is State Health Insur-
ance," at which time addresses were delivered
by the following: Dr. William M. Hillegas,
Philadelphia; Dr. G. A. Knowles, Philadelphia;
Dr. Clarence Bartlett, Philadelphia ; Dr. F. L
Digitized by
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May, 1921
OFFICERS' DEPARTMENT
599
Van Sickle, Harrisburg, Pa.; Hon. Wm. T.
Ramsey, chairman of commission; Dr. E. S.
Snyder, Lancaster, Pa.; Dr. G. Harlan Wells,
Philadelphia, Pa.
The commission held a joint meeting with the
Medical Society of the State of Pennsylvania
at its annual meeting in Pittsburgh, October 6,
1920, at which time addresses were delivered
by the following: Dr. Henry D. Jump, presi-
dent of the Medical Society; Dr. Frederick R.
Green, Chicago, 111.; Hon. Wm. T. Ramsey,
chairman of the commission.
A meeting of the commission was held in
Philadelphia, December 3, 1920, at which time
addresses were delivered by the following : Dr.
William E. Sweet, Philadelphia; Dr. Clarence
Bartlett, Philadelphia ; Dr. Edward M. Gramm,
Philadelphia; Dr. Harlan G. Wells, Philadel-
phia; Eh-. Henry D. Jump, Philadelphia; Dr.
Frank C. Hammond, Philadelphia.
A meeting of the commission was held in
Philadelphia, February 4, 1921, at which time
addresses were delivered by the following : Dr.
John B. Andrews, New York, N. Y. ; Mr. John
A. Lapp, Chicago, III. ; Mr. Miles M. Dawson,
New York, N. Y.; Mr. Joseph P. Chamberlin,
New York, N. Y.
A meeting of the commission was held in
Philadelphia on March 18, 1921, at which time
addresses were delivered by the following : Dr.
Edward Martin, Commissioner of Health of
Pennsylvania ; Dr. A. H. Doty, New York City ;
Mr. H. B. Anderson, New York City ; Hon. P.
Tecumseh Sherman, New York, N. Y.
The commission has also had the advantage
of studying the report of the investigation into
the operation of the British Health Insurance
Act made by Chairman Ramsey of the commis-
sion, assisted by Mr. Ordway Tead, who visited
England for that purpose. Owing to the dis-
turbed conditions upon the continent of Europe,
it was impracticable for them to make an in-
vestigation of health insurance in the central
European countries.
The previous commission had made a survey
of the sickness problem and this work was so
ably and efficiently performed that there was no
necessity for this commission to further inves-
tigate along these lines.
The commission has carefully studied the
investigations that have been conducted in the
States of California, Massachusetts, Wiscon-
sin, Kentucky, Ohio, Illinois, New York and
New Jersey, and in none of these states, nor in
any other state, have laws been enacted provid-
ing for health insurance. In some states, nota-
bly New York, bills have been proposed provid-
ing for health insurance, but these bills have
been defeated, and your commission has had the
advantage of making a study of this proposed
legislation.
In our study of this problem we have been
brought into contact with the notable work of
the more than eleven thousand physicians now
engaged in the practice of the healing art within
the borders of our Commonwealth, and we have
had emphasized for our consideration that the
excellent work in which they are engaged may
be classified under two general headings, first,
The Prevention of Disease, and, second. The
Cure of Disease.
We have found that these physicians are
working in close harmony and cooperation with '
our State Department of Health, and too much
credit cannot be given to Dr. Edward Martin,
Commissioner of Health of this Commonwealth,
and the able organization which he has devel-
oped, and to the physicians of our Common-
wealth for their successful efforts in reducing
the sicknesK incidence of this Commonwealth,
which is materially lower than in many other
states and countries.
A notable instance of this work is in the
conservation of the purity of our water supplies,
which has resulted in the prevention of an un-
told number of cases of typhoid fever, which
disease in the past was almost edemic within
the borders of our Commonwealth. Preventive
measures against smallpox, tuberculosis, ven-
ereal disease, and many other diseases have
been followed by a most gratifying result.
The splendid cooperation of our medical pro-
fession and of our hospitals, both state and
private, and the ability displayed by the nursing
profession resident within our Commonwealth
have resulted in 'not only the saving of many
lives, which would otherwise have been wiped
out by disease, but in shortening the period of
lost time resulting from illness.
Your commission is familiar with the medical
work being performed in many of the larger
industries, and the eminently successful work
being daily performed by the industrial physi-
cians of this Commonwealth- cannot be too
highly emphasized. Their work has meant that
in many cases disease has been diagnosed in its
incipiency, and under proper and adequate
medical treatment what might have terminated
in a serious illness, has instead, ended in prompt
restoration to good health. Their activity and
close cooperation with the Division of Indus-
trial Hygiene and Engineering of our State
Department of Labor and Industry have made
for better sanitation in the factories and, there-
fore, better health among the many thousands
of employes. . »
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600
THE PENNSYLVANIA MEDICAL JOURNAL
May, 1921
Your commission has been in receipt of reso-
lutions passed by the American Medical Asso-
ciation and by state and county medical socie-
ties, the State Chamber of Commerce and other
organizations, which have gone on record as
being opposed to compulsory health insurance
and this attitude has been emphasized at many
of the public meetings which the commission
has held.
We have further been in receipt of communi-
cations from many representatives of organized
labor, expressing their disapprobation of com-
pulsory health insurance.
It is the belief of the commission that so-
called health insurance patterned after laws in
effect in foreign countries more properly might
be termed "sickness indemnity" and would fall
short of its hoped-for achievements were such
a law to be enacted in Pennsylvania.
Theaimof those who urge legislation that would
lessen the existent loss of man power by reason
of neglected illness through compulsory prompt
medical treatment which would shorten the
period of sickness absence of wage earners, with
its attendant distress and wage loss, is in a good
direction; but an open-minded study of this
whole subject leads to the conclusion that a
plan which would extend the benefits of "sick-
ness prevention" so as to diminish the sixteen
million days of time loss, with its concurrent
wage loss of over fifty millions of dollars, now
existent in the State of Pennsylvania, and pre-
serve the wage-earning ability of the large class
intended to be covered and the full industrial
and commercial value of the increased labor
thus performed, would yield far greater benefit
than would legislation which contemplates the
payment of sickness allowances to the relatively
few who would qualify.
The whole problem of loss of working time
through illness, occupational disease, or physical
degeneration rather automatically divides itself
into the elements of either prevention or cure.
Wage earners find no substantial benefit from
either brief or prolonged absence from work by
reason of sickness, and even if it were possible
to continue their full wage during such periods
there still remains the many millions of day's
total absence from their vocations, with the
consequent commercial and potential loss in
their lines of work.
So far as the mechanical operation of a health
insurance system is concerned, it may be said
that where it is enforced by national legislation,
as in England, its difficulties may be diminished,
but if as is the case in that nation, there is a
decided division of opinion, as to its real bene-
fits, how much broader would be this variation
of opinion and the attendant difficulties if put
in force in one or more of the states of the
United States and not in the balance.
Prospective physical impairment that is likely
to prove permanent and so-called occupational
diseases usually have their forerunners of ex-
clusive warning to the individuals affected and
it is within the realm of probability that such
parties would, as their impairment increases,
seek employment in states having most liberal
health insurance laws in order that they might
ultimately come under the greatest possible in-
demnity benefit.
It might be argued that this condition would
be counterbalanced by interstate migration, but
as the laws providing for sickness indemnity
would not likely be uniform as to benefits there
would be a decided tendency toward imposition
by prospective beneficiaries seeking domicile,
when chronic illness impends, in the state which
has most liberal benefits of health insurance.
The State of Pennsylvania has always stood
at the fore and front in the matter of paternal
care of its citizens and there is abundant proof
of the genuine, wholesome benefits, protective
and otherwise which through law have been
conferred upon those who are engaged in its
industries, professions and various vocations,
and it is with the thought of leading to a higher,
more widespread and enduring beneficial result
that the suggestion is made that an enlargement
of the facilities and scope of function of the
State Department of Health, with the due sup-
port by appropriation and contributions, would
make possible a much more valuable result if
these activities were directed toward disease
prevention, maternity care, etc., and thus elimi-
nate or greatly lessen at their source, the condi-
tions, a neglect of which is the foimdation of
later illness, on which the desire for so-called
health insurance is based.
In conclusion, your commission would
strongly emphasize that this subject has been
under careful consideration and exhaustive re-
view for a period of four years in this State
and for a longer period in other states; that
the members of this commission have recog-
nized their duties to be more or less judicial,
that they have considered all phases of this im-
portant subject without prejudice and with
open minds ; that while there is an element of
idealism in the suggestion of health insurance
there is lacking to a surprising extent the degree
of benefit which without intensive study might
appear to develop from its operation ; that there
is a preponderance of belief against it and abun-
dance of evidence that leads the commission to
make a negative report, as to the enforcement
Digitized by
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May, 1921
OFFICERS' DEPARTMENT
601
of so-called health insurance legislation at this
time.
Signed by
G. Oram Ring, M.D., •
SUMMERFIELD J. MiLLES, M.D.,
Francis D. Patterson, M.D.,
Secretary;
WmiAM H. KiNGSLEY,
Morris Einstein,
Charles W. Sones,
Theodore Campbeli.,
John M. Flynn,
William T. Ramsey,
Chairman.
Appendix No. i : Report of Investigation into the Operation
of toe British Health Insurance Act by Hon. William T. Ram-
sey, chairman of the commission.
Appendix No. 2: Report of public hearings held by the com-
mission.
A minority report signed by William Plinn and William
Draper Lewis, was filed.
NEW AND NONOFFICIAL REMEDIES
Tolysin. — A brand of neocinchophen complying with
the N. N. R. standards. It is supplied in the form of
a powder and as tolysin tablets 5 grains. Caico Chem-
ical Co., Botmd Brook, N. J.
Saligenin — Salicyl Alcohol. — Saligenin is a local
anesthetic, similar in action to procaine. It is said to
be as effective as procaine but much less toxic; also
the anesthesia produced lasts longer, and for this rea-
son the addition of epinephrin is not necessary. Sali-
genin is a white solid soluble in water.
Pneumococcus Vaccine No. 14 — Beebe. — ^A pneu-
niococcus vaccine (see New and Nonofficial Remedies,
1920, p. 28s) containing Types I, II, III and IV
diplococci pneumoniae in equal proportions, suspended
in physiological solution of sodium chloride, each Cc.
containing 500 million killed bacteria. Marketed in
vials of 6 Cc., 10 Cc., and 20 Cc. Beebe Laboratories,
Inc.. St. Paul, Minn.
Typhoid-ParatyjJioid Vaccine No. 39 — Beebe. — A
typhoid vaccine (see New and Nonofficial Remedies,
1920, p. 291) marketed in packages of three i Cc.
vials, each Cc. containing 1,000 million killed typhoid
bacilli, 500 million each of killed paratyphoid bacilli
A and killed paratyphoid bacilli B, suspended in
physiological solution of sodium chloride; also mar-
keted in 30 Cc. vials. Beebe Laboratories, Inc., St.
Paul, Minn.
Colon Vaccine (Acne) No. 11 — Beebe. — A colon
bacillus vaccine (see New and Nonofficial Remedies,
1920, p. 282) marketed in packages of six i Cc. vials,
each Cc. containing 1,000 million killed colon communis
bacteria suspended in physiological solution of sodium
chloride ; also marketed in packages of one 10 Cc. vials
and in packages of one 20 Cc. vials. Beebe Labora-
tories, Inc., St Paul, Minn.
Acne Bacterin Mixed No. 10 — Beebe. — A mixed
bacterial vaccine (see New and Nonofficial Remedies,
1920, p. 295) marketed in packages of six i Cc. vials,
each Cc. containing 500 million killed B. acni vulgaris,
1,000 million killed staphylococci albi and 500 million
killed staphylococci aurei suspended in physiological
solution of sodium chloride; also marketed in 10 Cc.
vials and in 20 Cc. vials. Beebe Laboratories, Inc., St.
Paul, Minn.
Adalin Tablets 5 Grains. — Each tablet contains 5
grains of adalin (see New and Nonofficial Remedies,
1920, p. 63). Winthrop Chemical Co., New York.
Veronal Sodium Tablets 5 Grains. — Each tablet con-
tains 5 grains of veronal sodium (see New and Non-
official Remedies, 1920, p. 84). Winthrop Chemical
Co.. New York.
Novaspirin Tablets 5 Grains. — Each tablet contains
5 grains of novaspirin (see New and Nonofficial
Remedies, 1920, p. 248). Winthrop Chemical Co.
(Jour. A. M. A., Jan. 15, 1920, p. 179).
Phenetsal-Salophen. — The salicylic acid ester of
acetaminophenol. The actions of phenetsal resemble
those of phenyl salicylate (salol). It acts as an anti-
rhetunatic, antipyretic, antiseptic and analgesic. Phe-
netsal is white, odorless and tasteless. It is almost
insoluble in water.
Salophen. — ^A brand of phenetsal complying with the
N. N. R. standards. It is supplied as powder and as
Winthrop tablets of salophen 5 grains. Winthrop
Chemical Co., New York.
Salophen. — A brand of i^enetsal complying with
the N. N. R. standards. Morgenstern & Co., New
York.
Cinchophen-Calco Tablets 7.5 Grains. — Each tablet
contains 7.5 grains of cinchophen-calco (see New and
Nonofficial Remedies, 1920, p. 225). CaIco Chemical
Co., Bound Brook, N. J.
Procaine-Squibb. — A brand of procaine (see New
and Nonofficial Remedies, 1920, p. 29) complying with
the N. N. R. standards. Procaine-Squibb is supplied
as a^wwder, as hypodermic tablets procaine-Squibb J4
grains, and as solution tablets procaine-Squibb 1%
grains. Squibb & Sons, New York.
Globules Benzyl Benzoate— H. W. & D.— Each gelatin
capsule contains benzyl benzoate — H. W. & D. (see
New and Nonofficial Remedies, 1520, p. 49) 5 minims,
diluted with olive oil. Hynson, Westcott & Dunning,
Baltimore, Maryland (Jour. A. M. A., Jan. 22, 1921, p.
245)-
During December the following articles have been
accepted by the Council oh Pharmacy and Chemistry
of the A. M. A. for inclusion in New and Nonofficial
Remedies :
Calco Chemical Co. : Salicaine.
CoLBMAN Laboratories : Bacillus Bulgaricus.
E. R. Squibb and Sons: Procaine, H. T. Procaine,
Solution Tablets Procaine.
Winthrop Chemical Co. : Adalin Tablets S Grains,
Veronal Tablets S Grains, Novaspirin Tablets 5 Grains
Lederle Antitoxin Laboratories: Typhoid Glyc-
erol-Vaccine, Typhoid Combined Glycerol-Vaccine,
Pertussis Glycerol-Vaccine, Pneumococcus Glycerol-
Vaccine.
The Beebe Laboratories: Pneumococcus Vaccine
No. 14, Typhoid-Paratyphoid Vaccine No. 39, Colon
Vaccine (Acne) No. 11, Acne (Mixed) Vaccine No.
10.
Nonproprietary Articles: Phenetsal, Saligenin.
During January the following articles have been
accepted by the Council on Pharmacy and Chemistry
of the A. M. A. for inclusion in New and Nonofficial
Remedies :
Calco Chemical Co. : Cinchophen Tablets.
Hynson, Westcott & Dunning : Globules of Benzyl
Benzoate.
Heyl Labmiatories : Acriflavine, Proflavine.
Intra Products Co.: Calcium Cacodylate-IPCO.
Winthrop Chemical Co. : Salophen.
Morgenstern & Co. : Salophen.
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County Medical Societies
REPORTERS OF COUNTY SOCIETIES:
Adams — Henry Stewart, M.D., Gettysburg.
Allegheny — Lester Hollander, M.D., Pittsburgh.
Armstrono — Jay B, F. Wyant, M.D., Kittanning.
Beaver— Fred B. Wilson, M.D., Beaver.
Bedford — N. A. Timmins, M.D.. Bedford.
Berks — Clara Shetter-Keiser, M.D., Reading.
Blair — James S. Taylor, M.D., Altoona.
Bradford — C. L. Stevens, M.D., Athens.
Bucks — Anthony F. Myers, M.D., Blooming Glen.
Butler — L. Leo Doane, M.D., Butler.
Cambria — John W. Bancroft, M.D., Johnstown.
Carbon — Jacob A. Trexler, M.D., Lehighton.
Center — James L. Seibert, M.D., Bellefonte.
Chester — Henry Pleasants, Jr., M.D., West Chester.
Clarion — Sylvester J. Lackey, M.D., Clarion.
Clearfield — J. Hayes Woolridge, M.D., Clearfield.
Clinton — R. B. Watson, M.D., Lock Haven.
Columbia — Luther B. Kline. M.D.. Catawissa.
Crawford — Cornelius C. Lafler. M.D., Meadville.
Cumberland — Calvin R. Rickenbaugh, M.D., Carlisle.
Dauphin — F. F. D. Reckord, M.D., Harrisburg.
Delaware — George B. Sickel. M.D., Chester.
Elk — Samuel G. Logan, M.D., Ridgway.
Erie— Fred E. Ross, M.D., Erie.
Fayette — George H. Hess, M.D.. Uniontown.
Franklin — John J. Coffman. M.D.. Scotland.
Greene — Thomas B. Hill. M.D., Waynesburg.
Huntingdon — John M. Keichline. Jr., M.D., Petersburg.
Indiana — C. P. Reed, M.D., Indiana.
.Tefferson — W. J. Hill. M.D.. Reynojdsville.
Juniata — Benjamin H. Ritter, M.D., McCoysville.
Lackawanna — Harry W. Albertson, M.D., Scranton.
Lancastek — Walter D. Blankenship, M.D., Lancacter.
Lawrence — William A. Womcr. M.D., New Castle.
Lebanon— John C. Bucher, M.D., Lebanon.
Lebioh — Frederck R. Bausch, Wf.D., Allentown. .
Luzerne— Walter L. Lynn, M.D., Wilkes-Barre.
Lycouing — Wesley F. Kunkle, M.D.. Williamsport.
McKean— Fred Wade Paton, M.D., Bradford.
Mercer — M. Edith MacBride. M.D., Sharon.
Mifflin — O. M. Weaver, M.D., Lewistown.
Monroe — Charles S. Flagler, M.D., Stroudsburg.
Montgomery — Benjamin F. Hubley, M.D., Norristown.
Montour — John H. Sandel, M.D., Danville.
Nokthamptoh — W. Gilbert Tillman, M.D., Easton.
Northumberland — Charles H. Swenk, M.D., Sunbury.
Pbiry — Maurice I. Stein, M.D., New Bloomfield.
Philadelphia — John J. Repp, M.D., Philadelphia.
Potter — Robert B. Knight, M.D., Coudersport.
ScHUYHciLL — George O. O. Santee, M.D., Cressona.
Snyder— Percy E. Whiffen, M.D., McClure.
Somerset— H. Clay MeKinley, M.D., Meyersdale.
Sullivan — Martin E. Herrmann, M.D., Dushore.
Susquehanna — H. D. Washburn, M.D.. Susquehannm.
Tioga — ^John H. Doane, M.D., Mansfield.
Union — Oliver W. H. Glover, M.D., Laurelton.
Venango — John F. Davis. M.D., Oil City.
Waxken— M. V. Ball, M.D.. Warren.
Washington — Homer P. Prowitt, M.D., Washington.
Wayne — Edward O. Ban^, M.D., South Canaan.
Westmoreland — J. F. Trimble, M.D Greensburg.
Wyominc — Herbert L. McKown. M.D., Tunkhannoclc
York — Gibson Smith, M.D., York.
May, 1921
DELAWARE— MARCH
The March meeting of the Delaware County Medi-
cal Society was held at Chester Hospital on March
ID, Dr. George H. Cross presiding.
After the transactions of routine business the papei
of the evening was presented by Dr. Henry D. Jump,
President of the State Medical Society, his subject
being "Diseases of the Ductless Glands."
Dr. Jump began by calling attention to the difficul-
ties incident to the consideration of this subject and
the apparent contradictions which our present knowl-
edge presents. He spoke of the occurrence of pre-
cocious puberty in boys with associated teratoma of
the pineal gland. If the pineal gland is removed in
animals puberty is hastened in male animals, but not
in females.
Feeding animals with pineal gland apparently pro-
duces the same effect as ablation. He suggested that
in ablation the effect might be the result of damage to
other tissues incident to the operation.
The ductless glands were named and their inter-
relation emphasized. The conditions of myxedema and
hyperthroidism were dscussed. Dr. Jump called atten-
tion to the ease with which one can diagnose these
conditions when all the cardinal symptoms are present,
and the difficulty when one encounters borderline
cases. He spoke of the value in these latter cases of
the Getsch test and of the determination of basal me-
tabolism. The treatment was outlined and he called
attention to the value of limiting sugar in cases of
myxedema when breathlessness develops during the
administration of thyroid gland.
Tetany and its relation to the parathyroid glands
was spoken of, with the disappointing results of the
administration of the gland in treatment.
The thymus and thymic deaths were discussed.
Dercum's disease — adiposis dolorosa — was illustrated
by pictures and the possible thyroid influence sug-
gested. The pituitary gland and its relation to acro-
megaly; the use of pituitrin in the treatment of dia-
betes insipidus ; the occurrence of virilism in cases of
hypernephroma ; dystrophia adiposogenitalis ; eunuch-
oidism and pseudo-herhaphroditism were also dis-
cussed and their relation to the glands of internal
secretion described as far as known.
Dr. Jump's paper was well illustrated and was thor-
oughly enjoyed by all present.
Dr. Jump also outlined the work being done by the
Legislative Committee of the State Medical Society.
George B. Sickel, Reporter.
LANCASTER— APRIL
The regular meeting of the Lancaster City and
County Medical Society was held April 6 with Presi-
dent E. J. Stein in the chair and fifty members present.
The stated business of the day was a paper by Dr.
Samuel Stem, of Atlantic City, entitled "Original
Researches in Pulmonary Tuberculosis and Pneumonia
with Specific Medication Scientifically Applied." The
speaker had a paper that showed a remarkable amount
of thought and work in its preparation and he clearly
outlined the physical and chemical changes occurring
in these diseases. Upon the basis of these changes he
based his treatment, which consisted of the adminis-
tration of two drams of sodium citrate C. P., every
two hours, in four to six ounces of fluid. Under this
treatment he had observed the worst cases of pneu-
monia terminate by lysis in four to six days. In the
incipient cases of tuberculosis one dram of the drug
three times a day would result in a cure. The doctor
referred to a series of one hundred cases of pneu-
monia with but two deaths under the above treatment
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May, 1921
COUNTY MEDICAL SOCIETIES
603
Dr. T. B. Appel in his discussion brought out the
point that this treatment was the treatment of an
acidosis and was not specific in that similar treatment
was the rule in all inflammatory conditions. Drs. 6ary,
Pomerantz and Russell took part 'in the discussion,
which was closed by Dr. Stem, who reiterated his
contention that he had a specific in the treatment of
the above-named diseases.
WAtTER D. Blankenship, Reporter.
MONTOUR— APRIL.
The regular monthly meeting of the Society was
held at the Geisinger Memorial Hospital, Danville,
April 22d, and was called to order at 8 : 30 p. m., by
the president. Dr. R. A. Keilty, with a goodly number
of members and visitors present.
After disposing of the routine business of the eve-
ning, the scientific program, which consisted of three
papers, was taken up.
Dr. R. A. Keilty presented a well prepared paper on
"The Tonsils as Foci of Infection." He gave a de-
tailed exposition of the subject, especially from a
pathological standpoint, emphasizing the various types
of foci and dividing them into active and inactive
groups. He stated that, in the laboratory work at the
Geisinger Hospital, not a few diseased tonsils showed
tubercular bacilli, especially in the cheesy matter
found in the crypts.
In 388 cases examined, 985 organisms had been iso-
lated, composed of 15 different varieties, and found in
53 combinations.
Dr. J. H. Sandel followed with a paper on "Acute
Eye Conditions," in which he briefly outlined the three
most common acute eye diseases met with by the gen-
eral practitioner. He emphasized the need and impor-
tance of the early recognition and accurate diagnosis
of these conditions, in order that no time be lost in
applying proper treatment. He gave points in differ-
ential diagnosis and stressed the need of care, lest er-
rors in diagnosis lead to errors of treatment.
The final paper of the evening was entitled "Indica-
tions for Tonsilectomy," by Dr. Reid Nebinger. He
mentioned some of the early attempts at tonsil re-
moval, at which the protruding portion was simply
sliced ofT, and the indiflFerent results which followed.
He outlined five different classes of cases which were
suitable for operation for tonsil removal and showed
how chronic and obscure ailments were often relieved
or cured by the operation.
These papers all elicited active discussion and many
helpful points were brought out.
J. H. Sandel, Reporter.
PHILADELPHIA— FEBRUARY
The President, Dr. George Morris Piersol, in the
chair.
Arthritis and Rheumatic Affections
Nature and Treatment of Chronic Arthritis. — This
paper was read by Dr. Ralph Pemberton, of Phila-
delphia, who said that chronic arthritis was one of the
oldest diseases, long antedating cilivization. During
the war the number of cases had been very large —
about 40,000 cases in an army the size of that of the
United States in 1918. Dr. Pemberton said he was
fortunate in having been stationed at General Hospital
No. 9, where he was enabled to study the largest
number of cases of arthritis ever examined under
controlled conditions. Much that he had to say was
based on the experience thus gained with the help of
several collaborators. The more we learned of this
disease the more we realized that most types were
probably referable to the same pathology; perhaps
the great majority were referable to the same under-
lying cause. He studied 400 cases among soldiers and
found that exposure played a very large role in in-
ducing their attacks. The role of infectious foci in teeth,
tonsils, etc., to-day was widely accepted as true and
he had been much interested to find to what degree
exposure was a precipitating factor. The next factor
was dysentery, which held a role comparable to that
played by focal infection. The knee was the joint
most frequently involved. That tallied with experi-
ence in civil life. In soldiers it had been interesting
to see that drilling had not produced any greater in-
cidence of the disease in that joint The ankle and
shoulder followed in comparable numbers. The sur-
.gical foci were chiefly in the teeth and tonsils. The
genitourinary tract played a very small role in these
cases and lues was a negligible factor as a causative
element. The basal metabolism in this series of some
thirty arthritics fell below the normal range in- 20
per cent. As to the nitrogen of the blood, despite
much that had been thought and alleged in regard to
arthritis there did not seem any clear reason for
believing that there was any serious disturbance of
the nitrogenous elements. Withholding red meats,
for example, seemed to have no specific support. As
to the calcium of the blood it was of interest to note
that no disturbance could be detected in these indi-
viduals at the fasting level although nothing was more
clear than that calcium was disturbed in arthritis
because we know the bones become rarefied. A good
deal of evidence on the part of modern investigators
had indicated a definite relation between blood-crea-
tine and carbohydrate metabolism. In 50 per cent, of
these arthritics there were high values for the blood-
creatine and some of these higher values of creatine
fell to normal as the case progressed. There was no
disturbance of the carbon dioxid containing power as
indicative of any systematic acidosis in this conditon.
The output oi water and salt in normals and arthritics
was studied and it seemed from the so-called nephritic
test that there was apparently a little lag in the output
of water and salt as compared to the normal, indicat-
ing that the kidney function was to a small degree in-
volved. Dr. Pemberton believed personally this had
much more to do with the secondary results of
the disease than the causative factors. He did
not believe that the renal involvement played any
role in the production of the disease. There
was a good deal of evidence that there was
some disturbance of carbohydrate metabolism in
arthritis. It was interesting to note that 'the inci-
dence of arthritis was greatest at the time when the
metabolism went down physiologically. The age curve
of metabolism was one which rose sharply in childhood
and went down in later life. There was no question
that the outstanding causes of arthritis in civil life
were foci of infection which depending on the age of
the individual, occur chiefly in the teeth, tonsils and,
lastly, in the genitourinary tract. However, other
agents might do the same thing — ^pneumonia and dys-
entery may play a definite role. Other causes which
could produce arthritis are disturbances of the duct-
less glands. An undue food intake undoubtedly pro-
duced arthritis in those in whom the ground work
was provided. Finally, the large bowel might be a
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THE PENNSYLVANIA MEDICAL JOURNAL
May, 1921
factor as Lane had emphasized. The agents which im-
proved arthritis were those which tended, apart from
removing focal infection, to combat the tendency
towards a lowered metabolism. The more the speaker
saw of this disease the more he was impressed with
the difficulty of analyzing correctly for focal infection.
It was difficult to determine when focal infection was
present and where it was, but it was equally hard to
remove and there were some situations in the body
from which focal infection probably could not be re-
moved. Treatment of cases of arthritis based upon
removal of focal infection was not complete merely
with the removal of focal infettion. These cases had
more or less disturbance of the body chemistry. After
taking out a pair of tonsils in a subject with arthritis
we assumed, too frequently, that he would get well
and ignored the fact that there had taken place a
serious disturbance in physiology which we could
not entirely read. He might remain sick for several
years. The agents which were beneficial in arthritis .
were those which tended to combat this condition of
somewhat lowered metabolism. They were arsenic,
probably potassium iodide, certainly thyroid extract
when it could be used ; the x-ray ; radium, which had
great difficulty of application; electricity; exercise,
which was a perfectly definite means of raising metab-
olism; massage nonspecific protein; heat and hydro-
therapy, the last-mentioned playing a very important
and useful role in this disease.
Dr. J. Clarion Gittings, of Philadelphia, in the dis-
cussion said that the result of reducing the demand
upon the body metabolism in patients that had been
thoroughly studied and in whom all foci had been re-
moved and all other theoretical causes had been
eliminated was undoubted to his mind. In his talk
with Dr. Pemberton in attempting to determine what
was the particular food material at fault and what line
of treatment a man who knew comparatively little of
metabolic processes could carry out, he was impressed
with the fact that even Dr. Pemberton with all his
experience, was unable, without a great deal of study,
to determine what was the best measure of depriva-
tion for any individual and, as he had emphasized,
this question of diet, although in the main it may be
accepted as one of the most important measures in the
relief of these patients, was certainly one which could
not be attempted without knowledge of the tools, so
to speak. Dr. Gittings said he had also been impressed
with the figures of the effect of the removal of foci.
The fact that so many of the patients developed their
arthritis in the entire absence of foci and others re-
covered in the presence of foci showed that, although
the agency of the focus was certainly long established,
at the same time it was by no means the sole cause
per se in a very definitely large class of cases.
Dr. Na'than P. Stauffer, of Philadelphia, said that
at first he was under the impression that cases of ar-
thritis were all due to focal infection. As a nose and
throat man he was wont to ascribe brilliant recoveries
to operation, but Dr. Pemberton afterwards convinced
him bv his work and by his patients that he had seen
that it was due to many other causes than just focal
infection and he was quite sure that Dr. Pemberton
had found one of the theories in his carbohydrates or
intake theory. These patients were markedly improved
by regulating their diet even though they had focal in-
fections present at the time, because many of the
cases had gone on and not been operated on, due to the
patient's unwillingness to be operated upon, and even
those who had a focal infection removed had not been
entirely well until they had carbohydrate tolerance
established for them. He also believed that hydro-
therapy was a great help as a therapeutic measure, and
all had seen it probably in the ordinary cases of back-
ache which they all get.
Rheumatic Fever and Its Variants in Childhood and
Adolescence. — ^This paper was read by Dr. David Ries-
man, who said that rheumatism was not, like typhoid
fever or diphtheria, a unit disease manifesting itself
in a more or less uniform manner. The rheumatic
chain had a number of apparently dissimilar links the
connection of which with rheumatic fever was not
easily established although there was abundant evi-
dence that such connection existed. The links referred
to were chorea, tonsilitis, rheumatic skin affections,
cerebral rheumatism, acute rheumatic polyarthritis,
rheumatic carditis. The etiological factor in rheu-
matism has not been demonstrated. Perhaps we should
have to look for a filterable, or ultramicroscopic,
organism yet to be discovered. The greatest mortality
from acute articular rheumatism was in the age period
of from five to fifteen years. While in adults the dis-
ease spent itself chiefly upon the joints, in the child it
had a much greater tendency to attack the heart; the
joint involvement in the latter was often so slight as
to be overlooked, yet the cardias involvement might be
severe. Tonsilitis was in the child a frequent pre-
cursor of rheumatism while chorea was at times a
sequel. Cardiac involvement might come within
twenty-four hours of the beginning of the rheumatic
attack and its discovery depended upon a careful rou-
tine study of the heart The mitral lesions thus caused
were capable of complete recovery though the aortic
lesions practically never recovered. Because of com-
pression of the left lung by the pericardial exudate,
physical signs of pneumonia in this lung may present
themselves. The most characteristic skin lesion was
the so-called rheumatic nodule which histologically
resembled the miliary nodule in the heart muscle.
These were usually few in number, occasionally enor-
mous, and found chiefly about the elbows, backs of the
wrists, near the ankles and over the buttocks. Diag-
nosis offered a large field and there were many
chances of error. When only one joint was involved
great care must be exercised as the trouble was in
such cases apt to be due to osteomyelitis or gonorrhea.
As to treatment, the salicylates, whether specific or
not, held first place. The dose must be 90 to 150
grains in divided doses at short intervals during the
first 24 hours. The choice of preparation was not very
important ; personally he preferred the sodium salicyl- .
ate combined with a nearly equal amount of sodium
bicarbonate. After the first twenty-four hours the
doses might be lessened. If the case responded at
all the fever and pain would subside in forty-eight
hours. In some cases morphine must be given. The
joints may be wrapped in cotton or local applications
of lead water and laudanum, magnesium sulphate or
oil of gaultheria made. A splint might be applied.
Abundance of water, lemonade and orangeade should
be given. The food should be in the form of milk or
milk products, cereals and broth. Until the causative
agent had been isolated the use of vaccines and serums
was purely empirical. In rare instances the use of a
stock vaccine had proved beneficial. If the tonsils
were diseased they should be removed, but not, of
course, during the attack.
Dr. J. P. Crozier Griffith, of Philadelphia, said that
the frequent mildness of acute articular rheumatism
in children, young children who had passed the age
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May, 1921
STATE NEWS ITEMS
605
of five years, was to be particularly emphasized. Many
of us made a mistake in being too ready to call a
case rheumatism in a child under the age of five,
years, at which period of Hfe it was distinctly rare.
All statistics proved the same thing and yet it had been
Dr. Grifiiths, experience to see cases of scurvy in in-
fants where the diagnosis of rheumatism had been
blithely made by the physician who had had the patient
in charge. Anyone who would bear in mind that in-
fants did not get rheumatism would avoid this mis-
take. After the period of years it was likely to show
itself in a mild way until the period of puberty and
was therefore likely to be overlooked, consisting of
vague aches of various sorts of which the patients
had taken practically no notice at all. One of the
most important indications of rheumatism was cardiac
rheumatism. He believed thoroughly that the cardiac
manifestation might be the first manifestation of all
the rheumatic condition, that it might occur without
any rheumatic disease of any sort. Certainly it oc-
curred after chorea without any condition which we
knew. It was his firm conviction that the great ma-
jority of chorea cases rested upon a rheumatic basis
and that 50 to 75 per cent, were in reality rheumatic.
The subcutaneous nodules of which Dr. Riesman
spoke, common as they were in England, though first
described by a French writer, had been in Dr. Grif-
fiths experience rare in this country. He agreed that
purpura was not always to be called rheumatic, and
questioned whether it was ever to be called a symptom
of rheumatism, although it was true that joints were
often involved. We should treat rheumatism and its
complications in early life. He believed in the sta-
tistics which he had read that mitral disease (mitral
regurgitation) was probably present in every case of
endocarditis in childhood. AH the autopsies seemed
to prove that aortic disease was frequently present too,
not stenosis, but the regurgitant condition. In the
treatment of rheumatism he gave salicylates quite
faithfully. He did not know whether it was right to
be so much of a nihilist, but to tell the truth, except
to relieve pain, whether they had any influence upon
the disease he questioned very much.
Dr. A. Bruce Gill, of Philadelphia, said that the
subject of arthritis, whether of disease in childhood
or acute arthritis in adult life, was a large subject.
He thought there was a close relation probably among
all forms of arthritis whether in infancy, child life
or adult life. When we found that many of these
cases were due to focal infections, apparently as the
experience of all of us, then we jumped to the con-
clusion that the form of arthritis was an infection in
the joint. That was the easiest thing to say, but so
many investigators had shown that these joints were
sterile ; then we were obliged to take a step further
back and say it was the presence of a toxin which was
manufactured in some distant .part of the body. Do
we understand what that means? That was taking a
step further back in the dark into an undiscovered
country. Some of these cases were anaphylactic.
Then came a distinct relation between the general
metabolism of the body and arthritis. He thought we
were free to say that we did not yet understand the
direct relation between metabolic changes and the
changes in the joint. He was not quite clear in his
mind whether the metabolic changes could be as-
cribed to a concomitant condition or whether they
occurred with arthritic changes, or whether there are
other causes such as lowered resistance from injury
or faalty posture which gave a lowered resistance in
the joint thus giving these metabolic changes an op-
portunity to have effect upon the joint structures. His
hearers would be surprised if they knew how many
cases came to the orthopedic clinics with acute osteo-
myelitis and tuberculosis, which had been treated by
physicians for a considerable time as rheumatism.
Differential diagnosis was important. Damage was
done by falure of early diagnosis and failure of early
treatment. Also, in connection with this condition of
acute rheumatism Dr. Gill believed that, if the joint
was splinted, the pain would be allayed without the
salicylates.
Dr. Robert G. Torrey, of Philadelphia, said that the
whole point in treating rheumatic fever was to pre-
vent cardiac disease. Dr. Tyson had gone into this
subject from statistics gathered from all sources and
found these patients treated by salicylates showed a
higher incidence of cardiac involvement than cases not
so treated. That he did not think meant that salicyl-
ates should not be used, but it meant just this : that if
we could allay the acute arthritis by giving salicylates,
unless the patient were well under control, he would get
up too soon. If the joints were under control, the heart
would have a better chance of escaping damage.
English statistics seemed to indicate that salicylates
used early and in full doses certainly had a good in-
fluence in controlling, or rather in modifying, the
incidence of cardiac involvement.
STATE NEWS ITEMS
DEATHS
Dr. Harry J. Hartz, of Philadelphia, died April
1st. Dr. Hartz was born in 1883, and was a gradu-'
ate of Jefferson Medical College, class of 1908.
Dr. H. G. Chamberlain, Meadville, Pa., died
Thursday, March 17, 1921, of Bright's disease. He
was 74 years of age and was a graduate of the Uni-
versity of Buffalo.
Dr. DanielH. Long, a well-known physician of
Reading, was found dead on the floor of his oflke
March 31st, a victim of cerebral hemorrhage. He was
70 years of age, and a native of Berks County.
Dr. Samuei, L. Dreibelbis, 73 years old, a physi-
cian for fifty years, died in Reading, April 13th. He
was the father of Dr. S. Leon Dreibelbis and trustee
of the First United Evangelical church for thirty
years, as well as Sunday school superintendent for
many years.
Dr. R. W. Montelius, of Mount Carmel, 67 years
of age, who served in the Spanish-American war as
a lieutenant and was a retired lieutenant colonel of
the N. G. P., died April 19th, of pneumonia.
Among many other offices he held was that of trus-
tee of the Shamokin State Hospital, president of the
board of health and surgeon for the Susquehanna
Colliery Company and Midvalley Coal Company.
Dr. Robert W. Smith, of California, Pa., was killed
instantly and his wife was injured- to-day when their
automobile was struck by a Pittsburgh and Lake Erie
passenger train at the Newell Crossing. Dr. Smith
attended West Virginia University, a Philadelphia
medical school and the State Normal School at Cali-
fornia.
Edward Q. Hassler, aged yT, father of Dr. Samuel
F. Hassler, Superintendent of the City Department of
Public Safety, died Wednesday evenmg, March 30th,
at his home in Progress. Dr. Samuel F. Hassler, of
Harrisburg and J. Elmer Hassler, of Washington,
D. C. ; three daughters, Mrs. Gertrude Nissley, Mrs.
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THE PENNSYLVANIA MEDICAL JOURNAL
May, 1921
William StauflFer, of Progress and Mrs. Ross Hep-
ford, of Harrisburg and , three brothers, Collin C.,
Blain C. Hasseler, of Penbrook and Emery O. Hass-
ler, of Palmrya, survive.
Dr. James R. Thompson, of Forty Fort, died at
his home on the 19th of March, after a few days' ill-
ness from acute nephritis, following chronic myo-
carditis of two or three years' duration. He was for-
merly a member of the Pittston City Hospital Staflf,
but recently resigned on account of ill health.
Dr. Thompson was born in Pittston on October 27,
1868. He was a son of the late Alex and Anna
Thompson, pioneer residents of that city. He was
a graduate of the Physicians and Surgeons College,
Baltimore, Md., and of the University of Pennsyl-
vania. He had also completed a post-graduate course
in New York Medical School.
Three daughters, the Misses Marjorie, Kathry and
Anna Thompson survive him.
Dr. Frederick C. Seiberlinc, one of Allentown's
oldest physicians, passed quietly away at his home,
April 4th. He was in his eighty-first year. Recently
weakness due to his advanced age became apparent
and his decline came gradually to the end.
Dr. Seiberling was the second son of Joshua and
Catherine Mosser Seiberling and was born July 6,
1840, at Seiberlingsville, Weisenberg township. He
received his preliminary schooling at Lebanon, N. J.
As a young man he taught school for several terms
and then took up the study of medicine under Dr.
E>avid Mosser and later Dr. William Herbst.
With the preparation thus gained he entered the
University of New York, Medical Department, and
was graduated with the class of 1863. He then began
his practice at Seiberlingsville, where he continued for
seven years, then moving to Lynnville, remaining there
until 1902, when he removed to Allentown, where he
remained in the active pursuit of his calling until his
last illness.
Dr. Seiberling was a member of the Lehigh County
Medical Society, Lehigh Valley Medical Society and
the American Medical Association. In 1913 the Le-
high county doctors presented him with a silver cup
on rounding out fifty honorable and successful years
as a practitioner in the county.
In 1864 Dr. Seiberling married Sarah, daughter of
Charles Kline, of Weisenberg. She survives with
two daughters, Addie Laura Lovina, Catherine Helena,
both at home, and Dr. George F. Seiberling. Dr.
and Mrs. Seiberling celebrated their golden wedding
anniversary in 1914. There are five sisters surviving :
Mrs. Rosa Grim, of Coggon, Iowa ; Mrs. Mary Gross-
cup. Allentown ; Mrs. Anna Kistler, Lehighton ; Mrs.
E. P. Lobach, Philadelphia, and Mrs. L. M. Holben.
Dr. WiiiiAM Henry McIlhaney, of Easton, died
at his home, on Wilkes-Barre Street, at 2 : 30 o'clock,
March 28th, as the result of heart trouble. He had
been seriously ill for the past three weeks, but had
been in poor health for the past year.
Besides his wife, he is survived by two sisters, Mrs.
John Voorhes, of Bangor, and Mrs. Samuel Young,
of Edelmans.
Dr. Mcllhaney was born at Martin's Creek, a son
of the late Hiram and Rachael Mcllhaney. He was
bom October 14, 1855. He attended Blair Academy
and Newton Prep. School, later entering Lafayette
College as a member of the class of 1879. After two
years at Lafayette he took up the study of medicine
at Jefferson Medical College, from which institution
he was graduated in 1885.
Dr. Mcllhaney resided in Easton for the past
forty-five years, thirty-six of which he spent in the
practice of medicine. He was a member of the old
South Easton School Board for one term, and also
sen-ed as principal of the South Side schools, and
teacher in the high school, having been connected with
the schools for seven years.
He was always intensely interested in civic af-
fairs, was a member of many fraternal societies, and
took part in all the activities of the city.
ITEMS
Dr. Edwin C. McComb has returned to his practice
in New Castle after a visit in Florida.
Dr. and Mrs. H. C. PoHt, of Nazareth, left on the
9th of April for a short vacation in South Carolina.
Dr. John L. Atlee, of Lancaster, spent several
days visiting the various clincs of Richmond, Va.
Dr. and Mrs. Byron M. Peters, Jenkintown, are
spending some time recuperating in South Carolina.
. Dr. Raymond R. Decker has opened offices for the
practice of medicine and surgery, at 26 Chestnut
Street, Lewistown.
Dr. Martin L. Wolford, Harrisburg, is reported
seriously ill in the Harrisburg Hospital, with a ner-
vous breakdown.
Dr. Myer Solis-Cohen has been appointed Assistant
Professor of Internal Medicine in the Graduate School
of Medicine of the University of Pennsylvania.
Dr. W. J. Haymaker, of Export, has been in Flof
ida since November ist. He expects to return home
early this summer and will resume his practice.
Governor Sproul has reappointed Dr. George .\.
Knowles, of Philadelphia, a trustee of the State
Hospital at Norristown.
Dr. and Mrs. A. W. Baker, Harrisburg, both of
whom are recovering from illness, spent several weeks
in the country recently.
Dr. anr Mrs. Frank B. Gummey, Germantown,
Philadelphia, will sail for Europe early in June, where
they will spend several months.
The regular meeting of the Lancaster City and
County Medical Society was held in the rooms of the
Medical Club with President E. J. Stein in the chair
and a large turnout of the membership.
The Lancaster Medical Club had as its speaker
for the March meeting, Mr. Chester W. Cumniings,
referee under the Workman's Compensation Act, who
gave a very interesting paper on the work his board
has been doing.
Dr. and Mrs. Thomas Ashton and their family,
of Philadelphia, have closed their house in Ritten-
house Square and are occupying Redleaf, their coun-
try place in Wynnewood.
Dr. Walter Bortz, Dr. D. A. Murdock, of Greens-
burg; Dr. Charles Taylor, of Irwin, and Dr. Sankey,
of Jeannette, have returned from Rochester, Minn.,
where they had been attending Mayo clinics.
Dr. and Mrs. Francis X. Dercum and their daugh-
ter. Miss Elizabeth C. Dercum, of Philadelphia, sailed
for Europe on the steamship "Canopic," April 20th.
They expect to spend the summer touring Italy.
Dr. and Mrs. Alexis du Pont Smith, Pelham
Court, Germantown, Philadelphia, spent several weeks
in April, with their son-in-law and daughter. Captain
and Mrs. William Elliott Moorman, at Glen Dean,
Ky.
CoL. Edward Martin, State commissioner of health,
has announced these appointments of physicians in
charge of genito-urinary clinics: A. H. Hinrichs,
Pittston State Hospital ; John J. Sweeney, Bucks
County prison ; John B. Cressinger, Packer Hospital,
Sunbury; Dr. Donald Coover, Gettysburg Hospital.
On March 23P, Miss Florence Dougherty, R.N., be-
came the bride of Dr. E. K. Smith, of Millersville,
Pa. The Rev. Dr. Fink performed the ceremony at
the Evangelical Lutheran Church, Philadelphia. .\
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May, 1921
GENERAL NEWS ITEMS
607
honeymoon trip to Atlantic City was enjoyed, after
which Dr. and Mrs. Smith returned to their home in
Millersville.
The Secretary or the County Medical Society,
Philadelphia County, reports that to April ist, 2,017
members out of a total of 2,057 had paid their annual
dues for the year 1921. Approximately 50% of the
remaining membership unpaid, are nonresidents of
the county. A vote of thanks was extended by the
Board of Directors at their meeting on April nth for
the extraordinary ability of Doctor B oice, the Secre
tary, in his collection of dues.
The Reception to the Physicians op Dauphin
County held under the auspices of the Wimodausis
Club, composed of the wives, mothers, daughters and
sisters of the doctors oi this country, at the Civic Club
in Harrisburg on the evening of April 19th, was the
occasion of a very pleasant social event. Mrs. Charles
S. Rebuck and Mrs. J. Edward Dickinson were the
hostesses. An informal program was presented, con-
sisting of community sinking by the entire gathering,
violin solos by Mrs. William H. West, vocal solos by
Mrs. Robert McG. Hursh and piano solos by Mrs.
George W. Bauder. Delicious refreshments were
served, followed by an informal dance. About a
hundred guests were present, and the evening was
declared a great success.
Although he was himself hurt when he drove his
automobile against an embankment to prevent fatal
injuries to Howard Fachus, a small boy, on April i6th.
Dr. J. P. Van Keuren righted his car, took the boy
aboard and both went to the J. Lewis Crozier Hos-
pital. The physician has scalp wounds and Fachus
a broken arm. The accident happened at the entrance
to the quarters of the Springhaven Club, near_ this
city. Fachus, a caddie on the club's links, was riding
his bicycle down the lane. The boy lost control of
the wheel and when Dr. Van Kuren saw a collision
was inevitable, he swerved his car into the embank-
ment, and was hurled from his seat at tKe steer-
ing wheel.
Miss Florence C. Finger daughter of Mr. and Mrs.
A. S. Finger, of Steelton, became the wife of Dr.
Dwight C. Hanna, son of the Rev. and Mrs. D. C.
Hanna, of Gilbertsville, N. Y., March 19th. The
ceremony was solemnized at the home of the bride,
with the Rev. James Markley, of Highspire officiating.
Miss Azalea Wigfield played the wedding music.
Mrs. Hanna is a graduate of the local high school
and has spent the last two years as a registered nurse
at the Training School for Nurses at the Methodist
Hospital, Philadelphia.
Dr. Hanna is a graduate of the Medical School of
the University of Pennsylvania and is now located at
Port Allegheny, where Dr. and Mrs. Hanna will
reside.
Completion of the directorate of the Food Research
Institute, suggested to the Carn^ie Corporation by
Herbert Hoover, was announced April 17th.
The institute, which was formed under an agree-
ment between the Carnegie Corporation and the Le-
land Stanford Jr. University, where it will operate,
will be headed by Dr. C. L. Asberg, former chief of
the bureau of chemistry. United States Department of
agriculture.
Other members comprise Dr. Alonzo E. Taylor,
professor of physiological chemistry at the University
of Pennsylvania, and Professor Joseph S. Davies, as-
sistant professor of economics at Harvard University.
The directors, it was announced, will have authority
to determine the scientific policies of the institute.
Under the will of Dr. James A. Dale, of York,
the estate, estirnated at a quarter of a million dol-
lars, will be distributed among immediate relatives,
life-long friends, religious and charitable institutons.
The principal beneficiary is the York. Hospital, to
which, following a list of bequests, is left the remain-
der of the estate, both personal and real, to be used
entirely for the erection of a new hospital.
It is directed that the trustees make the improve-
ments east of the present hospital on grounds facing
Penn Common; or, if that site is not available, on
some other suitable location.
A building which is to be erected for a nurses'
home is to be a memorial to his mother, Catharine
A. Dale, a tablet designating this fact to be placed
upon the building. It is estimated that the hospital
will receive between $150,000 and $200,000.
Have you received your American Medical Di-
rectory? The Journal received a copy a few days
ago. It is without doubt the most complete directory
of the medical profession ever issued in the United
States— a truly multum in parvo. No up-to-date
. physician who is associated in any way with medical
affairs can afford to be without this directory. It is
a cyclopedia of facts conveniently arranged for ready
reference.
We are sure you will need the directory.
GENERAL NEWS ITEMS
With the May issue the name of Modern Medicine
will be changed to the Nation's Health, thus making
the title more clearly descriptive of the present scope
and the new and enlarged service of the magazine in
health promotion . and conservation. The Nation's
Health will continue those features which have proved
most interesting and serviceable to the readers of
Modem Medicine, but will cover the subjects treated
more completely, and will inaugurate other features
which are important in the new and wider field.
Dr. Charles Beylard Guerand de Nancrede died
at his home in Ann Arbor, Michigan, on April 13th.
Dr. de Nancrede was born in i&t7, was graduated
from the University of Pennsylvania in 1869 and
from Jefferson Medical College in 1883. He served
as a major in the Spanish-American War; was presi-
dent of the American Surgical Association 1908-09;
was Emeritus Professor of Surgery and Clinical Sur-
gery in the University of Michigan and Emeritus Pro-
fessor of General and Orthopedic Surgery in the
University of Pennsylvania.
Hubert Work, of Pueblo, Colorado, president-elect
of the American Medical Association, and once Repub-
lican national committeeman from Colorado, was
named in a recess appointment, March 28th, by Presi-
dent Harding as first assistant postmaster general.
Doctor Work succeeds John C. Koons, who will
continue as postal expert of the department and work
with the joint congressional commission on postal
service.
In HoNog OE Mme. Curie. — The June issue of the
Medical Review of Reviews will be a special radium
number dedicated to Mme. Curie. The issue will con-
sist exclusively of articles on radium and its uses,
written by the most prominent radiologists in the
United States and Canada.
Complimentary copies will be sent to every physi-
cian interested in the uses of radium and any readers
of this item who desire that issue may have it by
asking for it from the Medical Review of Reviews,
51 East 59th Street, New York.
Suprerenalin (epinephrin) the astringent, hemo-
static and pressor principle of the suprarenal or
adrenal gland as isolated by the Armour Laboratory
is again available in various forms — crystals, solu-
tion 1 : 1000 and ointment i : 1000.
Suprarenalin solution is stable, uniform and non-
irritating. It is supplied in i oz. g. s. bottles with the
popular cup stopper.
The beauty of it is that it is free from chemicals
and if protected from the air will remain clear and
potent for a long time.
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THE PENNSYLVANIA MEDICAL JOURNAL
May, 1921
The Victory Medal. — As a token of appreciation
of the services of men who served in the World War,
our government has awarded to each of them the
Victory Medal.
The medal is of bronze. On its obverse is the bas-
relief figure of Winged Victory. On its reverse, the
shidd of the United States superposed by the words
"The Great War for Civilization," and flanked by
the names of the allied countries which united to
crush the Boche and to check Hun "Kultur."
The medal is suspended from a ribbon of rainbow
tints, the blended colors of the Allies, and across the
ribbon are fastened bronze clasps each bearing the
name of an operation in which the wearer served.
To facilitate the distribution of these medals to
those men entitled to receive them, the War Depart-
ment has opened District Medal Offices throughout
the country. In this district, there are Victory Medal
o ces at Scarton, Pa., Post-o ce Building ; Harris- "
burg. Pa., P. O. Box No. 173; Pittsburgh, Pa., 431
Sixth Avenue.
Method op Obtaining the Medal. — ^The medal
may be obtained by calling at any of these offices with
the discharge which is there stamped and handed
back. The application is signed and, if the medal has
no battle clasps, it will be given to the applicant then
and there. If the medal has battle clasps, the dis-
charge is stamped and handed back, and the applica-
tion is forwarded to Philadelphia from where the
medal will be mailed direct to the applicant.
If it is not practicable for the applicant to call at
an office, he may write, requesting an application
blank. This he returns with his discharge. The dis-
charge will be stamped and returned to the applicant,
and the medal will be sent him by mail. It is proper
to say here that this office has handled about 13,000
discharges without the loss of one discharge.
Should the applicant, however, not wish to risk
sending his discharge to a V. M. office, he may request
a form for making a copy of discharge, when he re-
quests an application blank, which form he may for-
ward instead of the original discharge.
In the case of a deceased man, flje medal goes to
his next of kin, who should make the application.
The procedure in such cases is the same as in the case
of a living man, using, however, a different form. It
is not necessary in such cases to forward the dis-
charge, instead of which may be forwarded evidence
of death, such for example, as an official communica-
tion from the War Department, War Risk Insurance
Bureau, Graves Registration Bureau, Letters from
Chaplains, Newspaper Clippings, Affidavit Before a
Notary, etc.
Association, of the American Neurological Associa-
tion ; Fellow of the American College of Physicians ;
Foreign Associate Member of Societe Medico-Psy-
chologique of Paris, etc. Fifth Edition, revised and
enlarged, 269 pages, with illustrations. Philadelphia:
F. A. Davis Company, 1921. Price $2.00 net
Annual Report op the Surgeon-General op the
Public Health Service of the United States for the
fiscal year 1920. Washington: Government Printing
Office, 1920.
Optimistic Medione, or The Early Treatment op
Simple Problems Rather than the Late Treatment
OP Serious Problems. By a former insurance man.
318 pages, cloth, with an extensive glossary. Phila-
delphia : F. A. Davis, 1921. Price $3.00 net
The Wassermann Test. By Charles F. Craig.
M.D., M.A., F.A.C.S., Lieutenant Colonel, Medical
Corps, United States Army; Professor of Bacteri-
ology, Parasitology and Preventive Medicine, and Di-
rector of Laboratories, Army Medical School, Wash-
ington, D. C. ; Formerly Curator, Army Medical Mu-
seum, and Commanding Officer, Yale Army Labora-
tory School. _ Second Edition, revised and enlarged.
Illustrated with colored plates, half tone plates, and
sixty-one tables. Cloth, 279 pages. St. Louis: C. V.
Mosby Company, 1921. Price $4.25.
The American Year Book of Anesthesia and
Analgesia. F. H. McMechan, A.M., M.D., Editor.
Cloth, 483 pages, illustrated. New York: Surgery
Publishing Company (15 E. 26th St), 1921.
Transactions of the CotxEge of Physicians of
Philadelphia. Third Series, volume the forty-first
Philadelphia, 1919.
BOOK REVIEW
BOOKS RECEIVED
Practical Tuberculosis, a book for the general
practitioner and those interested in tuberculosis. By
Herbert F. Gammons, M.D., Supt, Woodlawn Sana-
torium, Dallas, Tex. ; Asst Instructor in Clinical Medi-
cine, Baylor Medical College, Dallas, Tex.; Formerly
Resident Physician, Cullis Consumptives' Home, Dor-
chester, Mass. ; Assistant Physician, Mass. State Sana-
torium, Rutland, Mass. ; Asst. Supt. Conn. State Sana-
torium, Meridan, Conn.; First Asst. Physician, Texas
State Tuberculosis Sanatorium, Carlsbad, Texas ; and
Supt. Deerwood Sanatorium, Deerwood, Minn. Intro-
duction by J. B. McKnight, M.D., Supt. and Medical
Director, Texas State Tuberculosis Sanatorium, Carls-
bad, Tex. 158 pages, cloth, price $2.00. St. Louis:
C. V. Mosby Company, 1921.
Practical Psychology and Psychiatry. For use in
training schools for attendants and nurses and in medi-
cal classes, and as a ready reference for the practi-
tioner. By C. B. Burr, M.D., Medical Director of Oak
Grove Hospital (Flint, Mich.) for Mental and Nerv-
ous Diseases; Member of the American Medico-
Psychological Association, of the American Medical
1920 THE PRACTICAL MEDICINE SERIES,
VOLUME III, EYE, EAR, NOSE AND THROAT.
Edited by Casey A. Wood, M.A.; Albert A. An-
drews, M.D.; George E. Shambaugh, M.D. Chi-
cago, Illinois: The Year Book Publishers.
This little volume is a review of the practice wid
progress in the above department of special medicine
for the year 1920. Its editor. Dr. Wood, with rare
good sense has not attempted to specially emphasize
military medicine, saying "that the subjects supposed
to be exclusively or largely military are, after all,
mostly civilian in their practical application."
The book consists of a series of abstracts of various
'published papers on these subjects which have ap-
peared in different parts of the world in 1920, and the
editor and his assistants are to be particularly congrat-
ulated on having prepared not only a very readable
little volume but one from which information can be
gained in a very short time. Many of these articles
are better written in the abstract than in the original.
In a book containing so much of value it would be
rather unfair to select special articles. A brief com-
prehensive review of the progress of ophthalmology
during the war period emphasizes the lessons learned
in war of the importance of fatigue and emotional
stress in bringing on night blindness, also, the frequent
involvement of the eyes in dysentery, etc., conjunc-
tivitis and iritis in dysentery, keratitis and iritis in ma-
laria, and recurring iritis in spriochetel jaundice.
The Intraocular War Injuries are also treated al
some length, but the treatment of these conditions in
no way differs from treatment of similar conditions as
a result of industrial accidents.
The Relation of Otology to General Medicine is very
ably treated and can be read by the general practi-
tioner with profit. In the Department of Laryngolog)'
there is also much of merit, attention being again
called, amorig other things, to edema of the larynx as
a complication. The danger of prescribing iodides
when the larynx is already obstructed by pathologic
infiltration is again called attention to.
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The Pennsylvania Medical Journal
Owned, Controlled and Published by the Medical Society of the Sute of Pennsylvania
Issued monthly under the supervision of the Publication Conraiittee
VobUMl XXIV
NUMBBH 9
212 North Third St., Harrisburg, Pa., June, 1921
SUBSCKIPTION :
$3.00 Pn Y(A«
ORIGINAL ARTICLES
HEREDITY AS AN ELEMENT IN
bacterial DISEASES*!
ROBT. A. KEILTY, M.D.
DANVILLE, PA.
The purposes of this paper are to present the
viewpoints of the physiopathological side of the
influences of infectious diseases upon heredity
and conversely of heredity upon bacterial dis-
eases, to stimulate new work, both on the part
of the clinician and the laboratory worker and
to offer suggestions whereby their cooperative
efforts may work out data of inestimable value
to that greatest of all products, the child.
THE PROBLEM
In the first place a clear understanding of
what is meant by an infectious or bacterial dis-
ease and of what is meant by heredity, as far as
their correlation is concerned, must be had.
An infectious disease is a reaction on the part
of the body to an invasion by a stimulus, where-
by there is a combat between the invader and
the grouped unit's forces of the body. As a
result of this conflict, certain toxins, and in a
broad sense antitoxins, are produced. The
stimulus, in this case the microorganism, is the
etiological factor and must be accepted as the
cause of the disease, as well as the factor which
continues the reaction of the disease.
Heredity is the transmission of physical and
psychical characters from the parent to the off-
spring developed from one living cell of each
parent. The chromatin of the nuclei is the ac-
cepted real bearer of heredity while the cell
protoplasm, that great laboratory of metabolism
and katabolism, plays but a minor role.
I am not here to discuss, to take sides or even
to stimulate a discussion in the battle still wag-
ing as to the merits or demerits of the variations
and laws of heredity, but as clear an under-
standing as possible must be had of their fun-
damentals before attempting any explanations
concerning their influences upon infection.
'Read before the General Meeting of the Medical Soeietr of
the State of Pennsylvania, Pittsburgh Session, October Si ipao.
,t(From the Depsirtments of Laboratories and Research Medi-
cine, Geisinger Memorial Hospital, and State Hospital, Dan-
Tille, Pa.)
In seeking these explanations, heredity must
begin in the germ cells and must end in the fer-
tilization and early segmentation of the female
ovum. From this point on any influence exerted
upon the growing embryo or upon the fetus must
come from the female alone and must be devel-
opmentally acquired and is not, therefore, purely
hereditary.
I should like to start by accepting the theory
of pangenesis. Every cell in the body gives off
a gemmule or more easily conceived an ion or
even a colloid which collects and concentrates in
the germ cell and from this, types are developed
in the offspring similar to the original gemmules
of the parent. The dominants and recessives of
the mendelian law undoubtedly play an impor-
tant role and explain certain confusing varia-
tions, especially in immunity. The controversy
between Neo-Darwinism and Neo-Lamarckism
may be enlightened by further work on the
transmissions of immunities. It is true these
theories center about evolution but their prin-
ciples must be taken into consideration in this
discussion. In a word, as explained by Darwin,
natural selection is the chief factor in evolution
and acquired characters are denied a part in in-
heritance. On the other hand Neo-Lamarckism,
as recently modified, maintains that the offspring
inherits characters acquired by the parent by
changes in environment. The inheritance of
characters acquired in one generation by future
offspring after missing one or more generations
is generally accepted but is it proved as far as
infectious diseases or immune factors are con-
cerned? The operation of Galton's laws, the
contribution of fifty per cent, by the parents,
twenty-five per cent, by the grandparents, twelve
and one-half by the great-grandparents, etc., may
be true for racial characters but must play only
a moderate role in immunity.
THE TRANSMISSION OE DISEASE
With this phase of the subject as the battle
ground (or better still, we may consider this
the field prepared for the sewing of the seed),
what are the several propositions to be consid-
ered, in the transmission of disease and its reac-
tions by either the father or the mother or both ?
We may generalize on the problem as a whole
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THE PENNSYLVANIA MEDICAL JOURNAL
June, 1921
i»ut the study of each specific disease is a priori
almost essential. If a disease is produced by a
specific stimulus, that stimulus must be trans-
mitted by the parent to the offspring in the germ
plasm in order that the disease may be carried on
in the offspring and be considered a purely he-
reditary disease. For example, if a father alone
is to transmit syphilis to the offspring, the
treponema pallidum must be carried to the fe-
male ovum by the spermatozoon, a process of
phagocytosis, and in the fertilization of the ovum
and growth of the embryo, the spirochaeta must
multiply and carry on the combat within the
growing fetus and independent of influences of
the mother.
CoUes' law, that a mother never having given
any symptoms of syphilis, may give birth to a
syphilitic child, was expounded in 1843. This
law, I consider absolutely impossible unless
proved later by a large number of cases worked
out by serological reactions and darkfield exami-
nations. This, in spite of the fact, that Levaditi
and Sauvage claim to have demonstrated the
treponema pallidum in the ovum or the demon-
stration of spirochaeta in the semen. Surprising
results are obtained in the routine serological ex-
aminations for syphilis where the reaction is
positive and all symptoms are denied.
If a disease is carried on in the offspring and
the etiological factor is demonstrated, that dis-
ease must either have been transmitted by one
or both parents in the germ cells or it must have
been acquired from the mother in intra-uterine
life. If it is denied, as I believe it should be,
that the father may transmit the etiological fac-
tor of any bacterial disease through the germ
cell, then the father as a responsible party to the
transmission per se of an infectious disease is
ruled out. This does not mean that the father
is relieved of all responsibility, as will be shown
in a moment. It cannot be denied that the
mother, having a given disease, may transmit it
through the ovum. Conditions are entirely dif-
ferent, and the close relationship between the
fertilization and the development of the ovum
Within the uterus makes the possibilty of mater-
nal transmission much greater. However, a dis-
tinct line must be drawn between factors which
develop directly from the germ cells and those
that are acquired in utero from the mother, al-
though the end result, the presence of the disease
in the child, may be the same.
From this discussion, several deductions open
to argument and even to proof may be drawn.
The etiological factor of a disease, so far as is
known to-day, cannot be transmitted as a heredi-
tary factor by the father. It may be transmitted
by the mother as a hereditory factor, but prob-
ably only under exceptional circumstances. The
etiological factor, in the vast majority of cases,
is acquired by the child during its development
in utero from the mother, who must of necessity
be infected. An infected father will produce the
same infection in a child by first infecting the
mother, and the mother in turn infecting the
child in utero as an acquired development. So
much for the etiological factor.
EFFECT UPON THE OFFSPRING OF DISEASE IN THE
PARENTS
The next phase of the problem would nat-
urally be, if the etiological factor is not heredi-
tarily transmitted, what would be the effect of
the disease unmodified by treatment in either
parent upon the oflFspring? The effect of a dis-
ease of the parent upon the offspring divides it-
self into two groups. First, is the disease in the
parent active, is reaction still taking place, and
is the etiological factor present or has the dis-
ease subsided, is the reaction completed arid has
the etiological factor been removed? Second,
what effect has this reaction had upon the indi-
vidual gemmules or ions of the germ cells of
the parent?
When the first group is operative in the male
only, the effect of the disease upon the gemmules
only would be expected in the development of
the offspring. When the female is also attacked,
the eflfect upon the gemmules would be supple-
mented by effect upon the growing embryo and
fetus as well as the transmission of the etiologi-
cal factor and independent reaction in the fetus.
When the second group is operative, the effects
upon the gemmules only with respect to the male
and female would be expected. In addition, an
effect from the general nutrition of the female
upon the growing fetus without transmission of
the etiological factor and without independent
reaction by the fetus would be present.
May I repeat syphilis as an example? If the
male has an active syphilis and the female is
clear, syphilis would not be transmitted to the
offspring but it would very probably show up in
the offspring as any One or all of the many de-
generative taints without the treponema pallidum
being present and without any syphilitic reaction
or progression in the offspring. If the female
in addition is actively syphilitic, the offspring
will not only show the degenerative taints as a
result of gemmule influence but will show tre-
ponema pallidum and will have a syphilitic re-
action and progression. In the second group, if
the syphilitic process has been completely ar-
rested in both the male and the female, the off-
spring will show just as much degenerative taint
as the gemmules have received permanent effect
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HEREDITY IN BACTERIAL DISEASES— KEILTY
611
from the syphilitic infection and in addition, any
other changes which the female by reason of
lowered resistance or of increased resistance may
have exerted upon the growing fetus.
THE TRANSMISSION OF IMMUNE FACTORS
So much for the principles of the transmission
of disease factors. We may next turn our at-
tention to the influences of immune factors.
Here is to be found not only the most important
I^art of the discussion, since upon its influence
corrective factors depend, but unfortunately the
most complex part and the part about which the
least is known. It is here that I urge the thought
of all, because I believe much could be accom-
plished. Fortunately, hand in hand with dis-
ease, immunity progresses, and while disease is
transmitted, immunity is also provided for. For-
tunately, too, in some instances, immunity may
be built up without the production of disease, as
in vaccination, and while this field is not as en-
couraging as it once seemed, it is nevertheless
attractive enough to stimulate more work along
its lines. In this connection, it must not be for-
gotten that therapeutic measures may be taken
advantage of and, while they do not have any
direct effect upon heredity, they may so alter
conditions that a natural or normal heredity will
take place.
In the study of the influences of immune fac-
tors upon heredity, I could not hope to cover the
field, so much has been written concerning im-
munity, so much is controversial and so much
has been taken for granted. However, there are
a few principles which it seems to me may be
applied. Immunity divided into two great
groups, natural and acquired, must concern it-
self with both in a way. Heredity is the crux
of natural immunity whether it be of the species,
racial or individual. If we start out with a basis
that the immune factor, if present in a given dis-
ease, is transmitted by the gemmule we have
followed the known laws. The small amount of
experimental data which is quite old would seem
to disprove this entirely. From the extensive
work of Ehrlich in 1892, using vegetable poi-
sons, the offspring of an immunized male and a
normal female failed to show antibodies. On the
other hand, an immunized female paired with a
normal male produced antibodies in the off-
spring. This was considered a passive transfer
of antibodies by the blood and milk of the
mother, rather than a germ plasm transmission.
Recently, Hadgedoorn reports what he thinks
is the first instance in which has been demon-
strated the part played by heredity in modifying
the susceptibility to bacterial diseases. A num-
ber of Japanese dancing mice were crossed with
white mice, and when an epidemic broke out in
700 cages in three different rooms, the Japanese
mice all died but not the white mice, and lack of
susceptibility proved dominant among the off-
spring as also among the offspring of the bas-
tards paired with the white mice. This would
undoubtedly be an example of gemmule trans-
mission of the lack of immunity in the Japanese
mice and the sustaining of immunity in the white
mice.
That an immunity sufficiently established by
natural selection or by acquired environment
may be transmitted by gemmules should be ac-
cepted and all work along this line must, to be
successful, take these facts into account. The
greater proportion of immunity will be not a
true natural immunity but one acquired by the
offspring in utero. This field offers the biggest
hope for future developments. Along this line,
the so-called Bang method of raising healthy
calves from tuberculous cows, is very important.
According to this idea the calf of a tuberculous
cow is taken immediately from its tuberculous
mother and not allowed a moment's contact. It
is fed from a known nontuberculous cow. I
should feel like going a step further and feeding
it artificially on its mother's safely pasteurized
milk in the hope of giving it not only its own
nourishment but possibly antibodies in the cow's
milk which might supply an acquired immunity.
In this connection, an important observation
was made several years ago by taking advantage
of immune bodies developed in cow's milk and
one which I think might have a very important
bearing on the production of acquired hereditary
immunity.
A man, highly susceptible to ivy poison, wSs
denied the pleasures of a country estate which
he desired very greatly. He fed a single cow on
a heavy diet of poison ivy leaves and after some
time drank the milk from this cow continuously.
To his surprise and great relief he developed an
immunity to the ivy which not only permitted
him to enjoy his farm but to handle the leaves
with impunity. I think that the lead should be
followed up and tried out on an extensive scale,
especially in connection with tuberculosis.
HEREDITY AND TUBERCULOSIS
What are the influences of certain specific dis-
eases? I cannot attempt to cover the field but
may take one of the most important as examples
of what might be expected in other diseases.
Heredity, for years bore the reputation of play-
ing an important role in the causation and propa-
gation of tuberculosis. Wliat is this mechanism ?
Of what does heredity in consumption consist
and what is its promise? Does it actually trans-
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THE PENNSYLVANIA MEDICAL JOURNAL
JuNiS, 1921
mit the disease directly from the parent to child
or does it merely produce an impression of or a
tendency to the disease?
May I attempt to answer these questions from
the pathological standpoint? Tuberculosis can-
not be transmitted directly by the male because
the tubercle bacillus cannot be carried over by
the spermatozoon. The male may have tubercu-
losis, general or focal, in the testicle and the
semen convey the tubercle bacillus. A uterine
tuberculosis may result, the embryo and fetus
being influenced by the endometritis ensuing, but
this is not hereditary tuberculosis. Tuberculosis
is not likely to be transmitted by the female ovum
for the same reasons and again, although tuber-
culosis of the ovary has been reported, it is ex-
tremely rare. Tuberculosis will develop in the
fetus acquired from a focal uterine or tubal
tuberculosis or by way of a blood infection
without focal tuberculosis. Both are excep-
tional, since focal tuberculosis in the female is
rare and while the tubercle bacillus occurs free
in the circulating blood, the disease is not a con-
tinual bacteriemia.
I have personal notes on the following case:
An active tuberculous mother gave birth to an
apparently healthy child. The mother had ad-
vanced tuberculosis and died about three weeks
later and at autopsy, tuberculosis was con-
firmed. She had sputum and circulating blood
positive for tubercle bacilli and at the time of
delivery, the placental blood also presented tu-
bercle bacilli upon smear. The child died shortly
after the mother, and from its- heart blood,
tubercle bacilli were demonstrable although no
gross lesions of tuberculosis were present at
dutopsy. There are two possibilities in this case.
The child did not have hereditary tuberculosis
as I have tried to explain heredity, but had an
acquired tuberculosis either from the circulating
blood of the mother in utero or from the breast
milk during lactation and although it had not
developed lesions of tuberculosis, it was lowered
sufficiently in resistance to have died of mal-
nutrition.
In the vast majority of acquired tuberculosis
in the small child the disease, aside from other
extraneous sources, is acquired from the tuber-
culous mother by nursing or other contact, and
possibly in a few instances from the circulating
blood in utero. Tuberculosis is not a hereditary
disease.
Is the offspring of tuberculous parentage more
susceptible to or fortified against tuberculosis?
When laboratory tests are developed with suffi-
cient accuracy, this point will be definitely deter-
mined. At present it is an open question. Theo-
retically in civilized communities the gemmules
of tuberculous parentage should fortify the off-
spring against acquiring tuberculosis, espedaUy
if Neo-Lamarckism is accepted, and I bdieve it
should be. On the other hand, the tuberculous
mother is so lowered generally in nutrition diat
the general physical qualities of the offspring are
equally impaired and in the presence of constant
sources of infection and invasion by the tubercle
bacillus, any immunity natural in tjrpe is not suf-
ficiently strong to overcome the disease, once in-
vasion has taken place. If I have offered some
suggestions to the clinical and laboratory worker
in tuberculosis, I am sure even now he can go
ahead with this problem because an attractive
field is opened up. The blood of the active case
of tuberculosis is a veritable storehouse. It con-
tains at times the tubercle bacilli, it is actively
bacteriolytic for the tubercle bacillus and has
immune bodies if they can be clearly discerned.
The problem of immunity and heredity must
be attacked, it seems to me, and must be worked
out for each individual bacterial disease, and I
include in the list such important diseases as
syphilis, pneumonia, meningitis, the contagious
diseases — ^t)rphoid fever, scarlet fever, and many
others.
Those diseases which produce antibodies resi-
dent in the blood serum cannot be expected to
have much effect in transmitting a natural im-
munity. They may, however, have a decided ef-
fect by controlling the transmission and devel-
opment of a disease in the fefus in utero by the
use of their action upon the female before and
during gestation. A fine example of this is the
active antisyphilitic treatment of an infected fe-
male after she has had several miscarriages with
the subsequent production of healthy offspring.
Those diseases which call upon transitory cells
such as the phagoc)rtes in turn cannot hope to
exert their full influence. Those diseases, how-
ever, producing immune bodies which are a part
of the fixed cells may well hope to pass on in the
gemmules of the germ cells certain characteristics
which may eventually build up a strong im-
munity.
The problem offers many possibilities, espe-
cially, it seems to me, in such diseases as tuber-
culosis, syphilis, typhoid fever, rheumatic infec-
tions and parasitism where more or less perma-
nent immunity may be slowly built up and does
not offer so much hope in the very acute infec-
tions where an immunity is of short duration
such as the pneumonias, meningitis and strepto-
coccemia.
SUMMARY AND CONCLUSIONS
The influences of heredity upon bacterial in-
fections is a timely and most important subject
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June, 1921 HEREDITY IN BACTERIAL DISEASES— DISCUSSION
613
and one which should suggest itself to different
workers on research problems taking advantage
of modem methods. The problem from this
viewpoint has almost no available data in the
literature. It seems to the writer that it should
be attacked along very specific lines and the facts
built up for each particular infection. The gen-
eral problem of heredity will base itself upon a
clear-cut understanding of heredity, i. e., the
transmission of factors by means of the germ
cells of the male and female, the fact that the
etiological factor cannot be transmitted per se
by these germ cells except under very unusual
circumstances. The transmission of a disease
and its subsequent developments and progres-
sions in the fetus must depend upon the presence
of the disease in an active state in the female and
is therefore an acquired intra-uterine infection
and not hereditary in origin.
The position of immune bodies is open to
much future study. The chances for germ
plasm transmission are much greater and, while
natural selection is very important, I am a firm
believer that acquired characteristics are incor-
porated in the offspring as a result of environ-
mental influence. The problems are for both the
clinical and laboratory worker and by their cor-
relation, future results of far-reaching impor-
tance to the child may be looked for.
DISCUSSION
Dr. Paui G. Weston (Warren) : This subject
might be approached from anx one of several angles.
One might take the biologists' point of view, split hairs
and differentiate between true heredity and congeni-
tally acquired conditions. The best way to settle that
question is to refer the interested persons to a library
where all the data will be found. Perhaps it would
be better if the subject were taken up from a more
practical point of view and the hair splitting elimi-
nated. Many interesting points suggest themselves and
I will mention only one or two. One of the first
things to be done in attacking a problem is to rid it
of the myths with which it is invariably surrounded.
Almost every subject is thoroughly saturated with
myths and medicine is no exception. One of the medi-
cal myths to be disposed of in this study is Colle's law,
and it would be well also to get rid of Profeta's law.
There was a time when we were dependent entirely on
the clinical evidence for the diagnosis of syphilis. We
had no checks on our diagnosis like the Wassermann
reaction or the darkfield examination. It is common
knowledge that there are many infected persons who
show no clinical evidence of syphilis whatever and it
was quite permissible in the past for the individual
after having submitted to a thorough physical exami-
nation to be declared free from syphilis. Often
mothers were declared free from the disease because
no clinical evidence of it could be found. Now we
know that we can get some negative Wassermann re-
actions with the blood and strongly positive ones with
the fluid of the same subject and our present methods
of diagnosis must be applied in the case of mothers
before we accept either Colle's or Profeta's laws.
After ridding the subject of the myths, we find
things that are. on the border line — things that we
know a very little about. For example, the transmis-
sion of something from infected persons to their off-
spring. They do not transmit the spirochaete or tu-
bercle bacillus or the organism of smallpox though
these organisms are carried over mechanically. We
know that there are children born of syphilitic parents
who, so far as we can determine by all our methods,
are free from syphilis, yet these children do not de-
velop well. They are puny. They are not robust,
healthy youngsters. What has been transmitted? So
far as we can determine, it is not syphilis. Mayhap it
is, but we are unable to prove it. To give a name to
the thing transmitted is difficult. The children are
somehow deficient. They are backward mentally, they
develop only a fair physique as they grow older and
are always just a little behind the average child. Evi-
dently, if we grant that syphilis has not been trans-
mitted, the children have inherited directly, in the sense
of the biologist, some defect. The same may be said
in a very general way of the offspring of tubercular
parents. Many of the tuberculous families are made up
of half-emaciated individuals. No matter how much
these people are fed or looked after, they rarely de-
velop a robust physique, and down through the gen-
erations one finds this poor physical state. Such peo-
ple are more susceptible to infection than those who
come from robust ancestors. There seems to be trans-
mitted a flat chest and a tendency toward anemia and
an absence of what might be called hardihood is noted.
Our knowledge of the transmission of immunity it-
self is little, and that little is quite chaotic. There are
scattered statistics on the subject but I know of no
long series of carefully controlled observations in in-
fections comparable, for example, with the work of
Dr. Slye in cancer. In order to get data that is at
least fairly accurate (for it is not controlled), I would
suggest that advantage be taken of the records made
by field workers. These individuals gather much data
that I regret to say is not used to the extent it should
be. Every first-class institution has one or more of
these workers. They collect an immense amount of
data concerning patients, their relatives and their en-
vironment. In the course of time, enough will have
been collected to give us some real information re-
garding the transmission or nontransmission of im-
mune factors. From the laboratory point of view,
much valuable data can be obtained from experiments
with animals, and for inspiration I would again call
your attention to the extensive and painstaking work
of Dr. Slye in cancer.
Dr. Keilty (in closing) : There is a great oppor-
tunity and a wide field. There is very little in the
literature. Correlation of field workers is a good
point. Correlation of the men working in infectious
diseases with men in the laboratory who do not see
the clinical side, may open out some big points, espe-
cially along the line of immune factors.
BE A BOOSTER
If you can't be a pine on the top of the hill.
Be a scrub in the valley — but be
The best little scrub by the side of the rill;
Be a bush, if you can't be a tree.
If you can't be a sun, be a star —
Be the best little booster wherever you are.
— Author Unknown.
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THE PENNSYLVANIA MEDICAL JOURNAL
June, 1921
BONE NECROSIS WITH SPECIAL REF-
ERENCE TO TUBERCULAR
LESION*
MARVIN W. REED, A.M., M.D.
BELLEFONTE
Anatomy. — Bone structure consists of a hard,
sparsely vascularized cortex, a soft, highly vas-
cularized medulla, and a very vascular peri-
osteum. In the long bones are contained a
greater proportion of cortex than medullary sub-
stance. A cross section shows the cortex quite
dense and solid, and the medulla shows inter-
woven spicules attached to the cortex between
which are spaces containing fat marrow cells and
thin-walled blood vesesls. These spicules and
spaces with their contents lose themselves within
the denser cortex in an indefinite interlacing, and
even the hard substance of the cortex is pierced
by small canals each containing a blood vessel,
and larger canals containing lymphoid tissue.
These haversian canals lessen in size as they ap-
proach the periosteum, demonstrating the possi-
bility of infection traveling with greater ease
from the interior of the shaft of bone towards
the periosteum than in the opposite direction. A
series of concentric columns of bone spicules
form the walls of the haversian canal, the minute
diyiding spaces are termed canaliculi, which
serve as communication areas from the central
haversian canal to the cells or lacunae. This
brief survey of the true nature of bone gives the
correct conception of not dealing with a crystal-
lized inanimate substance, but with an organized
mineral salt network of supporting blood vessels,
lined with cells actively obsorbing nutriment
from the blood coursing through, together, pos-
sibly, with a lymphatic system.
This bone system is invested with a highly
vascularized periosteum, which by capillary com-
munication conducts blood through the haversian
canals, though the greater supply is furnished by
the nutrient arteries which enter the bone
through faramina and course through the me-
dulla, giving off a capillary system which sup-
plies the haversiiui canals. Arterial blood filter-
ing through this intricate network of spaces, los-
ing its arterial impulse becames venous and
static, permitting bacteria contained in the blood
stream to find ready lodgment and multiply, in-
troducing a focus of infection in the process of
which the delicate lining cells of the blood ves-
sels become congested and inflamed, leukocytes
and fibrin accumulate, walling off the infected
area, bacteria multiply and disseminate, repro-
ducing and extending the process, as they break
•Read before the Section on Surgery of the Medical Society
of the State of Pennsylvania, Pittsburgh Session, October 6,
[920.
through the protective barriers. As inflamma-
tory debris and pressure increases within the
unyielding bone structure pain is increased and
the infection extended.
Bacteriology. — Rapid growing pyogenic or-
ganisms, as staphylococci, streptococci, pneu-
mococci, colon bacilli, etc., form an acute infec-
tious osteomyelitis, which most frequently oc-
curs in the femur ; due perhaps, to the fact of its
greater supply of nutrient vessels. Consequently
this bone is more subject to hematogenous trans-
portation of bacteria coursing through the gen-
eral blood stream.
Osteomyelitis. — The infected medulla becomes
congested, the periosteum over the involved area
hyperemic and edematous due to dilated blood
vessels carrying an increased volume of blood to
the infected area. In osteomyelitis the epiphyseal
cartilage acts as a barrier to the extension of the
infection into the joints from within the me-
dullary cavity, and the closely adherent perios-
teum at the epiphyseal line acts as a check on the
extension of subperiosteal suppuration in the di-
rection of the joints. In the very early stage of
acute osteomyelitis the periosteum over an in-
fected area is hyperemic, edema may be" noted by
pressure, and pus usually forms in from one to
three days from the onset. When the periosteum
is divided, hyperemia of the cortex is noted, sub-
periosteal abscesses may occur due to bacterial
infection, transported by vessels of the perios-
teum, and arterioles from the nutrient arteries,
via the haversian canals. Early, the pus is thick,
loaded with debris of destroyed cells, and as the
active inflamamtory condition lessens the pus be-
comes thin and serous. The entire medullar)-
cavity may be filled with pus under high pres-
sure.
Surgical Treatment. — Early opening and free
drainage relieves the pressure and checks exten-
sion of the necrotic process. Surgical removal of
the sequestra, when demarkation is complete,
stimulates the formation of new bone from the
subperiosteal and medullary surfaces.
Symptoms of acute osteomyelitis are briefly
acute, intense pain, accompanied or followed by
chills and high fever, general toxemia and sweat-
ing. Swelling, redness and edema of the af-
fected part follow. Secondarily the joints swell
and become oversensitive.
Actinomycosis of bone is caused by the en-
trance of the ray fungus within the medullary
cavity of the bone structure, and leads to the
overproduction of granulation tissue intermin-
gled with pus debrisi the bone is expanded and
becomes carious, and an overgrowth of new
bone tissue sometimes occurs resembling a tumor
mass. Actinomycosis simulates various inflam-
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BONE NECROSIS— REED
615
matory conditions and tumor formations, and
the diagnosis is definitely established only by
demonstrating the characteritsic microorganism
in the lesion. Surgical treatment consists of free
incision and open drainage. Medication is a
valuable aid.
SyplMlitic bone lesions are cortical and rarely
affect the joint or epiphysis, and are character-
ized by an irregular thickening of the cortical
surface, rather than a diminution of bone sub-
stance. If abscesses occur they are cortical and,
rarely if ever, medullary and sequestration proc-
esses are rare. In children congenital syphilis
shows irregularity of the epiphyseal line due to
irregular transportation of cartilage into bone,
in which case irregular lines of cartilage extend
into the diaphysis. Formation of new periosteal
bone may occur in congenital and acquired forms
of the disease, and may affect the shaft or ep-
iphysis, which thickening may go on to a large
size, especially in the tibia, which is most com-
monly aflfected. True gummata may occur with-
in the shaft or epiphysis and later may necrose.
Diagnosis. — Presence of moderate pain.
Thickening of the periosteum, which is best dem-
onstrated by x-ray. History and the prompt re-
sponse to some degree, at least, to specific treat-
ment are diagnostic aids.
Treatment is essentially antisyphilitic.
Tuberculosis of bone begins usually as an in-
fection of the epiphysis and while it may burrow
through the cortex and periosteum, and dis-
charge as an abscess into the surrounding tissues,
more commonly the process of advancement is
to extend into and involve the joint. Joint sur-
faces, short bones and epiphysis of long bones
are the points of election, and the shaft is only
secondarily involved.
The pathological condition is due primarily to
the presence of the tubercle bacillus in the af-
fected part, transported most probably by the
lymphatics from a primary focus elsewhere in
the body, attacking the bone peripherally, pro-
ducing a lesion characterized by loss of cortical
substance, and circumscribed by tuberculous
nodules composed of individual tubercles. As
the periphery of the tubercle extends caseation
occurs in its center, adjacent tubercles coalesce,
and degeneration and softening leads to abscess
formation, which suppurating process represents
the center of the tuberculous mass, while new
tubercular extension takes place in its outer mar-
gins. Sequestra are small and poorly defined.
Extending peripherally the process frequently
involves the joint surfaces. A diffuse infiltration
of the synovial membrane and articular surface
may follow with further degenerative changes
as : deposits of tuberculous granulations, erosion
of the cartilage and progressive infection of
neighboring tissues ; with secondary changes as :
fusion of muscles and tendon sheaths, retarding
joint function, together with bony new growth
from periosteal irritation.
Symptoms may in the early stage be very in-
definite: a sense of discomfort in the infected
limb rather than pain, moderate tenderness,
unilateral bone enlargement, usually spindle-
shaped in the phlanges, followed by suppuration,
with the skin tense and reddened over the local-
ized area of infection and fluctuation developing.
In joint tuberculosis swelling and pain may be
acute or absent, and pain, when present, may be
referred to a remote part. As the disease ad-
vances synovial effusion, swelling and pain are
likely to develop in the joint, together with
edema and restricted motion.
The etiology of bone and joint tuberculosis
may be essentially similar to tubercular involve-
ment of other organs of the body. General re-
duced vitality and lowered resistance, together
with trauma, are factors of importance in offer-
ing a suitable soil for the tubercle bacilli intro-
duced within the body, and transported by the
lymphatic or circulatory system from the pri-
mary to a secondary focus.
The treatment consists of general hygienic
management, and active surgical intervention,
depending upon the essential differences in the
tyf)e of the disease, acuteness, extent of destruc-
tion, location, impairment of function, presence
of suppuration associated with mixed infection,
danger to life, age of patient and the presence of
foci in other organs of the body.
Briefly, surgical treatment only will be con-
sidered here. Operative treatment in children
with tuberculous bone lesion finds a limited field,
while in adults it has a wider usefulness. The
question of going wide of the macroscopic limits
of the disease well into the good bone, and thus
incidentally removing the protective barrier of
protective tissue formation thrown about a tuber-
culous area, in our zeal to remove all the dis-
eased bone, is an issue. While thoroughness is
an aim, in children and young adults, whose
reparative powers are good, it is advisable to
avoid unnecessary sacrifice of apparently healthy
bone. Complete removal of a hopelessly dis-
eased joint by excision is sometimes a necessary
procedure, when extensive destruction of the
articular surface renders the joint useless and, if
allowed to remain, continues as a constant men-
ace by further tuberculous dissemination.
Amputation is justified in adults under certain
conditions of extensive destruction of bone,
hopeless loss of function and greatly impaired
general resistance, growing progressively worse.
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When possible to avoid more radical measures
and surgical treatment is indicated, free removal
of the necrosed area, thorough disinfection by
phenol 95% followed by alcohol, and wide open
drainage frequently gives good results.
CASE REPORTS
1. F. R., age I2. Family history negative. Necrosis
of ascending ramus of right inferior maxillary of one
and one-half years' duration, originating from ab-
scessed teeth. A discharging sinus opening on inner
surface of jaw present, marked thickening of cheek on
right side. X-ray showed necrotic area in ascending
rami, and the presence of a sequestrum. Operated
January 4, 1920, under general anesthesia, the mucous
membrane was freely incised and periosteum dissected
back, sequestrum removed and necrosed lining of cav-
ity curretted, without much pressure being used.
Cavity disinfected and carefully packed with bismuth
paste. Bismuth paste was renewed three times at in-
tervals of one week each. Wound granulated from
depth and healed well. Result after nine months, to
date, apparently complete cure.
2. H. K., age 26. Family history good. Wounded
in Argonne drive June, 1918, by shell fragment pierce-
ing left leg below knee, carrying away a portion of
tibia. Wound twice opened and necrotic bone re-
moved while yet in service. Patient came to us in
September, 1919, with a discharging sinus. X-ray
showed necrotic area in tibia. Operated September 24,
1918. Free incision was made and periosteum dis-
sected well back. Necrotic bone chiseled out, an ef-
fort was made to go wide of necrosed area well into
good bone, the cavity disinfected with carbolic acid
and alcohol, dryed and packed firmly. Result after one
year, to date, cure apparently complete. No external
signs. No subjective symptoms and x-ray shows no
further necrosis.
3. C. H., age 14. Family history negrative except
for mothier, who was infected with pulmonary tuber-
culosis at time of first operation, and has since died of
the disease. When patient was first' seen in spring of
1917, he was suffering from pain in region of right
tibia, swelling and tenderness were present and other
so-called rheumatic symptoms. X-ray showed well
advanced necrosis of tibia of apparently tubercular
type. Operated and an effort was made to remove all
necrotic bone, the cavity disinfected and packed.
Healing was not complete and a sinus later developed
in region of operative scar. X-ray showed further
necrotic area. Patient reoperated about six months
later, and apparent cure followed, the bone remaining
normal to date, three years after first operation.
4. E. B., age 18. Father died of pulmonary tuber-
culosis. Family history otherwise negative. Patient
was struck on left leg above ankle by a baseball, a
swelling developed which persisted for several months,
pain and tenderness gradually increased, patient went
about with crutches. First and second operations were
done in Philadelphia, where necrotic bone was re-
moved and a section of tibia grafted on fibula with
good success, though necrosis continued on tibia.
About one year after first operation, July i, 1917, the
tibia was again opened, necrotic area removed, cavity
disinfected and packed. Healing was slow but has
been permanent to date, three years later. Patient
leads an active life and has no weakness in limb.
DISCUSSION
Dr. Alexander Armstrong (White Haven) : I have
been asked to discuss this paper not so much because
I have had a great deal of experience from the sur-
gical end, but because these cases are referred to us
very frequently in White Haven both before and after
operation, oftentimes before, in the hope that opera-
tion may be obviated by return to health, and fre-
quently afterwards so that the patient may have the
benefit of ideal conditions in which to recover from
the effects of operation. The thing that strikes me
first is the infrequency of bone and joint conditions
in tuberculous cases. Of course I am discussing prin-
cipally tuberculosis. As an instance I may say that in
an average of 300 cases which we have at White
Haven to-day I can count only five cases of bone or
joint tuberculosis. Granted, as I think most of you do,
that the primary infection is somewhere else in the
body and probably in the lungs, it seems strange that
we do not see more cases of secondary tuberculosis of
the bone and joint. It is hard to understand. We do
see it in almost every other tissue of the body as the
result of chronic pulmonary tuberculosis.
I want to say at this point that I am glad the doctor
uses such radical measures in his surgical cases and I
feel that many of us, looking back over previous sur-
gical experience, feel not only in this line of practice,
but in accident cases, that we have oftentimes saved a
limb and lost a life. As an instance of this I have had
a case referred to me recently by one of the best ortho-
pedic men in Baltimore who had operated upon this
case six times for what was first supposed to be an
osteomyelitis in an ankle joint. The final operation
was removal of the os calcis. The whole foot was in-
filtrated with pus extending up along the muscles of
the calf. The point I am trying to make is that the
operation which should have been done, as events
proved, was amputation of the foot. When he came
to me he already had signs of infection of the elbow
on the same side. As most of you know, conservative
treatment of the elbow is not very efficient. We put
the patient under ideal conditions and tried to save the
arm but sent him back and the operation of amputa-
tion was done. In the meantime the foot had improved
because the toxin was being spent on the elbow joint.
I would refer you to the work of Rollier, of France,
in reference to the sun bath treatment. When you
cannot have sun baths, the x-rays often help in tuber-
culous joints which do not seem very acute. With
free pus, sun bath and x-rays and violet rays will give
astonishing results; but they will often give a joint
with function. There is a difference of opinion among
medical men as to whether a stiff joint is as good as
an amputated leg or arm. Some patients, also, would
rather have the leg amputated than go arotind with a
stiff joint. I have a case like that now in which the
patient went from surgeon to surgeon and they all
simply threw up their hands and said, "We can do
nothing for you except amputate," and after one year's
treatment by sun baths he has been completely healed.
He was one who would take advice and we have com-
plete healing so far as tuberculosis is concerned. He
has, however, only a limited use of his joint He can
get a certain amount of motion but we have at least
gotten past the stage of pus formation.
Dr. Reed (in closing) : I want to thank Dr. Arm-
strong for his discussion. In the presentation of this
paper I have not tried to give you anything new, but
merely to emphasize what is common knowledge to us
all : the necessity for early accurate diagnosis in these
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June, 1921 THOMAS SPLINT IN FRACTURES OF FEMUR— WEBB
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osteomyelitis cases that are due to pus organisms and
which so rapidly develop and so rapidly advance ; the
necessity of using every means of checking up our
diagnosis and getting the diagnosis settled early and
then, early free drainage. In these cases I take out a
section of the cortex of the bone just as long as the
diseased area is within the medulla, but I would not
disturb the medullary substance at all, rememebring
that just as soon as we take off the hard, cortical sub-
stance of the bone we relieve the pressure within the
bone and drainage is free, and keeping in mind the
fact that the medullary substance of the bone is highly
vascular and has remarkable recuperative powers. In
tubercular conditions I would lean toward the radical
in not waiting too long before operating. Sometimes
I think we forget that while the tuberculosis of the
bone is always a secondary condition due to the trans-
portation of germs from some other focus in the body,
we must remember also that if left there indefinitely
it in turn will be a secondary source of infection to
transport germs to some other part of the body, and if
left too long thus may be the means of again dissem-
inating the disease through the body. I have tried
both methods and have had just as good or better re-
sults from slightly radical than the more conservative
plan.
THE USE OF THE THOMAS SPLINT IN
FRACTURES OF THE FEMUR*t
D. A. WEBB, M.D.
SCSANTON
A few lessons of civilian surgical utility — not
many — were learned from war work, and of
those few the outstanding one is the use of the
Thomas splint in fractures of the lower extrem-
ity, more particularly of the femur. Again ne-
cessity asserted its' inventive genius and the re-
sult of that assertion is the present gradual
abandonment of the older methods of plaster,
Buck's extension, Liston splint and inclined
planes for the newer method here advocated.
Fractures at the front were compound with
much destruction of soft tissues and easy and
frequent access to them was imperative. Plaster
casts and wooden splints did not permit of this
access. A method had to be evolved applicable
to large numbers, suitable for the uninitiated and
with the ultimate aim not fair results only,
but the best attainable. It had to be (a)
suitable for transportation and for aftertreat-
ment, (b) to provide access to any wound of
the lower limb, (c) to be comfortable to the pa-
tient, and (d) efficient if properly applied. In
addition the apparatus had to be cheap, easily
obtainable in different sizes not specially made
to measure and durable. One after another the
'Read before the •Section on Surgery of the Medical Society
of the State of Pennsylvania, Pittsburgh Session, October 6,
igao.
tNoTK: The cuts used in this article are from "Treatment of
Fractures" by Drs. Blake and Bulkley, March 1918 Issue of
the Journal of Surgery. Gynecology and Obstretrics, through
the courtesy of W. B. Saunders Company, Philadelphia.
old methods were tried, found unsuited and
abandoned, and at the close of the war the
Thomas splint was the accepted method — ^ac-
cepted as the best and only safe appliance to ob-
tain good results. At the front it was used for
fixation during transportation, at the base for
traction and suspension. Those different pur-
poses of the splint must be appreciated. They
are not mutually exclusive but each is relatively
attainable in varying degree.
We shall give a description of the apparatus
as a whole, its use in transportation and its use
at the base, with a few details — not too involved
I trust — of the fixation, the extension and the
counterextension used. I regret that all needed
illustrations are not available.
APPARATUS
This simple bit of apparatus, hitherto dust-
laden in hospital attics or dark cellars, has come
into its own in a great crisis. Devised and given
to the orthopedic world by Thomas of Liverpool,
primarily to stabilize tuberculous knee joints, it
has exceeded and excelled its original purpose
and is now applicable to all joints and almost all
injuries of the lower limb. Thomas builded bet-
ter than he knew.
The splint consists of two parts: (i) a ring
large enough to encircle the thigh at the hip and
(2) two parallel iron rods obliquely fixed to the
ring and extending down the leg, continuing
crosswise at a right angle six or twelve inches
beyond the sole of the foot. The rods of three-
quarter-inch iron are of one piece bent beyond
the sole of the foot into the shape of a long U.
The parallel rods of the U measure 36 to 38
inches on the inner side and three inches longer
on the outer. Both rods are welded to the hip
ring, the outer at an acute angle of 45 degrees,
the inner at an obtuse angle of 130 degrees. The
ring is closely and firmly padded, especially the
inner half, with smooth leather — ^not chamois
skin nor cloth, which soil easily and remain
soiled. Measurements for the individual splint
are made from the ischial prominence.
Its efficiency depends on counterextension be-
ing maintained by pressure of the ring against
the ischial tuberosity. The extension is made by
fixing the foot to the crosspiece of the U. With
the ring thus driven and held home at the peri-
neum by the powerful foot traction, the leg is
suspended at each end and guarded against sud-
den jolts by rigid end and lateral supports. A
suspensory linen trough from hip to ankle is
made by running linen bandages to and fro
across the parallel rods under the limb. The
position of the fragments can be controlled by
the pull on the cross bandages. The remainder
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THE PENNSYLVANIA MEDICAL JOURNAL
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of the apparatus consists of weights and pulleys,
an overhead frame to suspend the leg in differ-
ent positions (as in the so-called Balkan frame),
ice-tong condyle callipers of the Besley type, and
finally a thinking and mechanically resourceful
apparatus in the head of the surgeon.
TRANSPORTATION AT THE FRONT
On the field and at advanced dressing posts
the splints were applied over the clothing and
before the wounds were dressed. Traction was
made with a clove hitch or figure eight bandage
over the soldier's boot firmly pulled and fixed to
Without change from the original stretcher pa-
tients were often transported from the A. D. P.
down to the base — subject to wound inspection
at intermediate hospital points.
A Thomas splint ought to be part of the equip-
ment of every ambulance and, like the stretcher
bearers in France, internes should be taught the
ready and intelligent application of it. Once
correctly applied it will supplant the Liston and
shorter leg splints.
TREATMENT AT THE BASE
For the further continued treatment other
methods of traction and suspension may be em-
Fig. 3. Illustrates the method of suspension in fractures of the lower leg. The splint is bent to about 135°. The
middle suspension cord is attached too far up the splint, which would balance better if this cord were attached nearer
the knee.
the crosspiece of the U. The clothing was then
cut, the wound dressed and a well padded coap-
tation splint placed at the point of fracture. An
encircling bandage outside of the splint bars was
then generally applied from hip to ankle. The
splint, holding the limb firmly fixed, is then sus-
pended at its distal end to a foot iron upright at-
tached to the handlebar of the stretcher. A frac-
tured thigh thus immobilized can be transported
with the least possible injury to the soft or bone
tissues and with comparative freedom from pain.
It was frequently used when the injuries were of
the soft tissues only, and not solely for fractures.
ployed with the following in view: traction in
the axis producing the most accurate alignment
of fragments, mobility of adjacent joints, no
change of splints until after union, ease of access
to wounds, results (functional and anatomical)
equally good. These results can be secured by
means of the weight and pulley attached to trac-
tion callipers at the condyles, an additional leg
splint hinged below to the parallel rods at the
knee (for flexion and extension of the knee
joint), continuous use of the same splint, inter-
rupted linen or metal pliable supports across the
rods adjustable for dressing wounds — ^all slung
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June, 1921 THOMAS SPLINT IN FRACTURES OF FEMUR— WEBB
619
in convenient ways to the Balkan frame, or the
projecting rod of a Pearson bed.
TRACTION
This is made upon the bone fragment by
means of the caUipers, shaped like ice-tong
hooks. These sharp pointed yet guarded hooks
are inserted about one-quarter inch into the
bone immediately above the condyles away from
the articular ring of the joint. This can be done
with local anesthesia. By a threaded pin in the
crossed handles of the hooks the grip of the
points is regulated, as also by a weight attached
to the handles and slung over a pulley to the
foot of the bed. This innovation of making a
fresh wound near the knee joint is the bete-
noir against which the uninitiated rebel. Myths
and traditions are conjured up 6f dangers which
in practice do not materialize, but the general
practitioner will be loath to give up his cherished
belief in the old system in exchange for this
wound-producing measure. This method gives
complete command of the bone, and none of the
effective force being lost on the soft tissues,
much less weight will maintain the required ex-
tension. It is moreover accurate. The distal
fragment can be pulled in exactly the correct di-
rection and rotated and deviated at will. It is
less painful. Rone is less sensitive to traction
and pressure than are the skin fascia and liga-
ments. No other method leaves the limb so free
Fig. 2. Showing the arrangement for a fracture of the upper
third of the femur. A Besley tongs has in this case been used.
Note the flexion at the knee, the abduction and external rota-
tion. The arrangement for 'the control of foot drop has not
been figured.
mas-
Fig. 4. To illustrate four methods of obtaining traction in
fractures, of the leg.
from Splints and bandages, permitting of
sage and joint movements early.
COUNTERTRACTION
With the weight and pulley method the splint
is not driven tightly home as for transportation ;
it is held lightly yet correctly against the tuber-
osity by a counterweight and pulley extension
over the crossbar at the head of the bed. This
detail is important. If not suspended the ring
will slip past the tuberosity, nullify the entire
traction principle involved, and make undue yet
fruitless pressure upon • the soft parts. The
splint is suspended by a balanced weight from a
trolley movable upon the pole of the Balkan
frame extending from head to foot of bed. The
injured limb having been fixed correctly in its
balanced position by weights and counter-
weights, the patient can, at will, move his body
without altering position of limb or fragments.
By raising the foot of the bed, body weight will
make countertraction.
HIP, KNEE, AND ANKLE MOBILIZATION
Hip — The limb in suspension can make all the
degrees of normal angulation with the pelvis —
flexion, extension, adduction, abduction and even
circumduction. The hip being free, the body can
likewise be made to conform to any desired po-
sition.
Knee — To the straight, rigid splint is attached,
opposite the knee, a mobile leg splint. All the
traction being at the condyles, and Qottlnoughf
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THE PENNSYLVANIA MEDICAL JOURNAL
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the knee joint, the leg in its own splint is free
for passive motion at the knee, by means of its
own separate weight and pulley. Within a week
after insertion of the callipers one can gradually
begin moving the leg up and down.
Ankle — ^The foot is suspended by a bandage
or board — Sinclair skate — glued to the sole,
leaving the dorsum and joint free for massage
and motion. The patient can at will move the
body and limb as one unit, weights and counter-
weights being evenly balanced. Hung in this
metal frame continous traction is effected, all
three joints are free, all parts of the limb are
accessible, there is freedom from pain and radi-
ography is facilitated.
The details of the methods employed for frac-
tures at various points must be carefully noted
for the individual case, as the lines of fracture
vary so greatly. Daily attention, with constant
supervision and revision of position and weights,
is necessary. If in doubt about the position of
the fragments a fluoroscopic or radiographic ex-
amination or both should be made.
UPPER, MIDDLE AND LOWER-THIRD FRACTURES
In upper-third fractures there is flexion, ab-
duction and external rotation of the proximal
end, due to the combined action of the psoas,
gluteal, pyriformis and obturator muscles. Apart
from the pressure of the outer ring upon the
upper fragment we have little control of it.
Flexion of the body helps a little. The lower
end must be made to conform to the upper end
as follows: flexion by higher suspension of the
splint, abduction by placing the controlling
overhead long pole of the frame into the proper
notch of the foot crosspiece, external rotation or
proper axis fixation by throwing the Sinclair
skate — glued to sole — outwards, to the usual
angle of 30 degrees or more.
In middle third fractures the deformity is a
posterior sagging due to gravity. This is cor-
rected by flexing the knee to relax the ham-
strings and by adjusting the bandage cross-
pieces at the place of fracture.
Lower-third fracture: The problem for solu-
tion here is a posterior angulation of the lower
n!?V^^^-:r-i-ri4:
Fig. I. To show the use of the straight splint and the method of obtaining traction.
Note especially the building out of the foot of the frame, the wide abduction obtained,
the angle of the supporting longitudinal bar closely corresponding to the angle of abduc-
tion of the leg, ana the tourniquet method of obtaining traction within the splint. The
method of preventing foot drop is also shown.
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June, 1921 THOMAS SPLINT IN FRACTURES OF FEMUR— WEBB
621
fragment due to action of the gastrocnemius
muscle. In the old method of treatment by in-
clined plane or plaster this problem was usually
solved imperfectly. With condyle calliper we
can rotate, deviate or elevate the upper point of
the lower fragment into its proper relationship
to the upper fragment.
RESULTS
At the close of the war there were 5,000 frac-
tured femurs in the British army. In 1916 the
mortality from thigh wounds was So^J). In 1917
Thomas splints were issued to the stretcher
bearers. Then cases arriving at the casualty
clearing stations, instead of being shocked and
moribund, were ready for immediate operation.
The death rate from thigh woimds dropped to
15%. Later, special femur hospitals were es-
tablished, when the rate was further lowered be-
cause of fewer secondary hemorrhages and less
sepsis, gas gangrene and general traumatism.
The following review was made after the gen-
eral adoption of the Thomas splint :
Knee joint — Over 90 degrees flexion — 81%.
60 to 90 degrees flexion — 14%.
30 to 60 degrees flexion — 4%.
Lengthening of femur — 7%.
Shortening of femur — 36%.
Without any shortening — 57%.
The figures for 1918 will undoubtedly show
far better results.
In a personal conversation with Major Gen-
eral Sir Anthony Bowlby, Consultant to the
Third and Fifth British Armies, he informed me
that the average shortening in the special femur
hospitals in France in 1918 was one-fifth of an
inch. That is a significant statement in view of
our past results with simple fractures, with un-
limited apparatus, unlimited time and unlimited
help available. It is so pregnant with meaning
that a change is inevitable and the teaching of the
principles of treatment of fractures in general
and of their practical application must be vastly
improved if ordinary justice is to be done to
fracture cases in the future. Colleges, insur-
ance companies and industrial plants ought to
utilize the colossal experience gained by those
privileged to treat fractures in large numbers
during the war. They are to-day probably the
most competent men to treat fractures. The in-
dustrial world needs all of them it can secure,
and Pennsylvania is an industrial state.
It is most difficult to intelligently convey on
paper, without illustrations, an idea of a working
apparatus of many parts such as the Thomas
.splint. To those interested I should commend
an excursion into the extensive illustrated litera-
ture on this subject now extant. Better still, I
should suggest a visit to hospitals where the ap-
paratus may be examined on the patient. The
principles involved are old, advocated long ago
by Lucas-Championniere and brought into prom-
inence during the war. He urged mobilization
of joints adjacent to fractures. We do this in a
Colles fracture, but in the femur we feared to
disturb the fracture. Anatomical results are not
alone sufficient; we want quick functional re-
sults as well. Prevention is better than the cure
of stiff knees ; robust better than atrophied thigh
muscles.
The statistics of industrial insurance com-
panies show that there is every year an enor-
mous sacrifice of useful limbs and working value
as the result of simple injuries. There is to-day
a call to the industrial front almost as urgent as
was that of our commanding officers on the fight-
ing front. The war could not go on without the
help of the physician — the enlisted civilian
physician; in the industrial strife his best con-
tribution to the economic salvage is by rapidly
returning to duty men physically fit.
DISCUSSION
Dr. William L. Estes (South Bethlehem) : I wish
in the first place to commend Dr. Webb for showing
the use of this most important apparatus, the Thomas
splint. Before the war we had been accustomed to
use it, but we used it without the combination of the
Balkan frame. With that properly adjusted it makes
almost an ideal dressing for fracture of the femur.
While we say that it is possible perhaps to learn from
one who has treated a great number of fractures, yet
each fracture is an individual study. No one who at-
tempts to treat a fracture by the same sort of apparatus,
even though it be as perfect as this, is going to get as
good results as the surgeon who studies the individual
case and adapts his apparatus to the fracture itself, not
to the fact that it is a certain kind of fracture of the
femur, of the tibia, or what not, and uses a splint or
apparatus which some textbook or monograph rec-
ommends for fractures of this particular kind. There
are many things about the Thomas splint which lend
themselves to fracture of the femur, however. In the
study of the Committee on Fractures of the American
Surgical Association of over 1,700 cases of fractures
we found in the ordinary traction methods that too
little weight was used. The old method of doing it
was Buck's extension, and the average weigBt used
was only 10 pounds. That was a ridiculously low
weight for traction on the femur by this method. The
old Buck's extension method had the great disadvan-
tage of extending the whole extremity, and especially
the knee joint, so that when one put enough weight on
to pull the bones in proper alignment, the knee joint
was frequently so extended it lost its function, so that
when the patient was well of his fracture and able to
be about, he could not flex his knee at all. It required
careful treatment to restore the joint functions, and
sometimes this was never recovered.
Treating of a fracture is not simply to get union of
bone. It is that, of course, but much more. It is get-
ting back the complete function of the part, and get-
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THE PENNSYLVANIA MEDICAL JOURNAL
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ting back a measure of usefulness which will make the
man perfectly capable again. Did you ever think what
it is that incapacitates a man after fracture? How
many of us can tell the degree of incapacity which re-
sults from shortening? Dr. Roberts and Dr. Newton
have shown that after mature development, people
have varying lengths of their lower extremities and
know nothing about it. Is it shortening that incapaci-
tates a man, and if so, how much shortening? Ho)^
many of us could go before judge and jury and swear
that because a man had an inch of shortening he was
incapacitated and not able to do his former work?
Is it shortening, want of alignment, distortion of the
joint, ankylosis, or what is it which especially incapaci-
tates a man after a fracture? In order to settle this
point as far as practical a committee of the American
Surgical Association was appointed to study fracture
of the long bones. This committee has been at it
something like six years. The work has been impeded
because very few men kept any proper records of
their fractures. They fail many times to keep good
records in the hospital and very rarely do they follow
up their cases. It is almost impossible, from the ordi-
nary records of fractures, to know how long a man
was kept from his work and whether he was able to
do the same sort of work that he did before he was
injured. Now that is the point we ought to determine
and must determine. So the committee, finally, in
order to stimulate the surgeons of the profession to
keep proper records offered certain data sheets, in
which the data that was necessary for our conclusions
were printed and we are asking that the surgeons keep
records of their fractures in such a way that we may
determine the points I mentioned above.
I want to enlist the assistance of every surgeon in
the room in an endeavor to try to find out the salient
points of fracture, so that we may suggest some stand-
ard apparatus for treating various fractures of the
long bones, and whether the Balkan frame which is so
exceedingly useful in military practice, will prove
equally so in civil practice. There is no reason why it
should not. Then is there anything better? Is this
applicable to every age group? Is it as good for chil-
dren as for adults? Is it as good for one sex as for
the other? For instance, this Thomas splint presses
uncomfortably on the scrotum of a man and the labia
of a woman. All of these points we wish to consider.
If the chair will permit me to send these sheets around
you will see what we are trying to do and you may
obtain samples of them. We ask you to adopt these
for the purpose of helping the committee in making
these determinations.
Dr. John H. Galbraith (Altoona) : My experience
with the Thomas splint has been limited almost en-
tirely to the straight Thomas, with adhesive traction
straps, as used at Liverpool and in front line work in
France. Even at a big base hospital we had no ice
tongs. I saw there one pair that had been applied at
another hospital. I heartily agree that all cases of
fractured femurs close to the condyles should have the
tongs applied, but it seems to me that the old-fashioned
adhesive traction straps will answer just as well for
fractures of the shaft higher up. In the few cases that
I know of where the tongs were used, the patient com-
plained bitterly of the pain and discomfort. In one
case the points of the tongs dragged through the bone,
being due, possibly, to the points being inserted too far
down, and too much weight being applied, and had to
be removed. As to the question of the ring making
undue pressure on the ischium or encroaching on the
scrotum of the male or the labia of the female, I be-
lieve, if the splint is properly applied and enough pull
made to get correction of the fracture, such a thing
will not happen.
Dr. John B. Lowman (Johnstown) : Just as the
doctor has said, it is the ideal first aid splint I do
not think any splint or any first aid appliance has been
made which, like the Thomas splint, was tried out dur-
ing the war by the number of cases that used to come
back in shock. After application of the Thomas splint
at the front we did not get these cases in severe shock
as we did before. That is one point as far as the first
aid is concerned. I think it is an admirable splint to
be used in all industries at the present time. In fact
we have adopted it and teach the application to our
first-aid men by moving pictures of this subject
Another point, about the pain of the ice tongs ; if the
ice tongs are applied properly you 4^ not get so much
pain. A good deal of pain is made by a little exudate
under the periosteum. If you nick the periosteum you
are not so liable to get pain. Another mistake is the
idea that you must press it into the bone deep. That
is not necessary. Another point, you can overextend
these fractures. It is only necessary to put your heavy
weight on for a certain length of time and in a few
days take your second x-ray and let the fragments
come back together. I think these three or four im-
portant points were not brought out and I therefore
mention them.
Dr. John DeV. Singley (Pittsburgh) : I have been
very much interested in the method of treatment of
fracture of the femur by the method of Pearson's bed
and Thomas' splint and callipers. This interest was
aroused mainly by Dr. Slocum, who has had a wide
experience with it. I have had a small experience, but
sufficient to emphasize several points in connection
with it In the first place, the results are immeasur-
ably superior to any method 1 have been familiar with
previously. Second, it is much more comfortable to
the patient. I cannot confirm the statements that
the callipers are painful. I have seen cases in which
the patients complained, but I believe it was due to
faulty application of the callipers. It is an important
point to make the incision extend one or two centi-
meters below the point of entrance of the callipers
through the skin, so that when traction is made it does
not come on the soft parts overljring the bone. Much
less weight is required than in adhesive plaster trac-
tion. In our experience from 8 to lo pounds is ample.
In compound fractures, with which I have had no ex-
perience, those who have used it find that much less
weight than this is sufficient, on accotmt of the fact
that the muscles are divided.
As to the care which is required on the part of
nurses, orderhes and the surgeon, I believe that it is
not an exaggeration to say that this is reduced at least
75%. I confess that in the early cases I was timid in
the use of the callipers. I feared that it would pro-
duce necrosis of bone and I feared infection of the
wound. I must say that these fears have not been
realized. We have had no bone necrosis. We have
had no infection. Attention must be given the callipers,
particularly to see that the stop screw is properly ad-
justed. As pointed out by Dr. Webb, one of the vital
and essential features in making the apparatus efficient
is to maintain competent pressure against the tuber-
osity of the ischium. This is most effectively done, I
believe, by the method of Pearson, which consists in
holding up the ring of the Thomas splint one or two
centimeters above the level of the mattress by vertical
extension and not by counter pull as in the apparatus
here shown. The care of the leather padded ring is
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June, 1921 TENOTOMY OF RIGHT INFERIOR RECTUS— SHUMWAY
623
important. Pearson advises as the most efficient way
of caring for it, that the nurse or orderly saturate a
piece of gauze bandage with tincture of green soap
and draw it around the ring once a day. We have had
no pressure sores over the tuberosity of the ischium,
nor have we found that any patients complained of
pressure upon the scrotum. All in all, I must say that
it is one of the most satisfactory methods for the
treatment of fracture of the femur that has been intro-
duced in recent years, so far as I am aware.
Dr. Webb (in closing) : All I have to say is that it
must be borne in mind that this apparatus was gotten
up primarily for compound fractures. That is the kind
we had at the front. It was gotten up to meet certain
definite indications in unusual wounds. It was neces-
sary to get at them to dress them, which could not be
done in a plaster cast. It was a gradual evolution
from 1914 to 1918. I am glad Dr. Singley answered
some and anticipated other objections. The danger
and pain due to the undue traction of the calliper at
the knee is something that will not materialize in prac-
tice. It is one of the phobias that one will hug until
dissipated by actual use of the Besley traction tongs.
I had a particularly fortunate privilege in France in
being placed where we had 3;o to 400 fractured femurs
to treat all the time. We had some 400 femurs the
night our institution was destroyed in an air raid and
we had to carry our patients out while a terrific bom-
bardment was going on and we did this as we could
in no other way. We got them out in the dark (no
lights were permitted), putting them here, there and
everywhere, and the next morning we had very little
readjustment of splints to do. Never was a surgical
mechanical appliance so thoroughly tested as was the
Thomas splint and, in my judgment, never were more
patients saved from morbidity and mortality by any
appliance.
TRAUMATIC PARALYSIS OF THE LEFT
SUPERIOR OBLIQUE MUSCLE. RE-
LIEVED BY TENOTOMY OF THE
RIGHT INFERIOR RECTUS*
EDWARD A. SHUMWAY, B.S.. M.D.
PHILADELPHIA
Traumatic paraly.sis of the superior oblique
muscle, without involveinent of the other ocular
muscles, is a comparatively rare occurrence, al-
though it is the most common of the isolated
palsies of the elevators or depres.sors of the eye-
ball. This is because of the fact that it has a
separate nerve supply — the fourth cranial which,
like the sixth nerve, is liable to involvement in
its course at the base of the skull. The paralysis
may be due to. injury of the nerve in the skull,
or, as a study of the reported cases has shown,
in about an equal number of times to direct in-
jury to the muscle or its tendon in the orbit.
According to Duane,' injury to the nerve in the
skull may be due to direct trauma, in which case
the paralysis is found immediately after the in-
•Read before the Section on Eye, Ear, Nose and Throat
Disease of the Medical Society of the Slate of Pennsylvania,
Pittsburgh Session, October 6, 1920.
jury, or to compression by displaced bone frag-
ments, effused blood, callus, traumatic cerebral
abscess or to a traumatic aneurism (especially of
the internal carotid), in which case it may not
develop until some time afterward. In some
cases, but probably not often, traumatic paralysis
is nuclear, being due, according to Bernheimer,
to distention of the ventricles, consequent upon
•njury, and leading to hemorrhage into the nuclei
adjoining. In orbital injuries one-half of the
cases have been due to direct injury by foreign
bodies penetrating between the eyeball and the
orbital wall, and the rest to separation of the
tendon during operations on the sinuses.
A very valuable contribution to the subject
was made by Muller,- in 191 1, in an inaugural
thesis at Leipzig, in which causes, results, and
operative methods were discussed, and a good
bibliography of the existing literature given.
In 1918, A. C. Snell," of Rochester, N. Y., re-
ported a case, and added others which he had
found in the later literature. He collected alto-
gether forty-two cases, twenty-one of which
were due to injuries to the head or face, where
the lesion was either to the nerve at the base of
the skull, or involved the motor center. Of the
forty-two cases, twenty-five made perfect, or at
lea.st satisfactory recoveries within a period of
fourteen days to eighteen months, without opera-
tion. I desire to place on record the following
case and discuss the proper operative procedure
when recovery does not occur within a reason-
able time:
E. W., age 38, a machinist at the Bethlehem
plant of the Bethlehem Steel Company, was in-
jured on April 17, 1919, when he suffered a
fracture of the skull in the right parietal region,
with an injury to the right eye. He is said to
have been unconscious several days, and on re-
covering consciousness complained of diplopia,
which persisted until the time of my first ex-
amination in February, 1920, at the Lankenau
Hospital, in Philadelphia. He also complained
of impaired hearing and taste, but this subse-
quently improved. While in St. Luke's Ho.spital
in Bethlehem, he was seen by Dr. Paul H. Klein-
hans, to whom I am indebted for the following
notes: "The patient complained of lateral dip-
lopia, most marked in the right field, and I
thought at first there was paresis of the right
external rectus muscle. On May 29, 1919, he
was sent to my office, when he complained of
vertical diplopia, most marked in the lower field.
A four degree prism base up before the right
eye, with a two degree prism base out fused the
imc^es, and I felt that the paresis involved the
superior rectus muscle of the right eye. Subse-
quently the right became the fixing eye, and I
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THE PENNSYLVANIA- MEDICAL JOURNAL
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finally decided that the superior oblique of the
left eye was the muscle involved. The strength
of the prism required to fuse the images stead-
ily increased to from 20 to 25 degrees, base down
before the left' eye. In treatment, I used elimi-
nation, mixed treatment and strychnine to the
point of toleration. Also some gold and sodium
chloride."
As the paralysis remained ten months after the
accident, he was referred to me for possible
operation. Examination showed vertical dip-
lopia, causing a left hyperphoria of 23 degrees,
at 5 meters, and an exophoria of 3 degrees. The
left image was below, and the greatest separation
of the images was in the lower right-hand field,
showing that there was paralysis of the left su-
perior oblique muscle. The patient held his head
tilted constantly to the right shoulder, and the
chin upward, to lessen the diplopia, and was
quite unable to perform his work as a machinist
because of the separation of the images, and he
could not work satisfactorily with one eye ex-
cluded from vision. After some consideration,
I decided to attempt correction of the defect by
tenotomy of the muscle associated most closely
in action with the superior oblique, the inferior
rectus of the opposite eye. He was admitted to
the Lankenau Hospital on April 14, 1920, and a
tenotomy of this muscle was done under local
anesthesia. Prompt healing was obtained, and
five days later a test showed a remaining left
hyperphoria of three degrees, but single vision
with a red glass and light at 6 meters. There
was still some diplopia down and to the right,
but now the right image was below, showing
over-effect of the operation. The head was
straight, however, and no diplopia was present
in other parts of the field. On May 8th, there
was vertical orthophoria on the horizontal level,
at 6 meters. Up and to the right, with a red
glass and light, the left image was slightly above ;
down and to the right, the right image was be-
low, but in other parts of the field there was
fusion. One month later a test showed right
hyperphoria of one degree, with some diplopia
down to the right, which could be corrected by
a prism of two degrees, with the apex at 45 de-
grees. On July 24th he returned, complaining
again of diplopia. The right hyperphoria had
now increased to six degrees at 6 meters, and
was four degrees at 33 cm. I ordered a prism
of 3 degrees base down before the right eye, and
one of the same strength base up before the left
eye. This relieved the diplopia successfully, but
the patient wrote me subsequently that the dip-
lopia had finally disappeared, and that he could
work without the glasses, so had discarded them.
Later in the summer he developed an attack of
typhoid fever, and I have been unable to learn
the conditions present, although Dr. Kleinhans
has promised to reexamine him, as soon as he
has sufficiently recovered. The result, however,
promises to be satisfactory, disposing of 23 de-
grees of vertical hyperphoria, after a period
(which is commonly the case) of over-effect of
the operation.
The determination of the proper muscle or
muscles to operate upon, in the various ocular
muscle palsies, has been debated many times, but
very little can be added to the discussion of the
subject which was made by Albrecht von Graefe*
in 1864, and which was followed by Alfred von
Graefe in both editions of the Graefe-Saemisch
"Handbuch der Augenheilkunde." In any case,
one of the following may be done :
1. Reenforcement of the paretic muscle, by its
advancement.
2. Weakening of its antagonist, by tenotomy.
3. Weakening of the muscle, which is asso-
ciated with it in the other eye, also by tenotomy.
4. Advancement of the antagonist of the lat-
ter.
For instance, in the case of the lateral muscles,
as in the external rectus of the left eye, one could
(l) advance the left external rectus; (2) tenoto-
mize the left internal rectus; (3) tenotomize the
right internal rectus; or (4) advance the right
external rectus.
The conditions become more complicated when
an elevator or depressor is at fault. Here, in-
stead of four muscles, we have to deal with eight
muscles which are concerned in elevating or de-
pressing the eyes. For example, in the case of
the superior oblique, leaving out of consideration
for the time being, unsurmountable difficulties
in operative technique, we could consider (i)
advancement of the superior oblique itself ; (2)
advancement of the inferior rectus, its associate,
in the same eye; (3) and (4) tenotomy of the
superior rectus and tenotomy of the inferior
oblique, its two antagonists, in the same eye;
(5) and (6) tenotomy of the superior oblique
and tenotomy of the inferior rectus muscles of
the healthy eye (associated muscles) ; (7) and
(8) advancement of the inferior oblique and the
superior rectus of the healthy eye. The same
scheme may be worked out for each of the other
elevators or depressors.
In the present instance, we must throw out,
because of operative difficulties, advancement of
either oblique or tenotomy of the superior
oblique. This leaves us: (i) tenotomy of the
superior rectus; (2) advancement of the in-
ferior rectus; (3) tenotomy of the inferior
oblique, in each case of the affected eye; (4)
tenotomy of the inferior rectus or (5) advance-
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June, 1921 TENOTOMY OF RIGHT INFERIOR RECTUS— DISCUSSION
625
ment of the superior rectus of the unaffected
eye. Careful consideration of the physiological
action of these muscles, as Eperon* demonstrates,
will show theoretical objections, at least, to oper-
ations on all but the inferior rectus of the
healthy eye. Tenotomy of the superior rectus
and advancement of the inferior rectus of the
paralyzed eye, while assisting in the depression
of the eye, would add to the pathological inclina-
tion of the retinal meridians, which is one of the
difficulties present in paralysis of the superior
oblique. Tenotomy of the inferior oblique of
the aifected eye, and advancement of the supe-
rior rectus of the healthy eye are likewise theo-
retically unsound because, while in either case,
the relative vertical positions of the eyes would
be improved and the faulty rotation of the lines
of vision corrected, both would increase the
pathological convergence resulting from the
weakness of the superior oblique.
Tenotomy of the inferior rectus of the healthy
eye is the only one which theoretically would re-
establish equilibrium perfectly : ( i ) making the
lowering of the healthy eye more difficult, or its
elevation easier, as in the case of the paralyzed
eye; (2) weakening slightly the exaggerated
convergence, and (3) reestablishing the parallel-
ism of the retinal meridians. The result, more-
over, would hold good in all parts of the visual
field, which would not be the case in the other
possibilities. This operation is the one that was
recommended by von Graefe, and the advice was
followed in a number of instances, in Germany,
with good results. Subsequently the French
school, under the leadership of Landolt* and his
pupil Eperon,* believing that tenotomy was an
incorrect operative method and should always be
replaced, where possible, by an advancement, ad-
vised under the circumstances advancement of
the inferior rectus muscle of the affected eye,
rather than tenotomy of the inferior rectus of
the sound eye, while admitting that the latter
operation was best supported by theory. Eperon
reported several cases, in one of which, however,
after advancement of the inferior rectus, he did
not succeed in getting a satisfactory result, until
he advanced the opposite superior rectus, and
subsequently tenotomized the same inferior
rectus.
In the case reported by Snell, an attempt was
made to advance the injured right superior
oblique, but this was unsuccessful because of
operative difficulties. A tenotomy of the supe-
rior rectus of the injured eye was not effective,
and finally, following a suggestion of Posey, a
tenotomy of the inferior oblique of the same eye
was performed and orthophoria was secured.
In his case there was a vertical deviation of 12
degrees, and in the final result there was added
to the diplopia in the lower left field a reversed
diplopia in the upper right field.
As von Graefe says in the Graefe-Saemisch
Handbuch, "Other proposals, such as tenotomy
of the superior rectus muscle of the affected eye,
or separation of the attachment of the inferior
oblique of the same eye, are to be thrown aside.
We would thereby, at best, achieve the desired
correction for a definite position of the eye ; but,
as the result of the .operative muscle insuffi-
ciency, we would risk causing diplopia in other
parts of the visual fields, which had been free
from them." It is true, as Eperon observes (loc.
cit.) that facts are not always entirely in accord
with theory, and as good results have been se-
cured by him, by Stanculeau' and others in
France by advancement of the inferior rectus
muscle of the paralyzed eye, this operation can
not be summarily dismissed from consideration
for purely theoretical reasons. The operative
choice, I think therefore, lies between this and
tenotomy of the inferior rectus of the good eye,
as recommended by von Graefe. The tenotomy
is the simpler operation, and its effect may be
graduated by the completeness of the operation,
and by a conjunctival suture, if the effect at oper-
ation seems likely to be excessive. On the other
hand, with a low degree of hyperphoria, prob-
ably the safer method would be the advancement
operation on the inferior rectus muscle of the
affected eye.
BIBLIOGRAPHY
I. Duane, in Posejr and Spiller: "The Eye and the Nervoua
System," p. 335.
a, Muller: Ueber traumatische Augenlabmunffen." Inaug.
Dissert., Leipzig, 1911; Arch, fiir Augenheillc., Ixix, p. 178,
and Ixx, p. 54.
3. Snell: Archives of Ophthalm., Vol. 48, p. iii.
4. A. von Graefe. Klin. Monatsbl. f. Augenheilk, 1864.
5. Landolt and Eperon in deWecker-Landolt's "Traitt
Complit d'Ophtalmologie," Vol. m, P- 784: also in Norris and
Oliver. "System of Diseases of the Eye," Vol. 4, p. 74.
6. Eperon: "Deviations Oculaires Verticales Paralytiques,"
Archives d'Ophtalmolo^e, ix, p. 115 and p. 242.
7. Stanculeau: Archives d'Ophtalmologie, Jan., 190a.
2046 Chestnut Street
DISCUSSION
Dr. William Campbell Posev (Philadelphia) : Dr.
Shumway has given us a most interesting and instruc-
tive paper and the reasons he has cited for his choice
of tenotomy of the inferior rectus muscle of the un-
affected eye to relieve a paralysis of the superior
oblique muscle in the fellow eye are to me, at least,
entirely convincing. In any event, the result obtained
is proof of the wisdom of his choice. Sometimes,
however, after paralysis of the superior oblique we
see secondary spasm of the inferior oblique of the
same eye. Under such circumstances tenotomy of the
inferior oblique is indicated but, as Duane has pointed
out, should only be resorted to if the condition is
permanent and the symptoms are such as to justify the
operation. I have elsewhere reported two cases of
this nature in which the insufficiency in the superior
oblique was congenital. Briefly, they were as follows :
Case I. Insufficiency of right superior oblique with
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THE PENNSYLVANIA MEDICAL JOURNAL
June, 1921
spasm of right inferior oblique in a ten-year-old boy.
Right eye deviated up and in, the deviation being
nore pronounced as fixing object was carried to the
left. Downward motion of right eye limited, espe-
cially down and in. No primary or secondary limita-
tion or exaggeration of motion in left eye. Free
tenotomy of right inferior oblique relieved the up and'
in tilt, but eye still showed tendency to converge at
times.
Case 2. Insufficiency of left external rectus and
left superior oblique in a girl aged 17. Left eye con-
verged since infancy. Glasses worn, several pairs,
without relief to squint. Examination showed left eye
convergent 45° and slightly up. Upward motion in-
creased when eyes turned to right. All motions in
right eye normal. External motion in left eye defec-
tive. Downward motion in left eye also limited, espe-
cially down and in. Advancement of left external
rectus. No muscle found. Capsule of Tenon ad-
vanced. Tenotomy of left internal oblique. Left eye
still convergent. Both internal recti carefully tenoto-
mized, with resultant convergent squint in left eye of
15°. A year later, eyes perfectly straight. No up and
ill tilt of left eye. Ocular movements free in all direc-
tions.
In Snell's case, referred to by Doctor Shumway, if
my recollection is correct, my advice to tenotomize
the inferior oblique of the affected eye was given with
the idea of controlling the spasmodic overaction of
that muscle which arose after the superior rectus has
been tenotomized.
I support Doctor Shumway in his conclusion that
the operative choice lies between tenotomy of the in-
ferior rectus of the good eye and advancement of the
paralyzed muscle of the paralyzed eye, and since tenot-
omy is the simpler operation, it is to be preferred to
the latter except in cases of a low degree of hyper-
phoria, where an advancement operation is to be pre-
ferred on account of its greater ease of controlling
the effect. As Duane pointed out, an objection against
advancement in cases of marked vertical paralytic in-
sufficiency is that not infrequently in advancement
operations of high degree there is produced marked
rest-iction of movement in the field of action of the
antagonist. To avoid this, a good plan in cases of
high degree is to first tenotomize and then advance.
That rare condition of anotropia in which there is
excess of the upward rotation in each eye and, ac-
cording to Stevens who described the condition, is as-
sociated with a declination of the meridians, as a con-
sequence of which the simultaneous and synergic ac-
tion of the superior obliques is suppressed and the
superior recti act alone, is illustrated by the following
case:
Child, 6 years old, with skull too long in antero-
I)osterior diameter. When fixing in the median line,
and screen placed over the right eye, right eye devi-
ated directly up under cover, slowly but steadily swing-
ing down again to fix. When left eye was screened
cff, the deviation was up but also in, in the same slow
rhythmical fashion as in the right eye. There seemed
to be a lagging in the left eye when the object was
carried down to the right and this eye showed a ten-
dency at times to slight convergent strabismus. H.
equaled 1.5 D. in each eye and vision was normal. In
answer to a letter asking for his most recent views on
this little understood deviation, Duane wrote me as
follows :
"1 used the terms in a somewhat different sense to denote
tile condition (heterophoria or squint) in which behind the
screen both eyes deviated upward. I think I should have
used a different term in order not to cause confusion vnib
Steven's nomenclature. What I called anaphoria and am-
tropia (and the same is true of catophoria and catotropia)
can almost always be resolved into a condition of paralysis of
one or more of the -/ertica] muscles with secondary deviations."
I have obtained marked relief in several cases from
the severe asthenopia usually accompanying this con-
dition when regarding objects below the horizontal
plane of the eyes, by the use of prisms, bases down, in
each eye, the strength of the prisms varying in degree
in the two eyes, according to the difference in extent
of the deviations.
Dr. Shumway (closing) : I have not much to add
except that these cases should not be operated upon
early. Experience shows that they will recover muscle
balance in six or eight months, and they certainly
should not be operated on within that time. If, how-
ever, you have a vertical deviation which would pre-
vent the use of a man's two eyes together, as in the
case of a machinist who had to do delicate work re-
quiring binocular vision, then I think operation should
be attempted.
The inferior oblique muscle is the muscle to operate
upon in case you have a paralysis of the superior
rectus muscle on the other side. You have oftentimes
a congenital weakness of the superior rectus of one
eye with marked deviation, and the first operation is
advancement of the superior rectus which is weakened.
If that is not sufficient, then the next procedure is a
tenotomy of the inferior oblique of the other side. In
paralysis of the superior oblique the choice lies be-
tween the two muscles — tenotomy of the inferior rectus
of the healthy eye, or advancement of the inferior
rectus of the affected eye.
SOME OBSERVATIONS ON THE MUS-
CULAR ADVANCEMENT
OPERATION*
WILLIAM CAMPBELL POSEY, M.D.
PHILADELPHIA
On the way to the last meeting of the Ameri-
can Medical Association, in New Orleans, a half
dozen of us engaged in an informal discussion
regarding the best means of increasing the effi-
ciency of an ocular muscle by advancement. The
lack in uniformity of methods employed was
soon manifest, for it became apparent that no
two surgeons followed the same method; in-
deed two of those taking part in the discussion
had devised methods of their own. The same
will hold true for similar discussions wherever
held, for there is no operation in eye surgery re-
garding which there is such a diversity of opin-
ion and practice. The reason for this is un-
doubtedly the unsatisfactory results which at
times attend the performance of any advance-
ment procedure, in consequence of which the
surgeon, chagrined by his failures, seeks to ob-
viate similar mischances by a change of meth-
ods, hoping to obtain in the end some form of
•Read h-fore 'he Section on Eye, Ear. Nose and Throat Dis-
eases of the Medical Society of the State of Pennsylvania.
Pittsburgh Session, October 6, 1920.
Digitized by VjOOQIC
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MUSCLE ADVANCEMENT OPERATION— POSEY
627
operation which may prove universally satisfac-
tory and applicable.
Without attempting to go into this subject too
far, for it is one which manifestly could engross
the attention of the section throughout its entire
session, let me say briefly that I doubt greatly if
such a universally applicable operation will ever
be found and I question very strongly if any one
procedure can correct certain cases of squint, the
reason for this lying, not so much in any fault in
ihe operation of choice, but in certain idiosyn-
crasies of the case operated upon, for how often
have we not performed our favorite operation
upon certain classes of cases with every appear-
ance of success, to have after some days the de-
viation existing previous to the operation return,
if not to the same degree, at least to an extent
sufficient to mar the expectations of patient and
operator as well. In cases of this type there are,
in all probability, anomalous insertions of mus-
cles into the globe which exert such a faulty
traction upon the eye that even though the visual
axes of the two eyes be rendered parallel for a
time, when binocular vision is resumed after the
removal of the bandages the malpositioned mus-
cles soon drag the squinting globes into their old
faulty deviations. Congenitally squinting eyes
form the major part of such a group, and a se-
ries of operations is usually necessitated before
parallelism of the visual axes is attained in this
unfortunately not unusual type of cases.
Deviation in the, axis of an eye may be over-
come: (a) by tenotomy of an antagonist, or (b)
by drawing the eye into the position desired by
shortening a muscle or its tendonous attachments.
This latter is accomplished either by "tucking"
the tendon or the muscle itself ; by resection of
the muscle; or finally, by advancing the short-
ened muscle into a portion of the globe closer to
the corneal limbus thjm it had hitherto occupied.
While deviations of not considerable degree
may be successfully controlled by, let us term
them, the minor fjrocedures, deviations of con-
siderable degree dt . land a method which will ob-
tain and retain the maximum effect, and I think
that however widely surgeons may differ in their
choice of particular methods, they are agreed
that the advancement of a simultaneously short-
ened muscle is the best means of obtaining this.
In my endeavors to secure a proper advance-
ment procedure, like the rest of the world, I have
searched the literature for information and have
practiced a variety of procedures. For the past
few years, however, in high degrees of squint,
abandoning all other procedures, I have prac-
ticed solely the single stitch operation, as de-
scribed by Jackson in "A System of Ophthalmic
Operations," Vol. I, p. 707 and 708, with the
employment of a duplicate stitch in many of my
more recent cases. Jackson describes this method
as follows:
"A curved incision in the conjunctiva and
episcleral tissue is made, 10 mm. long and con-
cave to the cornea. The flap toward the canthus
is held up and dissected free from the sclera by
snips of the scissors. The dissection is first to
be made a little above or below the insertion of
the intemus, until one blade of the Prince ad-
vancement forceps can be slipped beneath the
tendon, back from the insertion almost as far as
it will be necessary to place the suture. The
other blade of the forceps is pressed on the sur-
face of the conjunctiva, so that the whole mass
of tissue to be advanced is caught between the
blades, which are closed upon it. With the flap
thus held, the insertion of the tendon and all
other adhesions of the flap to the globe are di-
vided by snips' of the scissors. The flap can then
be drawn forward into its desired relation with
the eyeball and the position of the suture neces-
sary to retain it there and the amount of redun-
dant tissues to be removed, decided on.
"The finest curved needle is then passed
through the flap from the conjunctiva to the
scleral surface, back of the blades of the ad-
vancement forceps and about 2 mm. above (or
below) the center of the tendon. The needle is
then passed into the sclera, parallel to the cor-
neal margin and i mm. from it, in such a way
as to take a firm hold in the sclera without pass-
ing through it. It should include one-fourth or
one-third the thickness of the sclera, and the
points of entrance and emergence should be 3 to
4 mm. apart. If at the first attempt the needle
cuts or pulls out of the firm tissue, it should be
introduced a little deeper and a little farther back
from the cornea. The needle is then passed be-
neath the flap and through it from the sclera to
the conjunctival surface, back of the blades of
the forceps, opposite the original point of entry,
and 2 mm. below (or above) the center of the
tendon — that is 4 mm. from the first entrance.
Any tissue that will be clearly redundant, includ-
ing that held in the forceps, should now be ex-
cised, the flap drawn forward, and the suture
tied. If after this there still remains redundant
tissue, it may then be trimmed away.
"Generally the above suture is all that is nec-
essary, and upon it is to be placed the chief reli-
ance for the success of the advancement. If,
however, there appears a tendency of the con-
junctival wound to gape near its upper and lower
angles or if the tissue seems to be much dragged
toward the central suture, with tendency to nar-
row the new attachment of the tendon to the
eyeball, additional sutures may be placed above
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628
THE PENNSYLVANIA MEDICAL JOURNAL
June, 1921
and below the first one. To introduce such a
suture, thrust one blade of the forceps beneath
the flap, and raise the tissues from the sclera.
The needle may be rather larger than for the
first stitch and carrying thicker silk. It is thrust
from the conjunctival to the scleral surface of
the flap, then carried under the conjunctiva
above (or below) the cornea close to its margin,
almost to its vertical meridian, but without any
attempt to enter the sclera. This suture should
be so placed that beside closing the conjunctival
wound it will tend to spread the end of the ten-
don and secure as broad an attachment as pos-
sible for it in its new position.
"The after treatment consists in keeping both
eyes closed for the first day with a light dressing,
cleansing the eye once or twice daily, and con-
tinuing the dressing on the operated eye for four
or five days. The sutures should remain from
four to eight days. Early removal of the
stitches is indicated when the effect seems likely
to be excessive, or when profuse conjunctival
discharge develops."
The one objection I have found to this method
is the amount of tension placed upon the scleral
anchorage in some cases of very marked devia-
tions, in consequence of which, the stitch may
cut through the tissues on the third or fourth day
after the operation, thereby nullifying the effect
of the operation. This has been overcome by
the employment of two sutures instead of one,
placing them parallel with one another, the su-
perior including the upper half of the tendon,
the inferior the lower half.
The virtues of this operation consist in the
following: i. Its simplicity. The procedure is
really nothing more surgically than the conjunc-
tival incision, the resection of the muscle and its
sublying tissues, and the closing of the wound
by two mattress sutures.
2. The avoidance of looping or knotting the
suture in the muscle, which tends to impede the
vascular supply of the tissues and produces un-
favorable reaction, and also renders the removal
of the stitches difficult.
3. The simultaneous inclusion of all the tissues
in the suture prevents the pulling out of its mus-
cular anchorage, which sometimes happens when
the muscle alone is secured.
4. The slight traumatism done to the parts
and the absence of puckering and rucking of the
tissues.
The scleral anchorage stitch should be inserted
as far forward as possible (e. g., as close to the
corneal margin) to obtain the maximum effect.
The operation aims at a real advancement of the
muscle and its surrounding tissues as well as
their resection. A degree of caution must be ex-
ercised not to resect too much of the capsule,
else the orbital ligaments are shortened unduly
and the effect of the operation negatived. In tie-
ing the sutures and closing the wound the fl^
should be drawn forward jnto the proper posi-
tion by forceps and then tied to its new insertion.
If the flap is advanced in the act of tightening
the sutures, the latter are liable to cut through
the tissues and the results of the operation be
minimized.
In conclusion I append a brief description of
the results obtained by this method upon cases
illustrating various types of squint.
1. Girl, age 14 years. Congenital alternating con-
vergent strabismus of 50°. Left eye the preferred fix-
ing eye. Under atropine —
Right eye -|- S. 1.5 D. O + C. 0.50 D. ax. 50*=5/S
Left eye + S. 2.5 D. O + C. 0.50 D. ax. i6s*=5/f5
Double advancement of the extemus, with cautious
tenotomy of both internus muscles. Visual axes par-
allel 3 months after operation.
2. Mrs. W., age 40. Paralysis of right external rec-
tus muscle, following ptomaine poisoning. Paralysis
of muscle remaining stationary 2 years later and caus-
ing marked disfigurement of an otherwise handsome
woman ; operation decided upon. Right external rec-
tus muscle advanced and cautious tenotomy of right
internus. Slight overcorrection for a time. In one
month, visual axes parallel, i. e., right hyperphoria of
154°. Esophoria of 5° at five metres.
3. Mrs. K., age 38. Right eye divergent 50° and all
converging movements lost in consequence of a too
free tenotomy of right rectus internus for correction
of convergent squint in childhood. Operation under
ether. Two months later, eye in perfect position. Ten
months later, visual axes parallel and convergence in
right eye normal, notwithstanding marked degtree of
amblyopia exanapsia in former squinting eye, i. e.,
Right eye -f S. 45 D. O -f C. 2.5 D. ax. 7o°=3/6o
Left eye + S. 5-5 D. O + C. i. D. ax. iio°=s/9
DISCUSSION
Dr. Edward B. Heckel (Pittsburgh) : Doctor Posey
has well said that the great variety of this operation
is evidence of the fact that no single operation is per-
fect or satisfactory. The doctor has described his
operation so thoroughly that any further elaboration
is tmnecessary except to emphasize the point that all
the tissue should be advanced with the muscle. A lit-
tle scheme I have employed (it is not original with
me; I do not remember where I got it) is to use a
guy suture so as to take the tension off the suture
advancing. For instance, after the internal rectus is
advanced, put a guy suture through and pull it to-
wards the nose and thus relieve the tension on the
internal rectus. That can be left in, it is very com-
fortable for forty-eight hours ; or if the operation is
on the external recti then the guy suture is placed
over the internal and fastened with adhesive tape and
held in position.
Another procedure that I use is iced pads instead
of bandages. They are really very comfortable, but
of course require the services of a nurse.
Dr. William H. Wilder (Chicago) : This is a very
interesting subject, but I think we must answer the
question — "Do we get the effect of an advancement
operation from the advancement, or from the resec-
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June, 1921
ANTISCORBUTIC VITAMINE— GIVENS
629
tion?" I used to think we got it from the advance-
ment, but I have come to feel that the result we get is
from the resection of the muscle. I believe the muscle
when it is reattached to the eye gets its direct pull, its
dynamic power, not from the point to which we ad-
vance it but from the same point to which it was at-
tached before, and therefore, that the effect we get
from our so-called advancement is really from the re-
section. Hence, in any operation of this kind it is im-
portant to decide how much resection of the muscle is
necessary, and this will be determined by the judg-
ment of the operator. The man who has had expe-
rience seems to know by intuition the amount of resec-
tion necessary to get the best results.
An operation which will hold the tendon firmly in
place so it will not slip back during the time of heal-
ing, is the one to be practiced. Personally, having
tried a good many of the operations, the stitch that
I prefer is that proposed by Worth. I prefer two
sutures or even three at times, for the reason that it
seems to me the tendon is spread out and there is a
better chance to secure a good, firm hold. Also with
two sutures, one at the upper edge and one at the
lower edge of the tendon, one can more accurately
adjust the new position of the muscle so as to avoid
elevation or depression of the eyeball. This is par-
ticularly important in advancement operations for
exophoria or esophoria. In such cases, after tying the
first loop of the knot in the upper and lower suture,
tests with the Maddox rod and candle can be made
and if it is apparent that the eye has been elevated or
depressed too much, one or other of the sutures can
be tightened or loosened to bring the eye into proper
equilibrium. Then the final loop in the knot can be
tied. It would be difficult to make such adjustments
with a single stitch.
The suggestion that Doctor Heckel has offered is
valuable. So far as I know it was originally done by
Professor Hotz of Chicago — at least I learned it from
him twenty-five years ago. It has proved extremely
valuable. For example, in a case of divergent squint
where one is advancing the internal rectus and feels
uncertain about the stitches holding because of con-
siderable tension on them, a firm suture may be placed
through the attachment of the external rectus, and
then through the skin of the bridge of the nose at
such a point that when the suture is tied the eyeball
will be rotated inwards and held in this strongly ad-
ducted position for two or three days, until the ad-
vanced tendon has time to attach itself firmly. It may
be necessary to place a little roll of gauze or cotton
under such a guy suture to make sure that it will not
come in contact with the cornea. Such a suture could
be used in advancement of the external rectus, being
placed in the internus and then in the skin of the
temple, passing over a roll of gauze suitably placed,
thus abducting the eye sufficiently to relieve the ten-
sion on the suture placed in the external rectus ten-
don. Usually such retaining sutures can be removed
in two or three days.
Dr. Luther C. Peter (Philadelphia) : Dr. Wilder
is correct in his statement that the shortened muscle
operates only from the stump of the cut tendon. The
pull of the newly attached muscle is from this point
and not from its attachment near the cornea when this
method is practiced. There is a vast difference, how-
ever, in the results obtained because one not only gets
the benefit of the part of the muscle excised but an
increased shortening of 4 or s mm. depending upon
how far forward the muscle is attached.
Dr. Posey (in closing) : I practiced the Worth
operation for a number of years, but gave it up, as it
seemed to me that in some cases the complete inclu-
sion of the muscle by the sutures produced too much
reaction and when it came to getting the sutures out
there was frequently difficulty, particularly in yoimg
subjects.
I agree, and I have stated in my paper, that to get
the maximum effect you must both shorten the muscle
and bring it "forward into a new position upon the
globe. What Doctor Wilder has said about the double
stitch bringing the tendon closer to the globe, is true
of the method which I have cited, the tendon being
spread out over the globe and uniting with the sub-
lying tissues by flat adhesions.
It seems to me that the operation which I have de-
scribed is especially applicable to children, a class of
patients upon whom all advancement operations are
difficult and not without danger. I rarely advance a
muscle in a child until it is eight or nine years old,
and I want something then which will be simple, com-
paratively easy of performance, and causing as little
reaction as possible.
THE ANTISCORBUTIC VITAMINE*t
MAURICE H. GIVENS, PH.D.
PITTSBURGH, PA.
The subject assigned to me is one which deals
with a certain form of malnutrition — scurvy. A
discussion of the clinical aspects of this disease
is presupposed. However, not being a clinician,
I must perforce speak from the standpoint of an
experimentalist.
The present conception of those forms of mal-
nutrition called deficiency diseases is not wholly
dependent upon a belief in the existence of
vitamines. A dietary lacking in inorganic salts
or complete proteins, that is those yielding all
the amino acids, will lead to disastrous results.
Because we have been unable to isolate in a pure
condition the various vitamines there has been
some doubt as to their existence. There is no
justification for this attitude because the con-
ception of vitamines is based upon carefully con-
trolled experiments which are unquestionably
conclusive. Of course it is unnecessary for me to
defend animal experimentation upon the subject
before this audience, because we all recognize
that any procedure which causes "absolute fail-
ure in the fundamental nutrition of one kind of
mammal will most certainly be liable to produce
untoward results of some kind in the case of any
other mammal."'
Scurvy has made its appearance wherever and
whenever the supply of fresh food has been lim-
ited by any circumstance. Mention only need be
made of its appearance in consequence of depri-
*Read before the Section on Pediatrics of the Medical So-
ciety of the State of Pennsylvania, Pittsburgh Session, October
5. 1920. •
tProm the Research Laboratories, Western Pennsylvania Hos-
pital, Pittsburgh, Pa.
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THE PENNSYLVANIA MEDICAL JOURNAL
June, 1921
vation of green stuffs as on old sailing ships
long at sea ; during the siege of cities under war
conditions, for instance, in Paris in 1870; on
polar expeditions; during our own Civil War;
the late World War; and numerous other in-
stances. Poverty and ignorance together or sep-
arately frequently permit us to see it at close
hand. Scurvy has made its appearance too often
to enumerate all the instances. However two
facts have stood out for centuries, namely, that
scurvy has appeared when greenstuffs have not
been available and that it has been cured when
the greenstuflfs were provided. Notwithstand-
ing the clear-cut relationship of green foodstuffs
to scurvy there have appeared at various times
different theories as to the cause of the disease.
Experimental data no longer allow us to consider
the infectious idea* nor the absorption of toxin
following poor bowel elimination.*
The classical work of Hoist and FroHch* at
the University of Christiania, Norway, proved
beyond doubt that by dietary restrictions a con-
dition could be produced in guinea pigs which
was analogous to that of human scurvy. Fur-
thermore they showed that the animals could be
cured or the onset of the disease prevented by
feeding them greenstuffs. Hoist and Frolich pro-
duced experimental scurvy in guinea pigs by feed-
ing them oats and water. If this animal is fed
such a diet, in fourteen to twenty-one days it
will begin to lose in weight, the wrists will be-
come swollen and tender, and unless curative
measures are instituted the animal will die in
about seven days. At autopsy the following
anatomical changes are seen: the wrists are
swollen and hemorrhagic; there are subcutane-
ous, deep intramuscular, and subperiosteal hem-
orrhages; the costochondral junctions are en-
larged ; the molar teeth loose ; and often hemor-
rhagic gums are present. Microscopically alter-
ations are found in the bone marrow. The
picture is practically identical .with that observed
in human scurvy.
The work of Hoist and Frolich was repeated
by McCollum. The latter investigator criticized
correctly the basal diet of oats alone charging it
with being inadequate in several respects. A
main part of the criticism was that oats alone led
to impaction and thus injury of the cecum with
a subsequent absorption of putrefactive toxins.
This idea has been proved incorrect by Cohen
and Mendel," Chick and Hume,* and Cohen and
myself.' In our investigation we have used a
perfected basal diet made of autoclaved soy bean
flour, milk, yeast, paper pulp, calcium chloride,
and sodium chloride dried down to a cake. This
diet contains:
1. Proteins adequate in amount and composi-
tion.
2. Fats "I
3. Carbohydrates ^sufficient in amount.
4. Inorganic saltsj
5. Bulk to facilitate elimination.
6. The fat soluble vitamine A.
7. The water soluble vitamine B.
The above basal diet is deficient in the anti-
scorbutic vitamine but otherwise adequate. It
therefore serves as a basal diet to test out the
antiscorbutic potency of foodstuffs. If a guinea
pig is fed this soy cake mixture alone, in four-
teen to twenty-one days it develops scurvy and
shows at autopsy the conditions previously de-
scribed. We have used this method to determine
the antiscorbutic strength of a number of foods
subjected to different treatments. Our object
has been to determine as near quantitatively as
possible the antiscorbutic content of cabbage,
raw and dried ;' tomatoes, raw, dried,* and
canned ;' potatoes, raw, cooked, and dried ;"
meat dried ;" orange juice dried ;" apples, raw,
cooked, and dried;" bananas, raw, cooked, and
dried."
All textbooks discussing scurvy state that it
can be cured by the use of fresh fruit or vege-
tables. Usually a long list is given but there is
no indication of the relative antiscorbutic po-
tency of the foods. Can one vegetable or fruit
be replaced by any other one? What is the ef-
fect of cooking or preserving upon the antiscor-
butic value of the food ? The financial condition
of certain patients does not permit them to feed
their children orange juice, while they might be
able to afford a cheaper food, as canned toma-
toes. How can foods be preserved so that the
antiscorbutic vitamine is not destroyed ?
Our results are briefly as follows : raw orai^e
juice, tomatoes, cabbage, potatoes, apples, and
bananas are good antiscorbutic agents. Of these
foods our experiments indicate that the content
of antiscorbutic vitamine is greatest in orange
juice and least in bananas. Cooking tends to
diminish the amount of the antiscorbutic acces-
sory. Orange juice and tomatoes can be dried
so that they retain a significant amount of their
original vitamine content. Canned tomatoes are
good antiscorbutic agents.
BIBLIOGRAPHY
I. Hopkins, F. G., Br. Med.
Sii.
opi
2. Jackson, L., and
It. Med. J., 19JO. No. 3109. p. 147.
Moody, A. M., J. Infect Dis., I9»*.
3. McCollum, E. v., and Pitr, W., J. Biol Chem., 191 7. 3',
229.
4. Hoist, A., and Frolich, T., Zeit. Hyit.. 191 2, 7*. '•
5. Cohen, B., and Mendel, L. B., J. Biol. Cbem. 1918, 35.
425.
6. Chick. H., and Hume, E. M., Special Report Series, Xo.
38, British Med. Research Comm., 1919. This report conuins
a resume of the work of these investigators and their associate*.
7. Givens, M. H., and Cohen, B., J. Bilo. Chem., 1918. 3i.
127.
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June, 1921
ANTISCORBUTIC VITAMINE— DISCUSSION
631
8. Givens, M. H., and McCIugage, H. B., J. Biol. Chem.,
■ 9>9. 37, 253.
9. Unpublished data.
lo. Givens, M. H., and McCIugage, H. B., J. Biol. Cfaem.,
■ 9^0, 41, 491.
n. Givens, M. H., and McCIugage, H. B., Science, N. S.,
i9»o, 51, 273.
I.:. Givens, M. H., and McCIugage, H. B., Am. J. Dis. Chil-
dren, 1919, >8, 30.
13. Unpublished data.
14. Unpublished data.
DISCUSSION
Dr. John F. Sinclair (Philadelphia) : The very in-
teresting presentation of this topic by Dr. Givens has
teen entirely from a laboratory standpoint which I
cannot discuss. I have had no experience from that
standpoint. What I have to say must be said entirely
from a clinical point of view.
The experimental data in regard to scurvy shows
the error in the two theories that have previously been
widely held as to its etiology. The first looked upon
scurvy as being infectious in origin, the second held
the absorption of the putrefactive toxins following
poor bowel elimination responsible for its causation.
These theories have likewise been disproved clinically.
Were the cause really an infection how could we then
explain the fact that in certain cases we can get our
patients well, or at least greatly improved, by increas-
ing the amount of the intake of the same foodstuff
that has been previously employed, thereby raising the
amount of the vitamine in the food. An example of
this is shown in those cases presenting the early symp-
toms of scurvy in which the scorbutic symptoms dis-
appear on the addition of more milk to the formula.
As to the absorption of the putrefactive toxins fol-
lowing poor bowel elimination, that has long since, I
think, been clearly disproved clinically, as well as ex-
perimentally in the laboratory. As examples let us
turn to the failure of certain drugs as the salicylates,
sodium benzoate, calomel, diuretics and laxatives, all
of which have been widely employed in the treatment
of scurvy in the past without avail. With the failure
of drugs which promote diuresis and catharsis this
theory of absorption of the putrefactive toxins as the
causative agent in the production of scurvy falls into
the discard from a clinical viewpoint.
An interesting bit of evidence is the work of Hess
in New York, which has shown that very quick and
very prompt results can be gained by using orange
juice intravenously. He has done this in infants with
perfect safety with very prompt results. At least it
is an added proof, I think, that the causative agent
must be outside of the alimentary canal.
It does not concern us to go into the various forms
of scurvy, but I think it is important for us to know,
especially in the feeding of our cases, how much milk
we are giving to our babies, and to be able to judge
and analyze our cases of scurvy, to determine exactly
what the amount of milk is that an individual baby is
getting. The point I wish to make is this: for in-
stance, let us suppose an infant is on a malt soup mix-
ture, with a definite amount of milk, say one pint of
milk and one pint of water, some wheat flour, some
malt and potassium carbonate. The child begins to
develop the early symptoms of scurvy. Some of these
children, perhaps not all, but certainly some, if they
can bear added amounts of milk in the formula show
rapid amelioration of the scorbutic symptoms, show-
ing that it is really an important thing to know the
amount of milk we are using. The reason, I believe,
that malt soup mixtures are not sufficient is largely
because there is in the first place a barely sufficient
amount of vitamine in the milk. Sometimes it is suffi-
cient but at the most it is barely sufficient. Then this
mixture is boiled and that adds to the trouble. It is'
frequently made in the first place from pasteurized
milk so that it is practically heated twice. From lab-
oratory tests it has been found that the heating of milk
has considerable to do with the destruction of the
vitamine. Last of all, there is the addition of alkali,
which undoubtedly is a very considerable factor, for
the antiscorbutic vitamine seems to like acids and to
be interferred with by alkalies.
Some one may bring up the question of cases that
occur on breast milk, for they have been reported.
It is probably due in part to the. scanty supply of
i-itamine in the milk or the scanty amount of milk
with sufficient vitamine. Also it may be due to the
diet of mothers. It has been shown conclusively that
cow's milk has more vitamine in it when feeding on
fresh food than on winter fodder in the barn and it
is very likely that the diet of the mother has also
something to do with vitamines in the breast milk.
There has been iti the past a good deal of misconcep-
tion in regard to scurvy. Probably some of these
cases have really been cases of hemorrhage associated
with an infectious condition rather than true cases of
scurvy.
When, then, may the antiscorbutic diet be com-
menced? This is a great thing for the clinician to
know. I believe we can begin it very early, in the
early weeks of life, because orange juice can be given
very safely to babies but a few weeks old. If it
creates vomiting, as it does in some cases, that can be
overcome by rendering it neutral by a normal solution
of sodium hydroxide.
I should like to ask one question. Is the antiscor-
butic vitamine potent and active for an indefinite pe-
riod after orange juice is subjected to the process of
desiccation or does it lose its potency rapidly after
three months?
Dr. Givens (in closing) : Again I must repeat that
my paper was given from the standpoint of the lab-
oratory man. However, the lesson to be learned,
which is of practical importance to the pediatrician, is
the comparative antiscorbutic value of different foods
as determined by feeding experiments on guinea pigs.
Eventually through such investigations we will be
able to express in a rough quantitative way the rela-
tive antiscorbutic vitamine content of foods.
Most of us are aware that the children of Vienna
are in a pitiful condition, suffering from many defi-
ciencies, among which is the shortage of antiscorbutic
foodstuffs. The English have sent a commission to
Vienna to study and attempt to remedy matters. These
investigators had not data on the apple and fed raw
apple juice on the basis of assumption. The quantity
they assumed necessary did not protect against scurvy,
and it was necessary to resort to 10 grms. of raw
neutralized lemon juice.
The question has been asked, "What is the vitamine
content of milk?" A definite answer cannot be given
as the subject is under investigation at present in a
number of laboratories. Most important evidence has
come from the University of Wisconsin to the effect
that the kind of diet (that is whether summer or win-
ter feed) plays an important role in determining the
vitamine content of the milk secreted by the cow. As
for dried milk, the English consider its antiscorbutic
protency nil. In this country one brand of dried milk
is claimed to contain some of the antiscorbutic vita-
mine. The subject needs laboratory study. The in-
fluence of heat on the antiscorbutic vitamine is an
attractive field for research.
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THE PENNSYLVANIA MEDICAL JOURNAL
June, 1921
The question of ageing has been brought up. We
are investigating at present tomatoes canned three
years ago. To date we have found that 3 c.c. of this
material will protect a guinea pig against scurvy for
at least five months. So far as dried orange juice is
concerned, we have under way feeding experiments to
determine the antiscorbutic value of this material after
it is a year old.
Some one brought up the question of vomiting in
yotmg babies from the use of raw orange juice. This
leads me to call attention to the report of Prof. Har-
den of the Lister Institute, England. He states that
babies tolerate raw neutralized lemon juice much bet-
ter than the unneutralized material.
PYLORIC STENOSIS WITH A REPORT
OF FIFTY CASES*
H. C. DEAVER, M.D.
PHILADELPHIA
During the past five years fifty cases of con-
genital pyloric stenosis have been admitted to
the Children's Hospital of the Mary J. Drexel
Home of Philadelphia. Of these, forty-six re-
ceived operative treatment. The remaining four
were cases of stenosis of mild degree, which
were demonstrated by fluroscopic examination.
These cases recovered under proper feeding. A
gastro-enterostomy was performed on eight of
the earlier cases. Four of the patients died, giv-
ing a mortality of fifty per cent. Since the
Rammstedt operation has been the operation of
choice in this hospital we have treated thirty-
eight cases surgically, with the gratifying result
of only three deaths, or 7.9 per cent mortality.
The series of fifty cases shows the marked
disproportion of ninety per cent males to ten
per cent females. A preponderance of males is
likewise noted by other authors, some of them
also claiming that the disease is apt to be more
severe in boys than in girls.
The ages of the patients ranged from eight
days to eleven weeks. One case included in the
series, apparently congenital in origin, was ten
years old at operation. Excluding this patient,
since true congenital stenosis is rare after the
first year, the average age at which the patients
came to operation was nine and one-half weeks.
All the cases gave a history of loss of weight
and vomiting, and in all but two constipation
was also noted. These two cases, however, re-
quired operation. The average weight on ad-
mission was seven pounds, six ounces, or ap-
proximately 2.5 pounds below the normal for an
infant of ten weeks. The average age at which
vomiting set in was three and five-tenths weeks.
In ten per cent of the cases vomiting set in at
•Read before the Section on Pediatrics of the Medical So-
ciety of the State of Pennsylvania, Pittsburgh Session, October
S, 1920.
birth, and in one instance this symptom did not
develop until the fourth month.
At the physical examination, before opera-
tion, exaggerated peristalsis was noted in 91
per cent of the cases, a palpable tumor being
present in 62.5 per cent. Both these signs were
present in one-half the cases while six per cent
showed neither of them. On x-ray examination
complete stenosis was reported in twenty per
cent, a slightly patulous pylorus in thirty per
cent and partial stenosis in fifty per cent of the
cases.
At operation (Rammstedt) the gastric mucosa
was inadvertently incised in two cases, one dy-
ing and the other making a good recovery.
Bleeding after section of the pyloric muscula-
ture was marked in thirty per cent of the cases.
All however recovered.
The post-operative course usually presented a
prompt febrile reaction, the temperature rising
to about 102° F. and occasionally to 104° F.,
but in the series twenty per cent showed no rise
at all in the temperature after operation. Vwn-
iting is a more constant post-operative sjmiptom.
It was noted in 85 per cent of the cases, the
average duration being about thirty-six hours,
but it was never protracted beyond the fifth day.
The stools became normal in from one to four
days. Convalescence averaged thirteen days,
ranging from five to twenty-five days, the pa-
tients on discharge showing an average gain of
six ounces over the weight on admission,
GENERAI, CONSIDERATIONS — HISTORICAL
The earliest recorded case of congenital py-
loric stenosis is that described by Hezekiah
Beardsley in 1778, at a meeting of the New
Haven Medical Society. The patient, a boy two
years of age, was treated medically and finally
succumbed to the disease. What appears to be
the second instance in which this condition was
recognized is one reported by Williamson in
1841. These two cases, together with the scat-
tering reports appearing in the literature, are of
interest in showing the difficulty experienced
by these early observers in recognizing the con-
dition as a clinical entity.
Surgical treatment of infantile pyloric sten-
osis was evidently not attempted until 1893, at
which time Cordua reported doing a gastro-
enterostomy with death as a result. Meltzer,
in 1898, also performed the same operation with
a similar fatal result. The first successful
gastro-enterostomy .is that reported by Lobker
also in 1898 ; while in the following two years
the first divulsion was done by Nicoll, and the
first pyloroplasty by Braun. Nicoll's patient
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June, 1921
PYLORIC STENOSIS— DEAVER
633
recovered, but Braun's succumbed to the opera-
tion.
In 1908, Fredet recommended treating these
cases by a longitudinal incision of the serous
and muscular coats of the pylorus, the essential
feature of the operation described by Ramm-
Ktedt in 1912, and which has come to bear his
name. Fredet in his procedure converted the
longitudinal incision into a transverse one by
suturing. Rammstedt, however, omitted this
step and permitted the pyloric wound to remain
gaping, which has become the adopted proce-
dure. It thus appears that priority in the mat-
ter of procedure belongs to Fredet. In view of
this, Downes has recently suggested that the op-
eration be designated as the Fredet-Rammstedt
(.peration.
The advantage of surgical over medical treat-
ment of infantile pyloric stenosis is apparent
even in the early reports in series of cases. In
1907 Voelcker treated seven cases medically
with five (71 per cent) deaths; while in the
same year among sixteen cases treated surgically
by Burghard the mortality was only thirty-sever.
per cent. Burghard's operation consisted of in-
cising the stomach and dilating the pylorus from
within. His series is of interest, in that it shows
a rather fair result from an operation now to-
tally discarded. More recently (1915) For-
cart, in fifteen cases treated medically, obtained
66 per cent complete cures. . This probably rep-
resents the best results as yet reported from
medical treatment of this condition. Neverthe-
less surgery shows the better figures. In 191 5
Lewis and Grulee treated five cases by doing a
gastro-enterostomy, all of which recovered;
while Richter in 1914 has reported only three
deaths (14 per cent) in a series of 22 gastro-
enterostomies.
In spite of this comparatively favorable show-
ing for the gastro-enterostomy operation, the
superiority of the Remmstedt method is today
generally recognized. Various authors are re-
porting results in more or less large series of
cases with continually improving figures. Holt
in 1917 reported 67 cases with 24 per cent mor-
tality. Later (1919) Kerley reported 26 cases
with 16 per cent mortality, which figure he
thinks will be reduced to five per cent when
cases are recc^ized earlier and brought to op-
eration without delay. This prediction was
more than realized by the recently reported three
per cent mortality in 103 cases operated on by
Strauss, of Chicago. Strauss has modified the
Rammstedt operation by shelling out the mucosa
from the muscular layer, and using the inner
part of the muscle tumor as a flap for the
muco.sa. Downes of New York, in a late report
of 17 per cent mortality in 175 cases, also em-
phasizes the importance of early operation in
reducing the mortality, which he believes should
not exceed eight per cent if the cases are seen
not later than the fourth week of the disease.
ETIOLOGY
Numerous explanatic»is have been offered to
account for congenital stenosis. Among the
early theories may be mentioned: (a) primary
congenital hypertrophy of the pyloric wall with
constriction of the lumen ; (b) functional dis-
order of the nervous mechanism of the stomach
leading to antagonistic action of the muscular
layers. Lately the condition has been regarded
as "primarily spasmodic," due to "gastric and
duodenal irritation • or nervous disturbances"
(Kerley). According to Strauss the condition
begins before birth and is caused by rythmic
contraction of the pylorus, due to abnormal
stimulation of the nervous mechanism, the hy-
pertrophy resulting from over-use of the mus-
cle.
It seems justifiable to assume that the condi-
tion is present before birth in every case. The
hypertrophy of the muscular layer, therefore,
must be due either to excessive use of the mus-
cle or to its primary pathologic over-develop-
ment. Most authorities, however, disregard the
latter possibility. The former can probably be
accounted for by assuming a fault in embryonic
development, resulting in an actual stenosis of
the pyloric orifice (this stenosis, in fact, can
sometimes be demonstrated at operation). In
the presence of such a narrowing of the pyloric
opening it is readily seen that hypertrophy of
the muscle is the result of the increased effort
required to force the stomach contents into the
duodenum. The hypertrophy thus is primarily
compensatory and not pathologic ; but once es-
tablished, a vicious circle is formed as the in-
crease in bulk of the muscle still further con-
stricts the already stenosed orifice. Eventually
a point will be reached where the stomach is un-
able to empty itself as fast as it receives nour-
ishment. The pylorus is thus kept in a constant
irritation, and vomiting begins. When there is
no primary stenosis of the mucous layer, there
is no compensatory hypertrophy of the muscu-
lature, and the condition is then one of pyloro-
spasm. Deranged secretion may be the etiolog-
ical factor in such instances, so that these cases
will respond to regulation of feeding and to
medical measures. While a primary stenosis of
the mucosa cannot be demonstrated in every
case, it is more reasonable to assume such a con-
dition than that of a primary muscular hyper-
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634
THE PENNSYLVANIA MEDICAL JOURNAL
June, 1921
trophy or nervous derangement, as the factor in
the etiology of this disease.
PATHOLOGY
Pathologically all cases show a simple hyper-
trophy of the circular muscle layer, the fibres
being increased in number rather than in size.
Occasionally there is also a slight increase in the
longitudinal fibres. Grossly the pylorus is car-
tilaginous, thickened and elongated into the
.shape of a bulging cylinder, measuring from
two and a half to three and a half centimeters
in length, and from one to two centimeters in
thickness. The stomach may or may not be di-
lated.
S Y M PTOM ATOLOG Y
The most conspicuous symptom of infantile
pyloric stenosis is vomiting. It is present in all
cases and is primarily due to irritation of the
pylorus by the attempted passage of food, and
secondarily to over-distension of the stomach.
This accounts for the typical projectile character
of the vomiting which generally sets in imme-
diately or very soon after feeding. Where there
is gastric distension, vomiting may occur at any
time irrespective of feeding, and more than the
total amount of feeding may be expelled at one
time. In cases of marked distension the vomit-
ing is not always projectile. This vomiting most
often begins at the end of the third week in
breast-fed babies, but it may appear at birth or
as late as the fourth month. The act itself ap-
pears to be painless and to cause no marked dis-
comfort, although it may be ushered in by cry-
ing or signs of distress. The vomitus consists
of food, generally little changed, unless the
stomach is distended, when it shows more or
less evidence of digestion. It is more or less
acid and occasionally contains small amounts of
bile.
Loss of weight is also a constant symptom,
and with regard to prognosis is a most important
one. In the average case the child is about one-
third below normal for its age. If the loss of
weight does not exceed this, prognosis is favor-
able in the absence of other disease. Below this
prognosis is correspondingly clouded.
Constipation is nearly always noted, although
it is not a feature of every case. Where steno-
sis is complete the stools consist of small
amounts of material resembling meconium, and
are passed with difficulty at considerable inter-
vals. Ordinarily, the .stools are small, greenish
or dark brown, and contain mucus. They are
hard to pass and usually require the administra-
tion of an enema. Sometimes, however, suffi-
cient material pa.sses into the pylorus to provide
a daily small stool, although it is not sufficient
to nourish the child, so that the patient may
reach a fatal degree of starvation without any
conspicuous history of ccmstipation. Infants
suffering with stenosis are always hungry and
will take any liquid food, although not more
than a small amount at a time. They cry con-
siderably, apparently from hvmger and not from
pain.
On physical examination the leading signs are
increased peristalsis and the presence of a py-
loric tumor. Visible peristaltic waves are seen
in practically every case, appearing in the upper
abdomen just beneath the skin, like a series of
one to three billiard balls in motion. They can
best be observed by placing the infant upon the
back and administering a small amount of milk,
after which the abdomen may be stroked in their
direction of travel. Immediately before the
waves appear, the child which hitherto may
have been restless becomes quiet. The waves
then begin. Each successive wave, it will be
noted, terminates at about the same spot, be-
neath which is situated the pylorus ; so that the
pylorus can thus be located before operation.
The pyloric tumor can be made out in about
two-thirds of the cases. It is hard, resistant,
and about the size of a filbert nut, located in the
pyloric region.
Emaciation corresponds to the degree of star-
vation. But the other sequelae of starvation —
weakened circulation and acidosis are of greater
importance. Many cases that succumb to oper-
ation occur among infants whose general ap-
pearance fails to indicate the exact state of the
circulatory system or the true degree of starva-
tion and the danger of acidosis. It is advisable,
therefore, that besides circulatory stimulation,
an attempt be made to determine the chances of
acidosis and to correct any deficiency in alkali
by a brief period of enteroclysis or intravenous
medication before submitting the patient to op-
eration. Such a precaution would no doubt be
the means of saving more of the moribund
cases.
DIAGNOSIS
The diagnosis rests upon the hi.story of vom-
iting and loss of weight, and is indicated by
visible peristalsis and the pyloric tumor, con-
firmed by x-ray. The presence of pyloric sten-
osis should suggest immediate operation. Every
infant with a history of progressive toss of
weight and vomiting of any type should be
x-rayed at once, since such a child must be con-
sidered a potential case of pyloric stenosis until
the x-ray proves that no stenosis is present.
Bismuth may be administered in water or milk
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June, 1921
PYLORIC STENOSIS— DEAVER
635
v/hile the child is in the horizontal position.
Strauss observes that in the fluoroscope small
amounts of bismuth are seen to squirt through
the pylorus, followed immediately by snake-like
contraction in the pylorus exclusively. This he
believes to be pathognomonic. The stomach
should be radiographed again at the end of two
hours and of four hours. If more than two-
thirds of the bismuth mixture has passed the
pylorus in two hours, the case may be consid-
ered medical.
The determination of the amount of gastric
retention is merely of academic interest. Dunn
emphasized the fact that a catheter of a certain
size will pass the normal pylorus at a given age,
and by this means the degree of stenosis can be
determined. According to Kerley true stenosis
demands hypertrophy of the musculature of the
pylorus, and in the absence of this the condition
.should be regarded as pylorospasm. The fact
of the matter is that the seriousness of the con-
dition depends on the rate with which the food
passes through the pylorus, and this can be de-
ternnined promptly, safely and accurately by
means of the x-ray only. All other methods of
diagjnosis are of subordinate interest and non-
essential.
In a word, there are two vital points in diag-
nosis. First, that the condition be suspected as
.«^oon as a child begins to vomit and lose weight.
Secondly, that diagnosis be confirmed or other-
wise by immediate x-ray study. Early recogni-
tion of the condition means or should mean early
operation, in the suitable case, which in turn will
mean a probable mortality of less than five per
cent. In the present series fourteen consecutive
cases were operated on without a death. The
moribund cases which come to the pediatrician
or the surgeon for diagnosis are no credit to the
diagnostic ability of the general practitioner, if
one has been in attendance, and are the ones that
furnish the greater percentage of the mortality
figures.
PROGNOSIS
From what has gone before it is evident that
prognosis is decidedly favorable provided the
cases are brought to operation early. As a rule,
a favorable prognosis may also be given, other
conditions being equal, if the child's loss of
weight is not more than one-third below normal
for its age. A greater loss of weight darkens
prognosis, as do also poor circulation and a low
alkaline reserve which may be expected in cases
of advanced starvation. On the other hand,
prognosis is in no way affected by the age of
the patient, the degree or the type of vomiting,
the presence or absence of a palpable tumor nor
the chariacter of the feeding. All the cases of
complete stenosis in this series recovered.
The inherent danger of the operation itsdf is
slight, barring accidents such as incision of the
mucosa which make prognosis less favorable.
The mortality, we repeat, is due to late opera-
tion, and with early diagnosis and early opera-
tion should be reduced to a minimum.
OPERATION
All cases which by means of x-ray or without
are diagnosed as pyloric stenosis should be op-
erated on as soon as possible. Moribund cases
should be given the opportunity, for even these
can sometimes be saved. The operation of
choice is the Rammstedt operation, under ether
anesthesia. Its simple technique enables it to be
completed within fifteen minutes and thus re-
duces shock. In cutting the hypertrophied py-
lorus it is important to avoid the small blood
vessels lying beneath the peritoneal covering.
The bleeding is carefully arrested, the pylorus
not being replaced until hemostasis is complete.
Care must be taken not to nick the mucosa;
this is a serious accident, and one that is more
apt to occur at the duodenal end of the incision.
The abdomen is closed by a through and through
silkworm gut suture, no attempt being made to
restore the layers. Healing is slow because of
the malnutrition of these patients when brought
to operation.
POSTOPERATIVE
Postoperative treatment consists chiefly in
feeding and stimulation. As soon as the child
is well out of the anesthetic a small amount of
water, about five cc, may be given by mouth.
This may be repeated every hour for the next
four hours, after which five cc. of mother's milk
or a weak artificial preparation may be given at
intervals of one or two hours. In i8 hours the
amount may be increased to ten cc. and after
36 hours have elapsed the food may be gradu-
ally increased in strength and amount until the^
normal amount is reached on about the fifth
day after operation.
Meanwhile water containing one per cent
saline or soda bicarbonate or peptonized milk
may be administered per rectum. Two ounces
of any of these fluids may be given at three-
hour intervals, or, if preferred, a pint may be
given less often by continuous enteroclysis.
Abundant alkali may be supplied in this way.
In exceptional cases hypodermoclysis may be re-
quired before or after operation.
Stimulation, if necessary, may consist of
brandy or whiskey added to the fluids given by
mouth or by rectum, and camphorated oil,
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THE PENNSYLVANIA MEDICAL JOURNAL
June, 1921
adrenalin, or strychnine hypodermically as re-
quired.
The most prominent postoperative symptom
is apt to be vomiting, although it is not projec-
tile, and does not follow feeding. It usually
consists of large amounts of dark brown or
greenish fluid, and as a rule, is repeated only a
few times, and disappears in from one to three
days. Sometimes it is entirely absent. Fre-
quent and distressing vomiting can be relieved
by gastric lavage with warm water or a solu-
tion of soda bicarbonate and the temporary
withdrawal of everything but water by mouth.
Sometimes small doses of lime and cinnamon
water will bring relief.
Following the immediate postoperative rise
in temperature which is generally seen, the tem-
perature quickly falls to normal and remains
there during convalescence, provided there is no
intercurrent disease. Bowel movements begin
soon after operation, being small at first but be-
coming normal by the end of the second day.
The stitches can be removed on the tenth day
and, as a rule, the patient is discharged by the
fifteenth day, and generally is slightly heavier
than on admission.
CONCLUSIONS
Congenital pyloric stenosis is not a rare dis-
ease.
It should be suspected as soon as the infant
l)egins to vomit and lose weight. .
Diagnosis should be confirmed or disproved
by immediate x-ray study.
Diagnosis, once confirmed, the patient should
at once be referred to a competent surgeon.
The mortality in this series is slightly less
than eight per cent when the Rammstedt opera-
tion is employed. The mortality in this and all
other series of Rammstedt operations is largely-
due to patients who come to operation in a mori-
bund condition. It should be practically nil if
cases are diagnosed and operated on early.
• REFERENCES
Beardsley, H.: Arch. Ped. 1903, xx, 355 (republished with a
note by Sir William Osier).
Braun: Munch. Med. Wchnschr., 1901, xlviii, 280 (discus-
sion).
BurKhard, F. F.: Trans. Clin. Soc. Lond., 1906-07, xi, 122.
Cordua: Mitt. a. d. Hamb. Staatskrankenanstalt, 1897-98, vl,
351-
Downes, W. A.: J. Atn. M. Assoc., 1920, Ixxv, jj8 (July
24).
Dunn. C. H. : Pediatrics, etc., 1020, New York,
Forcart, M. K.; Arch. f. Kinderh., 1915. Ixiv, 234.
Fredet, P. (Dufour and Fredet) : Rev. de Chir., 1908, xxvii,
208.
Holt. h. E.: J. Am. M. Assoc. 1917. Ixviii, 1^17.
Kerley, C. C. : J. Am. M. Assoc, 1919, Ixxii, 16. Prac-
tice of Pediatrics. 1918, Philadelphia.
Lewis, D., and Grulee, C. C: J. Am. M. Assoc, 1915, Ixiv,
410.
Looker: Cenlralbl. f. Chir., 1900, xxvii. Beilage, 70.
MelUer, S. J.: Med. Red., 1898. liv. -253.
Nicoll, J. J.: Brit. M. J., 1900, ii, 615.
Rammstedt, C. : Med. Klin., 1912, viii, 1702. Centralbl. {.
Chir., 1913, xl, 3.
Richter, H. M.: J. Am. Assoc. 1914, Ixii, 353.
Strauss, A. A.: burg. Clinics. Chicago. 1920, iv, 3.
Voelcker, A.: Trans. Clin.. Soc. Load., 1906-07, xJ, 108.
Williamson, J.: Lond. & Edinb. J. Hed., 1841, i. 23.
DISCUSSION
Dr. Alfred Hand (Philadelphia) : My inclination
in discussing Dr. Deaver's paper is to second the mo-
tion and sit down. Dr. Deaver's point of view is that
of the surgeon who sees most of his cases well-devel-
oped and with the diagnosis already made. And I do
not know anything easier to diagnose than a case of
hypertrophy of the pylorus with practically complete
obstruction of from two to six weeks' standing. With
projectile vomiting, visible peristalsis, emaciation, con-
stipation, and a palpable hard mass present, it is no
more credit to recognize the condition than it is to
diagnose an empyema with a chest full of pus.
The physician who sees these cases from birth often
has a number of puzzling problems to solve before he
can make the diagnosis, especially when the obstruc-
tion to the pyloric orifice is not complete, some food
passing through, sufficient to maintain nutrition, ren-
ders the palpation of the tumor difficult and sometimes
impossible.
I count myself fortunate that early in my experience
with this condition I was able to avail myself of Dr.
Deaver's surgical skill and judgment. Most of us
had been well-grounded in pyloric stenosis before we
saw a case, owing to English writings. Then it was
brought forcibly to the attention of the American pro-
fession at the Toronto meeting of the British Medical
Association in 1906 by Still and Cautley. Shortly after
this I was invited by one of my colleagues to witness
an operation for pyloric stenosis in which pyloroplasty
was the method used, but the infant died and so I was
somewhat prejudiced against surgical treatmenL
Later, I had in the wards a case of visible peristalsis
with persistent vomiting and the surgeon said he
would operate if I told him to do so, but as the respon-
sibility was thrown on me and as I felt uncertain about
surgical measures, feeding was tried a little longer,
using, instead of weak mixtures, fairly strong ones,
which were retained. The baby gained rapidly and I
began to think that all any of the cases needed was
skilful feeding. I was further confirmed in this opin-
ion by this case (chart exhibited). The patient was
a girl, weighing seven pounds at birth. Projectile
vomiting developed, so that at the age of three months,
after being treated by one or two skillful pediatricians,
she weighed five pounds, fourteen ounces. The history
suggested pyloric stenosis but the occurrence of sev-
eral daily bowel-movements kept me from advocating
operation. The progress was very slow, with a gain
of an ounce or two every ten days, and at the end of
the first year the weight was fourteen pounds.
I was therefore sure that these cases could be treated
medically if fed properly, and then my pride had its
fall when, in 1915 I came across a well-marked case.
The patient was a healthy, breast-fed boy who gained
for two weeks and then began to vomit, going down to
five pounds, thirteen ounces in weight. I worked for
three weeks, trying many methods of feeding and also
giving belladonna. There was no improvement, so I
turned him over to Dr. Deaver, who did a posterior
gastro-enterostomy, and in six weeks the baby had
gained six pounds. I saw him two years ago and he
is a beautiful six-year old specimen. Such cases can
be cured only by operation. Complete obstruction can
never be cured by medical treatment; operation is
absolutely necessary.
To be fair to medical treatment I quote, not from
my own experience, but from the experiences of other
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PYLORIC STENOSIS— DISCUSSION
637
men and especially John Thomson (Osier Memorial
Volume), that "obstruction with nonsurgery may be
followed by recovery in perhaps 48 per cent of cases,
1/ they do not die in the meantime." The italics are
mine. Others claim a mortality ef only 30 per cent,
but against the 30 to 52 per cent mortality I would
place the mortality of 5 per cent in the twenty cases
I have had operated. When the diagnosis is . once
made and operation seems indicated but is deferred,
the longer the delay, the harder it will be for the pa-
tient, if one case is a suitable criterion. That patient
was a boy five months old when I first saw him and,
although it would seem that because of his age he
would stand the operation better than one of two or
three months, yet he had a much harder time than we
expected, giving us many anxious moments before re-
covery was assured. At the operation, done by Dr.
Deaver, the stomach was found to be greatly dilated
and the pylorus displaced to the right flank. So my
present feeling is that when the diagnosis of hyper-
trophic stenosis of the pylorus is established, an early
operation will improve the chances of recovery by
from 30 per cent to 45 per cent.
Dr. Edwin E. Graham ( Philadelphia) : The prob-
lem that confronts the pediatrician is diagnosis. You
may have persistent vomiting, you may have very
marked retention as shown by the x-ray, you may have
a tumor, you may have constipation and you may have
a peristaltic wave and yet under proper medical treat-
ment we know that children do well and make very
satisfactory progress. In other words, what Dr. Hand
said about seeing these cases before they get to Dr.
Deaver is what worries the pediatrician. After they
get to Dr. Deaver — then we do not worry.
In regard to statistics, it depends a good deal upon
whose statistics you take. You can find that there are
a great many men who report very good results from
medical treatment. The whole question is to say what
child has a sufficiently marked pyloric obstruction and
what child has not. I have gotten to the point where
the only question that decides me is as to whether
there is a gain or loss in weight, not any of the others
— vomiting, x-ray, tumor, constipation or peristaltic
waves (I have seen them all) — for the children often
get well under proper medical treatment. The trouble
ii that the pediatrician gets the cases late and he has
not got very much time in which to decide. The prob-
lem as it presents itself to me is to treat these children
medically if not too far gone; and the majority of the
cases of vomiting that come to me are not in a des-
perate condition. All pediatricians are coming more to
operation. The only question is what cases to refer
and what not. The question is decided not by any one
of these symptoms but by gain or loss in weight. I
treat the child medically and if it gains two or three
ounces a week, I let it alone, but after a period of
treatment, I cannot say just how long, if the weight
remains stationary or goes down, I refer it to the sur-
geon immediately.
The problem of the physician and the surgeon is
radically different. It is up to the pediatrician to make
the diagnosis.
Dr. Harry Lowenburg (Philadelphia): I want to
congratulate Dr. Deaver on his comprehensive paper
and to touch on a few things that he mentioned.
I want to ask Dr. Deaver whether he considers the
presence of a tumor positive indication for operation.
.A palpable tumor and visible peristalsis are no cri-
'terion to operate in my experience.
The problem of the diagnosis of pyloric obstruc-
tion is easy. The pediatrician's business is to diagnose
the difference between the surgical and the non-
surgical case. This is more difficult. All of the mor-
tality should not be credited or discredited to the
medical man, because not all of the surgical cases
recover even when operated upon early. Further the
doctor has to get the parents in a frame of mind about
surgery. This is not the easiest task in the world and
takes valuable time. The doctor must improve his
technique to distinguish between operation and non-
operation within a reasonable time and the surgeon
must improve his technique at operation. He must
remember that not all cases that have acidosis have it
by reason of starvation, but also from being under
ether too long. On the one hand the surgeon must
improve his technique and his speed and not talk too
much while operating and the pediatrician must im-
prove his ability to distinguish between operative and
non-operative caseif
The x-ray is absolutely not necessary to make the
diagnosis between an operative and a non-operative
case. You can make a diagnosis largely on the degree
of constipation, which is very important to my mind,
and also on the amount of milk in the feces. You
can be assisted greatly if you adtpinister 10 grains of
charcoal and watch for its appearance in the stool. If
the character of the weight curve resembles the crisis
of pneumonia the chances are for surgical treatment.
Observation for a week is sometimes necessary. If
the weight curve is like the fastigium of a typhoid
fever chart the probabilities are that the case is a non-
operative one.
I believe, therefore, we will get nowhere by incrim-
ination and recrimination. The surgeon puts it up to
the medical man entirely but the medical man must
study cases more closely to see if operation is needed
and if so then turn the child over to the surgeon. The
child should not be exposed too long to ether.
Dr. Edward L. Bauer (Philadelphia) : It strikes
me that the medical man as represented, by the pedia-
trist, and the surgeon, are not quite so much at odds
as one would be led to believe by the discussion this
afternoon. Really I think that aside from Dr. Lowen-
burg's hasty reference to the fluoroscopic examination
that Dr. Deaver emphasizes so well, fluoroscopy has
not been given its proper position of importance in
these cases. Both Dr. Lowenburg and Dr. Graham
want a week to see if the child gains or loses weight,
and the surgeon wants that week because the chance
of recovery following early operation is thereby
greatly enhanced. We must remember that the re-
sponsibility must rest upon the man who will present
a baby that has lost weight, because about four hours
time will tell whether it is safe to run the risk of
waiting that week. If in four hours time two-thirds
of the food does not pass through the pylorus one can
readily see what will happen in a week. If it does not
go through in four hours consult the surgeon for it is
'his equal right to pass judgment. This practice is cer-
tainly far safer, it seems to me, and should help to
bring the medical man and the surgeon on more nearly
common ground.
Let me emphasize. A child under my care presented
the symptoms of a marked pyloric obstruction. I im-
mediately took the case to the Drexel Home and had
it fluoroscoped. We found that two-thirds of its food
did go through in four hours. I then decided to wait
and see. With the use of strontium bromide and
atropine together with breast milk, the fluoroscope
showed the meal going through more readily. Weight
was stationary and general condition all that could be
desired. Later the child began to gain and the vomit-
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THE PENNSYLVANIA MEDICAL JOURNAL
June, 1921
ing to taper off, a complete recovery .without operation
being the result. Do not neglect the fluoroscope. True
one can look for food ingestion or charcoal in the
stools, but it is not quick or accurate.
Pyloric stenosis was treated medically with recover-
ies before surgery was attempted. Cautley's statistics
up to 1910 show a fifty per cent mortality. The ac-
curate medical statistics cannot show better now, un-
less their cases are selected per fluoroscope. Certainly
these figures are a great deal higher than Dr. Deaver's,
Dr. Downes' or Dr. Strauss' are, or would ever dare
to be.
Acidosis has been spoken of by Dr. Lowenburg,
who stated it was not always or altogether due to
starvation prior to operation. That may or may not be
true, but the likelihood of an acidosis following the
administration of from five to ten c.c. of ether is not
nearly so great a possibility as the^acidosis for which
we would be responsible following a week's procrasti-
n?tion. Bevan of Chicago recommends the use of
local anesthesia. I cannot endorse this. The child
cannot be controlled, evisceration is hard to prevent
during this procedure, and the post-anesthetic discom-
fort is trifling in theje infants.
Dr. Harry Lowcnburg (Philadelphia):
I do not advocate the use of the x-ray and think
it is wrong to say that the issue must be determined
by means of it. I am sorry that Dr. Bauer took me
li'.erally as I do not need a week in which to make the
diagnosis as to whether these cases are operable or not.
The first cases which the Deavers operated upon were
mine and probably the first surgical case which Dr.
Bauer saw operated upon at the Mary Drexel Home
was mine. I think I have sent more cases for opera-
tion to that institution than any single physician in
Philadelphia. You cannot draw absolute conclusions
from x-ray studies alone. I may truthfully say it
does not take me a week to diagnose the case nor do
I let these cases starve.
Dr. Deaver (in closing) : I grant you that the ad-
vanced cases of pyloric stenosis are easily diagnosed
and that fluoroscopic study is not essential. Fluoroscop-
ic study of the suspected cases is yery important and I
think will be the means of bringing these cases earlier
to the surgeon. Fourteen successive recoveries prove
my position, as these cases were operated early be-
fore marked emaciation and malnutrition occurred,
which is always present in the advanced cases. The
pyloric tumor could be felt in 60 per cent of the cases
reported. I do not rely on this, but persistent vomit-
ing, progressive loss of weight and fluoroscopic study
will make your diagnosis and by bringing these cases
to the surgeon early will make the mortality practically
nil.
SELECTIONS
MECHANICAL INFLUENCES IN
SCIATICA*
EBEN W. FISKE, A.M., M.D.
PITTSBURGH
Pain in the sciatic nerve, or so-called sciatica,
presents to the medical profession one of its most
difficult and unsatisfactory problems. From the
s'andpoint of chronicity and intensity, the pain
•Read before the Allegheny County Medical Society. Feb.
IS. 1921.
of sciatica may equal any known suffering, not
excepting tic douloureux. The diversified meth-
ods of combating this affliction give eloquent tes-
timony to the various conceptions of its origin,
from which the general inadequacy of its treat-
ment naturally results. Undoubtedly the chief
reason for this confusion lies in the usual meth-
ods of presenting the condition in medical teach-
ing. Sciatica is for the most part found in the
textbooks of general medicine and neurology,
where it is enshrined as a clinical entity. Little
is made of it in the works of surgery and the
sjiecialties, because its common occurrence as a
symptom of surgical disease has been largely
overlooked. As long as sciatic neuritis is con-
sidered a distinct disease, and so treated, just so
long will the underlying causes of this neuritis
be neglected, with obvious failure of relief.
It is safe to assume, however, that the second-
ary nature of sciatica is becoming more generally
recognized and that it is falling into its properly
related place in the various fields of medicine.
The now ancient argument between the theory
that sciatica is an intrinsic inflammation in the
course of the nerve, and the belief that it is a
secondary referred pain due to pressure at or
near the nerve origin, should not be the subject
of discussion. Unquestionably both do occur,
and the argument, if any, must lie either in their
ratio, or in terminology. "Sciatica" as com-
monly used does not differentiate between a neu-
ritis and a neuralgia, nor do the usual methods
of treating the affection recognize this difference.
That an essential neuritis may be caused by sys-
temic infection, toxemia, and constitutional dis-
ease does not seem open to doubt, although even
here it would appear that there must be a local-
izing factor to account for the selection of the
sciatic nerve, usually unilateral. On the other
hand, the causes of local pressure on the nerve
somewhere in its course would seem to be suffi-
ciently numerous to justify a very serious con-
sideration of the probable secondary involvement
of the sciatic in every case. Intrapelvic diseases,
neoplasms and displacements must often cause
sciatic pressure and pain, and hip disease, ab-
scesses of various origins, or even a dilated
colon, may do so.
The region of origin of the nerve, however, is
undoubtedly its most vulnerable point. The close
apposition of the lumbar and sacral roots, the
lumbosacral plexus and cord, to the bony and
ligamentous structures of the lower spine and
posterior pelvis cannot fail to invite a local dis-
turbance of these primary sciatic elements in the
various and numerous affections of this area.
Bone and joint changes due to infection, bony
malformations, mechanical displacements, and
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June, 1921
SELECTIONS
639
the inflammatory reactions of traumatisms and
strains, will press or stretch these nerves, or in-
volve them as a reflex from the close lying joint.
In twenty consecutive cases of sciatica, which
' came under my observation in the past year, not
one has failed to reveal an apparent primary
cause in the low back. The circumstances sur-
rounding the following case, the physical find-
ings, and the response to mechanical treatment,
may be taken as representative of the group.
Case I. Patient, G. H., aged 39, was admitted to the
West Penn Hospital, April 4, 1920. The chief com-
plaint was intense pain in the right thigh, posterior
surface, from buttock to knee, which had been present
for about 4 weeks.
He was the private case of another doctor and re-
mained on his service tmtil April 24. A diagnosis of,
right sciatica was made, and examination at that time
was recorded, briefly, as follows : Well developed, gen-
erally negative except for eczema in palms of hands,
scar of old fracture on right elbow, enlarged epitroch-
lear and axillary glands on both sides, tonsils atro-
phied, poor teeth, tenderness over right sciatic nerve.
The back was considered negative. Blood showed
5,020,000 reds, 6,800 whites, 85% polynuclears ; urine
normal except for Occasional white blood cells. Was-
sermann, gonococcus and tuberculosis complement
fixation tests and Widal were negative, and the von
Pirquet positive. The prostate and seminal vesicles
were negative. X-rays of the lumbar and sacral spine,
and right hip and teeth were reported negative.
On April 5 and again on April 9, injections of 2%
novocaine in normal salt solution were made into the
sacrum, with slight and temporary relief. Salicylates
and heat were given, but there was no material change
in the condition previous to April 24. At this time an-
other x-ray was taken, and a "decalcified area in the
upper portion of the sacrum, suggestive' of tubercu-
losis," was reported. For this reason the orthopedic
surgeon was asked to see the case.
The history which I obtained at this time, and the
examination, quickly excluded tuberculosis of the
sacrum. The short duration and the absence of any
inflammatory signs, or even deep tenderness, over the
body of the sacrum were later confirmed by a new
x-ray which showed normal bone. Many facts of
much greater significance were, however, revealed. A
few days previous to the onset of acute sciatica the
patient had slipped while going down stairs, and had
saved himself from falling by turning quickly to the
left and grasping the stair rail. Some discomfort in
the right buttock was felt at once, and this gradually
increased until he was obliged to go to bed four days
later. Moreover, five years previous he had had
sciatica following exposure, confining him to bed for
three days, the pain lasting five weeks, gradually
diminishing. Otherwise he had been very well, active
and strong and was a hard worker.
He was now suffering pain of considerable intensity
in the back of the right thigh and knee, and there had
been none elsewhere at any time. His greatest relief
was in lying with the right thigh acutely flexed. He
could stand and take a few steps, carrying his weight
on his left leg, although weight bearing on the right
did not increase his pain. He stood with a marked
list of the trunk to the left, with a total left scoliosis,
and a marked prominence of the lumbar spine pos-
teriorly and a forward stoop, holding the right thigh
flexed — this syndrome being the typical so-called "sci-
atic scoliosis." All motions of the spine were re-
stricted, with increased pain in the right sciatic, espe-
cially on bending to the right (homologous pain). He
lay in bed with the same left curve and could not lie
on his face at all because he could not extend his lum-
bar spine. Flexion of the straight leg and hyperex-
tension of the thighs all referred pain to the right
sciatic notch. There was very little tenderness to pres-
sure anywhere, except deep pressure to the right of
the fifth lumbar vertebra (right iliolumbar notch).
The lumbar spine was symmetrical, and the hip joints
negative, with no psoas contraction. The ri^t knee
jerk was absent and the right leg slightly atrophied.
The x-ray of the lumbar spine and sacroiliacs was
negative, and showed remarkably little evidence of the
marked curve and rotation of the patient's spine.
The diagnosis made at this time was mechanical de-
rangement of the lumbosacral spine, with secondary
sciatica and scoliosis. The heterologous list, and
homologous pain on bending, indicated a lesion of the
weight bearing structures in the right side of the low
spine, and this was further borne out by the deep ten-
derness at this point (the only tenderness present) and
the mechanism of the trauma, which was a quick twist
to the left with the sudden weight of the lower body
pulling downward. Such a mechanism would probably
produce a partial if not complete dislocation of the
right lumbosacral articulation. It did not remain dis-
located— few of them do — but the symptoms and sec-
ondary inflamation of acute sprain persisted, followed
by gradually increasing pressure on the adjacent lum-
bosacral cord, and producing the secondary muscle
spasm and deformity. On the basis of this diagnosis
a manipulation of the low spine was advised, and per-
formed on April 28. With the muscle thoroughly re-
laxed, a complete stretching of the muscles and liga-
ments of the lower spine and sacrum was produced by
forcible flexion of each extended leg on the pelvis, the
pelvis being similarly flexed and extended on the trunk
in the same manner. An attempt was also made by ro-
tation of the pelvis on the lumbar spine to reverse the
probable mechanism of the original trauma. The
lumbosacral and sacral region was then strapped very
tightly with adhesive, and a plaster of Paris shell
molded to the patient's back, as he lay on his face with
a pillow under the chest, so partially extending the
spine. The partly dried shell was then removed and
padded, put back on the patient, and he was turned
over on his back in the shell and bound in.
In the 24 hours following the manipulation, the pa-
tient had very little pain, all of this being in the lum-
bar spine. There was no pain in the leg, nor did any
symptoms of sciatica again appear. He was kept very
quiet in his shell for two weeks, at the end of which
a wide reinforced belt was fitted to him and the shell
replaced by a lumbar pillow. He was up and about
daily after May 10, and was discharged May 30, with
no deformity or pain. The patient returned to his
work one week later and the symptoms have never
recurred.
One other (Case 2) may be briefly cited as
typical of this class.
W. J. F., age 35, first seen on Aug. 13, 1920, was
suffering from pain in the left buttock and back of the
left thigh and leg. Three weeks before he had done
some heavy lifting, followed by sudden pain in the low
back, sfightly to the left. At first the pain was in the
back only, and he could straighten and do his work as
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THE PENNSYLVANIA MEDICAL JOURNAL
June, 1921
a railroad tower switchman. The pain increased,
however, attacked the leg, which became weak, and
for about two weeks he had noticed an increasing lat-
eral deformity of his spine. Two years before this
he had a short attack of pain in the back, of unknown
origin. Ten years previously he had had rheumatism
in his feet and legs, and damp weather had affected
him some since then. Otherwise his history was nega-
tive.
His general examination was negative. Locally, he
presented a typical sciatic scoliosis, with lumbar kypho-
sis, motions of the spine restricted, increasing pain at
the level of the lumbosacral joint on the left side, espe-
cially when attempting to bend to the right and back-
ward. He was slightly tender over the left sciatic
nerve, more so at the left iliolumbar notch and pos-
terior iliac spine, which was more prominent than the
right. His leg tests were positive for pain in the Same
regions, straight leg raising increasing his sciatica.
X-rays were negative, except for an apparent slipping
forward of the fifth lumbar body on the sacrum, or
spondylolisthesis, as seen on the lateral lumbosacral
exposure.
The diagnosis made was subacute lumbosacral liga-
mentous sprain, with possible subluxation, and second-
ary sciatic and scoliosis. On August i6 he was manipu-
lated and put at rest in the usual manner. There was
no pain following the manipulation, and five days later
he was allowed out of bed. On August 26 he was dis-
charged, wearing a lumbosacral belt, standing perfectly
straight and without symptoms. There has been no
recurrence, and he has returned to his heavy work.
Case 3 may be recounted briefly, as represent-
ing the class that have been benefited with me-
chanical fixation alone.
N. P., age 25, was examined on Dec. i, 1920. In
August, 1919, while on a transport, he had sudden pain
ill the lower back and right leg, later in the left leg,
where it has remained. There was no known cause
for the pain. The previous history was negative ex-
cept for chronic indigestion and constipation. He was
extremely nervous and worried and, though working
daily in an office, was suffering constantly from sci-
atica. Treatment by osteopaths and chiropractors had
given no relief. A plaster jacket had been advised at
one time but never had been applied.
Examination showed the typical syndrome — left sci-
atica, list of the spine to the right, restricted motions,
increasing the pain in the left sacroiliac and buttock,
especially when bending to that side. There was very
little tenderness. The right posterior iliac spine seemed
more prominent. Leg tests were positive in flexion on
the left. The x-ray showed only a slight list of the
fourth on the fifth lumbar body.
The diagnosis made was a chronic sacroiliac lesion,
left, with secondary sciatic scoliosis. He was fitted to
a wide reinforced belt, advised as to rest and baking of
his back, and referred to an internist for treatment of
the gastrointestinal disturbance. Five days after he
had received his belt, and before the internal treatment
began, he reported that his back felt almost well, and
his leg much better. On January s, one month after
starting treatment, he had no constant pain, but occa-
sional discomfort with the belt removed. Moreover,
he had not rested, but continued at very active work.
The histories and physical findings in these
three cases are typical of the group, and very
strikingly point to mechanical origins of sciatic
pain, relieved by mechanical means. In a com-
pilation of the 20 cases, the following facts are
brought out. The apparent causes are trauma in
60%, exposure or infection in 30%, in 10% un-
known. In addition to the sciatic nerve, pain is"
felt in the lumbosacral region in 55%, in the
sacroiliac in 65%. In only 10% was no pain felt
elsewhere. In 75% the pain was increased by
activity, and in 25% relieved by rest. Sixty-five
per cent showed list or scoliosis, of which 60%
were heterologous and 5% homologous. Simi-
larly, 90% gave increased pain on motion, 855*
in the low spine only, 5% in the sciatic nerve
only, 15% in both. Asymmetry of the posterior
iliac spines was observed in 25%. There was
tenderness in the lumbosacral spine in 45%, in
the sacroiliac region in 75%, in the sciatic in
50%. Leg tests increased the pain in 85%. An
infectious focus was considered likely in io*7r,
suspected in 25%. The x-ray showed a possible
bone anomaly in 15%, possible infectious in-
volvement in 15%, and possible lumbosacral or
sacroiliac displacement in 15%. There was a
postural tip of the lumbar spine in 35%, while
30% were definitely negative and 15% not re-
corded.
The diagnosis made was sciatica secondary to
sacroiliac sprain in 55%, to lumbosacral lesion in
25%, to musclar back strain with myositis in
15%, and to a possible infectious bone condition
in 10%. The treatment was manipulation fol-
lowed by fixation in 40%, fixation only in do'y:,
but not carried out as advised in 20%. Of the
manipulation cases, recovery occurred in 50*^,
satisfactory improvement in 25%, some improve-
ment in 25%, no improvement in 0%. Of the
fixation cases, recovery occurred in 175^. satis-
factory improvement in 33%, some improvement
in 0%, none in 8%, condition undetermined in
25%, treatment not carried out in 17%.
The theoretical explanation of these findings
is not far to seek. The pain and tenderness in
the back are symptoms of a local joint lesion, of
which the deformity of scoliosis and restricted,
painful motions on bending and leg tests are the
usual concomitants, as in any joint affection.
The absence of positive x-ray 'findings is quite
typical of this class of back conditions, and does
not rule out minor sacroiliac or lumbosacral lux-
ations, or the strains following transient displace-
ments, which are far more common.
The secondary involvement of the sciatic
nerve may be accounted for in several ways.
Probably in a majority of cases there is' a direct
pressure on portions of the lumbosacral plexus,
either from bone or infiltrated soft parts, the
latter also being the chief factor in pressing on
the lumbosacral cord as it crosses the face of the
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June. 1921
UNIVERSITY OF PITTSBURGH ALUMNI
641
sacroiliac joint. There may also be a reflex from
the affected joint, or from the small nerves in
apposition to the joint ligaments, and which have
been stretched or torn with these ligaments, or
in cases of persistent malposition. Furthermore,
the importance of secondary muscular spasm,
which accompanies all joint lesions, must be
considered as a factor in the maintenance of de-
formity and its secondary pain, including sciatica.
If, however, mechanical conditions in the low
back could not be proved as causes for sciatic
pain on the basis of such a pathology, surely the
practical proof of such causes can be found in
the response of these cases to mechanical treat-
ment. Fixation and rest are the fundamental
principles in joint disorders, whether infectious
or traumatic lesions. The relief of the sciatica
in the majority of these cases, by furnishing
proper support for the accompanying back con-
dition, points very definitely to the dependence
of the nerve pain on the joint inflammation, and
to their simultaneous recovery. More striking,
however, is the result of manipulation under
anesthesia. While we are still somewhat in the
dark as to the effect and results of manipulation
on the spine, it is certain that some definite
changes can be produced by this procedure. In
the first place, a very thorough stretching of the
relaxed muscles puts a sudden end to chronic
muscular spasm, with its secondary deformity
and pain. Secondly, minor displacement and
luxation, if they exist, are very often replaced,
or adhesions broken up, merely by a series of
free, forced movements unguarded by the mus-
cles. Thirdly, manipulation may be carried out
to produce definite reductions, when definite dis-
placements are suspected. Fourthly, the position
obtained is held by apparatus, usually plaster, be-
fore the patient recovers the use of his muscles,
which may be a deforming influence. Whatever
may happen, however, I have not yet failed to
see complete relief from the sciatica follow im-
mediately upon the manipulation of the back,
and in most cases, relief has continued.
In conclusion, I wish to emphasize again the
fact that sciatic neuralgia should not be consid-
ered or taught as a separate clinical entity, but
rather that sciatic pain is a symptom of many
conditions, some of which may be constitutional,
causing a primary neuritis, but more of which
are local, causing secondary pain through pres-
sure, and that a great number of these may be
located in the low back. It does not seem un-
reasonable in view of the findings in such cases
as the above, to advocate orthopedic examination
in all cases of sciatica, and orthopedic treatment
where such mechanical causes are found.
UNIVERSITY OF PITTSBURGH
MEDICAL ALUMNI
A reorganization meeting and smoker of the
Medical Alumni of the University of Pittsburgh
was held at the Americus Club, 211 Smithfield
Street, Pittsburgh, Pa., May 16, 1921. The
meeting was called to order at 9 : 30 p. m. by
Dr. R. J. Behan, temporary chairman, who
asked Dr. John W. Boyce to state the object of
this meeting. The speaker in his reply dis-
cussed the revival of the West Penn Alumni As-
sociation and of the West Penn Medical Club,
the combination of which forms the nucleus of
this new organization.
Dr. Edward B. Mayer was the next speaker.
His subject was the professional attainment
reached by the graduates of the university, and
his thought was that their record would compare
very favorably with that of other universities.
He urged the alumni to show a cordial interest
in the university in our own interest, as posterity
will recognize us only as a group and not as in-
dividuals.
The participation in the World War by the
graduates of the University of Pittsburgh was
taken up by Dr. John Hawkins, who gave the
number of men in the service from each class,
beginning with the first class to graduate from
the university. From 4 per cent to 90 per cent
of the different classes found their representa-
tives in the army and navy.
Dr. A. L. Lewin declared that this organiza-
tion should become a beloved benevolent power.
Dr. Edward A. Weiss, who was the next
speaker, called attention to the high standard of
the Medical School of the University of Pitts-
burgh.
The position of the present school was also
taken up by Dr. James McElroy and Dr. W. H.
Kirk, and the opinion was crystallized by Dr. J.
C. Vaux as to the advisability of reorganization,
which he recommended in a very eloquent man-
ner and moved the establishment of a temporary
organization, which was heartily accepted. Dr.
R. G. Burns was nominated as temporary chair-
man and a committee of nine was appointed to
help him arrange the details of the organization.
Large quantities of food and refreshments,
occasional strains of an extemporaneously or-
ganized band with the help of a broken-down
quartet, completed a perfect evening.
Lester HoivLander,
Reporter of Allegheny County Society.
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THE PENNSYLVANIA MEDICAL JOURNAL
June, 1921
HARRISBURG ACADEMY OF
MEDICINE
At the April meeting of the Harrisburg
Academy of Medicine Dr. William H. Mac-
Kinney, Professor of Urology in the University
of Pennsylvania Postgraduate School of Medi-
cine, gave a most interesting and instructive
illustrated lecture on "Hematuria and the Diag-
nosis of Tumors of the Bladder." In abstract
Dr. MacKinney said :
Hematuria is a most serious symptom and
should be investigated at once when reported by
the patient and the cause ascertained. As a help
in the diagnosis the analysis of other symptoms
should be considered, such as: i, pain — vesical,
renal or penile; 2, alterations in frequency of
urination — urgency, character of stream, inter-
ruption of stream, retention ; 3, absence of other
symptoms; 4, other urinary findings, such as
pus, tissue, casts and crystal formation. Men-
tion was made of how great numbers of calcium
oxalate crystals may cause hematuria. Absolute
diagnosis is made by: i, the cystoscope with the
examination of bladder or catheterization of
ureters; 2, functional tests of the kidneys; 3,
x-ray alone or combined.
TUMORS OF THE BLADDER
Types: i, primary; 2, secondary malignant
from the uterus, prostate, kidneys and intestines.
Histopathology types: I, papilloma; 2, papil-
locarcinoma ; 3, infiltrating carcinoma.
Diagnosis: made by cystoscopic appearance
and microscopic examination of tissue.
In an analysis of his 132 cases of tumor of the
bladder he found :
1. Average age, 54.2 years.
2. Youngest, 18 years.
3. Oldest, 72 years.
4. Males, 104.
5. Females, 28.
6. Occupation : all walks of life ; none of his
cases were dye workers.
7. Previous G. U. history:
( 1 ) Tumors elsewhere — 2 cases tumor of the
breast ; 4 cases renal calculi ; i case vesical cal-
culus ; 8 cases previous operation for tumor of
the bladder.
(2) Duration of symptoms before diagnosis
based on duration of hematuria :
a. less than i month — 2 cases;
• b. 3 months — 21 cases;
c. 6 months — 20 cases ;
d. 9 months — 12 cases;
e. I year — 22 cases;
f. 18 months — 8 cases;
g. 2 years and over — 38 cases ;
h. total — 132 cases.
i. Of these cases 30 were benign and 102
malignant, as based upon appearance
and microscopic examination in some
cases. The tumors were situated any-
where, but particularly around base
and neck of bladder and lateral walls
close to ureters. The size and multi-
plicity was various.
(a) Analysis of the benign cases — ^30 in num-
ber— all of which were successfully treated:
1. 20 cases cured by fulguration;
2. 10 cases cured by operation — ^no immediate
mortality ;
3. 10 cases have been observed from i to 7
years ;
4. 3 cases recurred after fulguration within 6
months to 2 years ;
5. 7 cases unobserved after apparent cure.
6. Operations in the benign cases, 10:
a. suprapubic cystotomy;
b. excision and use of cautery.
7. Results:
a. 2 well after i to 4 years ;
b. 7 recurred in 9 months to 9 years ;
c. I recurred in 22 years and became ma-
lignant.
(b) Analysis of the 102 malignant cases:
1. 26 were deemed inoperable by any method;
2. 32 cases deemed operable, but so far as he
knows nothing was done ;
3. 58 cases from which no conclusions have
been drawn ;
4. 44 cases were treated with the following
deductions :
a. 22 cases were treated by cystoscopic ful-
guration, x-ray and radium ;
b. 22 cases were treated by operation of
some kind, combined with other treat-
ments ;
c. of the 22 cases fulgurated, 18 cases were
treated unsuccessfully and 2 cases suc-
cessfully ;
d. two cases were fulgurated and treated
also with x-ray or radium (one died 4
months later and the other lived and
was an invalid for 5 years) ; of the 18
cases, most have died and some he has
lost track of. The treatments were in
most cases unbearable.
(c) Of the 22 malignant cases operated upon
1. 7 were by the suprapubic method for relief ;
2. 6 were with the suprapubic method and use
of cautery ;
3. 4 were with excision of malignant portion ;
4. S were with fulguration, radium and deep
penetration x-ray.
5. Of those operated upon for relief, all died ;
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June, 1921
ABSTRACTS FROM STATE JOURNALS
643
several had retention and the tumor and clots
demanded relief.
6. Of the 6 cases where the suprapubic method
and cautery were used
a. 2 cases are well at the end of 2 years ;
b. 4 cases recurred within 6 months (of
these 2 died at 9 and 14 months, re-
spectively; the other 2 were lost track
of).
7. Of the 4 cases with the suprapubic method
and excision
a. I died after operation at the end of 3
weeks;
b. I is cured at the end of 4 years ;
c. 2 recurred — i in one year and i in four
years.
8. In the suprapubic method with fulguration
(d'Arsonal and radium needles with subsequent
x-ray)
a. 5 cases are most too recent to speak of
and
b. all are under present observation ;
c. I died in 6 months ;
d. I is living and well at end of 8 months ;
e. 2 are living with carcinoma;
f. I is living with lesion in bladder and
there is doubt as to whether he is
actually cured.
In closing Dr. MacKinriey emphasized the se-
riousness of hematuria, and stated that :
1. The presumptive diagnosis is made only on
the basis of symptoms; positive diagnosis by
cystoscope-uretral catheters, x-ray and func-
tional kidney tests.
2. Symptomless hematuria is a cardinal symp-
tom of tumor.
3. Other symptoms are secondary, depending
on size, location, complications, etc.
4. Estimating from hematuria alone, the cases
remained undiagnosed very much longer than
they should have been.
5. The cases that are early benign and amena-
ble to treatment, often become malignant later,
and they are all potentially malignant.
6. In the benign cases cystoscopic fulguration
is the method of choice.
7. In the malignant ca.ses excision, when pos-
sible, is the best means of treatment ; when im-
possible open fulguration — radium needles and
after treatment with deep penetration x-ray — is
desirable.
8. Finally — all cases should receive periodic
cystoscopic examination and the more ideal the
result the more this should be insisted upon.
Frank F. D. Reckord, M.D., Reporter.
ABSTRACTS FROM STATE MEDICAL
JOURNALS
FRANK F. D. RECKORD, M.D.
Assistant Editor
THE FAR-REACHING EFFECTS OF RECTAL
DISEASES UPON THE GENERAL HEALTH
By Atwater L. Douglass, M.D.
Denver.
The common diseases affecting the rectum are hem-
orrhoids, fissure, fistula, papillitis, cryptitis, fibroid
growths and proctitis. Any of these diseases except
possible fistual may go on for years without any great
amount of distress as long as the pathological process
remains above Hilton's white line.
It is only when the disease reaches below this line
that the patients are aware, through subjective symp-
toms, that they have any rectal trouble, and for that
reason they neglect to mention the rectum when con-
sulting their physician, thus allowing a possible sim-
ple condition to develop into a cancer, stricture or some
other serious disease. In the meantime, while these
conditions are developing, the patient will be taking
treatment for constipation, headaches, spinal trouble,
rheumatism or some other group of symptoms without
relief, when a thorough examination of the rectum
and anus would reveal to the attending physician the
underlying cause.
Under the control of the sympathetic nerves, the
human body has one of the most perfect automatic
mechanisms functioning at the outlet of the bowel
that can be found in any part of our makeup. When
these nerves are broken or disturbed in any way, the
whole wormlike action of the colon ceases, thus al-
lowing accumulations to take place, affecting different
parts of the body through absorption of toxins. Tak-
ing laxatives does not remedy the trouble, for they
simply irritate the glands of the intestinal canal and
bring out more liquid which flushes out the new ma-
terial while the old materials remain in the colon un-
dergoing absorption and poisoning the whole system.
The sigmoid corresponds to a trap under a sink,
with this exception, however, that when the sigmoid
becomes filled it will automatically empty itself into
the rectum, and this is when we have our first warning
that there is something to be evacuated.
Should we fail to answer this call immediately, the
nerves at the outlet become accustomed to having the
substance there and they will not perform their func-
tion properly, then constipation with all of its far-
reaching results is started.
The disarrangement of this beautiful automatic ac-
tion brings about a general stasis of the whole colon,
and more or less accumulation of waste material re-
rrains permanently in the rectum, sigmoid, transverse
colon and cecum.
Keeping this in mind, one can readily see how rectal
diseases may be responsible for at least fifty per cent,
of the cases of acute or chronic appendicitis. It takes
but very little to upset the nerves of the rectum, and
many times a very little or slight operation will remedy
the condition before much damage is done.
If we had the same supply of so-called pain nerves
above Hilton's line that we have below there would
rot be enough men engaged in rectal work to supply
the demand, for then the subjective symptoms would
cause the victim to seek relief at once. Unfortunately
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THE PENNSYLVANIA MEDICAL JOURNAL
June. 1921
this is not the case, and unless there is severe pain the
tendency is to neglect to submit to a rectal examina-
tion, and to go on year after year receiving treatment
for the symptoms developed in other parts of the body
through reflex nerve action and absorption of toxins.
Any little growth just within the rectum, such as an
elongated papilla, small ulceration near the crypts, a
small fissure or a foreign body will develop some of
the most distressing symptoms in other parts of the
body, such as headaches, bladder irritation, rheumatic
pains in the back and lower limbs, due to the resultant
disturbance of the sympathetic nerves and absorption
of toxins.
Many of the former horrors of rectal operation have
been eliminated, and the public should be taught not.
only the importance of a rectal examination, but that
the work does not necessarily mean a serious opera-
tion. There are very few cases that need to be con-
fined to a hospital or the home.
If the physician in general practice will form the
habit of examining the rectum in his obscure cases he
will not only bring about the relief from much suffer-
ing, but will enhance his own reputation as a diag-
nostician and gain more success. — From the Journal of
the Colorado Slate Medical Society.
THE DIAGNOSIS OF CHRONIC MYOCARDITIS
By Frank N. Wilson, M.D.
St. Louis
SUMMARY
Six cases are presented, three of which were proven
at' necropsy to be coronary thrombosis.
The first case was one of angina major, such as the
case of "Thomas Arnold," with death with the first
breast pang. The second patient survived the attack
but died of rupture of the degenerated necrotic ven-
tricular wall, which had resulted from the infarction
that followed the thrombosis. Electrocardiograms
gave suggestive evidence of grave myocarditis.
Of the other four cases, the last one was proven to
be coronary thrombosis at necropsy while the other
three are highly probable cases. All had acute severe
ai!ginal attacks and presented high pulse rates, from
170 to 250 per minute, and characteristic electrocardio-
graphic findings (paroxysmal ventricular tachycardia),
which heretofore have been shown to be associated
experimentally only. One case is still living two years
after the attack. One died six months after the at-
tack. One died six weeks after a sudden onset, with
a persistent status anginosus without relief until death.
• The last one died twenty-six hours after the onset
of a terrific anginal attack. He had two long parox-
ysms of ventricular tachycardia. Necropsy showed
thrombosis of the descending branch of the left coro-
nary artery. This is the first clinical case on record
substantiating Lewis' experimental facts. The other
cases were similar in every way except that they were
not checked up postmortem. The pulse rates ranged
from 170 to 250.
Electrocardiograms are of considerable value in
these cases, and they have thus called attention and
fully explained a very important diagnostic sign, that
of tachycardia of from 150 to 250 occurring in parox-
ysms in cases with clinical symptoms of very severe
angina, in which there is any question of coronary
thrombosis.
Syphilis was the prominent etiologic factor in his
series. Only one case had a positive Wassermann.
Three at necropsy showed positive histologic evidence
of syphilis. Three gave definite histories of "hard
chancres." Four gave suggestively positive marital
histories. — From the Journal of the Missouri State
Medical Association, October, 1920.
ARTHROPLASTY— A SAFE, SANE AND
PRACTICAL SURGICAL PROCEDURE
By Georgb H. Sexsmith, M.D., F.A.C.S.
Bayonne, N. J.
SUMMARY
1. That the arthroplastic operation on either the
large or small joints is practical and safe.
2. That it pves us g^eat relief from disability, if
not greater than does the restoring of bone shafts in
ununited fractures, and requires practically no greater
skill.
3. The pedacled autogenous flap for interposition
between bone ends in reproduced joints is superior to
all other substances.
4. In the knee, special attention to reforming of bone
ends, having in mind the possible tendency to lateral
displacement.
5. The essential points in the successful arthroplastic
operation are: First, free incision of soft parts with
complete displacement of bone ends; making possible
and easy reforming steps in the reproduction of ar-
ticulating surfaces; second, leaving ample space be-
tween reformed bone ends which is most essential:
third, sufficiently large and thick pedacled flaps to in-
sure complete covering of all denuded bone surfaces,
with, in the large joint, some form of traction to con-
trol contraction of muscles, etc., about the joint. —
From the Journal of the- Medical Society of Xew Jer-
sey, Orange, New Jersey, October, 1920. '
A MAN IS AS GOOD AS HIS FEET
By AtPHONSE H. Meyer, M.D.
Associate Professor of Orthopedic Surgery, Universitj of
Tennessee, College of Medicine, Memphis
He urges upon the physician to pay more attention
to the foot, and if a weak one is observed to insist
upon its being treated while the condition is in its
incipiency, thus helping to conserve the physical effi-
ciency of the individual, thereby adding to the strength
of our country.
He believes a foot campaign should be nationally in-
stituted, and carried through the public schools of our
country and various other channels, and thus attempt
to spread the doctrine of "a man is as good as his
feet." — From the Journal of the Tennessee State Med-
ical Association, Nashville, Tenn., November, 1920.'
COMMUNICATIONS
Dear Editor:
I would thank you to print the following article in
the Pennsylvania Medical Journal:
MASSAGE AND THE CHIRO^QUACKS
It is now a good many years since "Mechano-
therapy" was introduced in this country in one form
or another. I cannot tell just how long it has been
with us ; but certainly it was extant when I gradu-
ated in the year 1877, though some modifications have
been devised since then. The whole thing, in its es-
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June, 1921
COMMUNICATIONS
645
sence, centers around the subject of massage; and
far be it from me to decry or discourage massage in
its proper realm.
VVhen called by its proper name, used in properly
selected cases and applied with skill and discretion, it
is one of the most potent forms of treatment that
medical science has yet produced. However, it is only
one of many important branches of treatment, and as
such should always be kept in its proper place. It
should be the physician's servant; not his master. It
falls in much the same rank as electrotherapy, and is
inferior to rest in the treatment of disease. Unques-
tionably all three of these elementary factors should
be united in the treatment of certain troubles, such as
neurasthenia, as was abundantly demonstrated by Dr.
S. Weir Mitchell and others.
It has been my fortune to be manipulated by one
Irishman, one Englishman and three Swedes; also to
train in an excellent masseur while I was .a patient for
seven months in a hospital for nervous diseases in
Philadelphia. I can truly say that massage and the
actual cautery were the most effective parts of treat-
ment in my case. I have seen massage and rest bring
through a case of diptheritic paralysis in the case of
a youth of sixteen years. He was so completely par-
alyzed that he could barely roll his head from side to
side; yet several months later he had entirely recov-
ered. In a case where another doctor and I were
unable to get results from the use of internal medica-
tion, because the woman's circulation was so defective,
we had a Swedish masseuse sent out to her three or
four times, and from that time on the patient re-
sponded to treatment quite nicely.
As I understand it, manipulation of the back, intelli-
gently executed, does two things, apart from its in-
fluence upon the muscles of the back. It relieves
sluggish congestion of the spinal cord, and it stimu-
lates the great sympathetic nerve system; and this
latter controls the general circulation to a very ap-
preciable extent.
Nearly every good thing has its counterpart and it
is eminently so in this instance. Massage was badly
neglected by the medical profession for at least a score
of years, and the average practitioner of medicine
learned far too little about it. Those who did succeed
in gaining some understandings of its value did not
always apply it in the most judicious manner. For
instance, a physician who formerly practiced here but
is now deceased, used to simply turn over his pa-
tients that needed massage to a Swedish masseur who
was located here at the time. The result was disas-
trous, for the masseur quickly got a severe attack of
the swelled head and imagined that he was "the whole
show." If the physician had held the management of
the cases in his own hands and seen them once a
week, it would have been far better for all parties
concerned.
When massage was not given its proper place, it
was natural that one-sided individuals should make a
tool of it and call their vitiated reproduction of it by a
new name. This perverted mongrel received the er-
roneous and unfortunate name of Osteopathy, and a
generation of rubber-doctors quickly sprang up; yes,
and flourished like the green bay tree. "Try osteop-
athy" became the phrase that was passed along from
one patient to another.
To my regret, I found that a number of- reputable
general practitioners were looking upon it as a sort of
specialty in medicine, which it distinctly is not. It
might have its sphere of usefulness if honestly con-
ducted; but it is not. As now conducted it is sub-
ject to at least two gra\e dangers. The first is that it
aims to include the treatment of acute diseases, and
may thereby readily delay matters until the disease has
gQtten beyond all human aid. The second is that it
pretends to be a system of medicine, supplanting all
internal medication, and as such, is teaching its patrons
false doctrines and systematically estranging them
from the broad principles of medicine. At its best, it
is simply massage run mad. Furthermore, wherever
you see a so-called osteopathist, there you find a prop-
agandist against the legitimate practice of medicine,
and one who is manufacturing patient propagandists at
as rapid a pace as possible.
After the osteopathists had established themselves
rather firmly, another set of mountebanks sprang up
to build upon their foundation — a foundation mostly
of fraud. These people saw an unusually easy oppor-
tunity for quackery, and were not slow to seize it.
The osteopaths had spent much time and patience in
inoculating the idea among the uninitiated that every
subject coming to them had a dislocated vertebra. The
new generation of pretenders, who call themselves
"chiropractors," but whom I call by a more appro-
priate name — "Chiro-quacks," go one better than the
people from whom they took their cue, and can al-
ways find two dislocated vertebra to one subject.
Hence, their principal discussion is about "adjust-
ments." They are springing up at about the rate of
mushrooms around a manure pile. Soon the plain old-
fashioned quack may find himself at a discount. Al-
ready the daily newspapers disclose a lively competi-
tion between the bunch of chiro-quacks and the so-
called osteopaths.
The latest thing heard from is another division,
calling themselves "Neuropaths," and they are so very
new that I am quite unable to assign to them any
distinguishing characteristics. Doubtless others will
follow for tnese are the days of "strong delusions."
G. Edgar Dean, M.D.
Scranton, Pa., April z8, jg2j.
THE ^SCULAPIAN CLUB OF PHILADELPHIA
To the Editor:
As an item of general interest I respectfully submit
the following:
The new clubhouse recently acquired by the Msax-
lapian Club of Philadelphia was opened for inspection
to several hundred physicians on Thursday, April 28,
1921. The members of this unique medical club are
very proud of their new home and have gone to great
trouble and expense to make it comport with the dig-
nity of the profession and at the same time to fill all
the needs of an organization intended to promote
sociability and general good fellowship.
The iEsculapian Club is rapidly forging to the front
as an influence for the betterment of the medical men
of the local community. It is preeminently a friendly
society and those who were invited to inspect the
beautiful colonial house, were unanimous in their ap-
proval of its appointments and arrangements as well
as impressed by its capacity, location and ability to
meet all the requirements of an amusement centre,
dining club and place of general assembly for musical
and other entertainments.
Membership in this club is limited to male, white
physicians practicing and residing in Philadelphia
County, with an associate membership practicing in
Philadelphia but residing in other counties.
The influence of this club has been radiated into the
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646
THE PENNSYLVANIA MEDICAL JOURNAL
June, 1921
strictly scientific medical organizations in the city as
is manifested by the enlarged attendance and greater
cordiality of the members. A great future is pre-
dicted for the ^sculapian Club.
Respectfully yours,
Edwin S. Cooke, M.D.,
Club Historian.
By request of the President,
Milton Frazier Percival, M.D.,
April 2<), igii.
FUTILITY OF ATTEMPTS TO CONVINCE AN
ANTIVIVISECTIONIST
The classical allusion to a maximum disturbance is
"a bulk in a china shop." However if we are to believe
the report which recently appeared in the Washington,
D. C, Evening Star, an even greater disturbance may
occur when a lover of animals speaks to a meeting of
antivivisectionists. Perturbed language marked the
meeting of the National Society for Humane Regula-
tion of Vivisection when its members were addressed
by Ernest Thompson Seton. Mr. Seton, it is reported,
had the audacity to say to these antivivisectionists that
the rights of human beings when they clashed with the
rights of animals should be paramount. Then he
added insult to injury by remarking that tie noticed
furs being worn by many of those of his audience, and
that animals had suffered from two to three days'
agonies in traps in all probability to provide those furs.
At the conclusion of the address, one of the woman
antivivisectionists asked the speaker if he believed that
animals should be put through the agonies of so-called
scientific vivisection in order to allow experimentation
of theories. Mr. Seton replied that if his child was
threatened with blindness and could be saved only by
the killing of an animal, he was in favon of the vivi-
section of one animal or loo animals to make it possi-
ble. The woman declared that she would go blind or
lame or ill rather than cause lOO animals the agonies
or suffering of vivisection. Then Mr. Seton countered
with the direct question, "Has the speaker a child?"
and' the lady admitted that she had not. With the
usual cool and calm logic of an antivivisectionist, she
remarked that she had a widowed sister who had a
child, and that this child, at the age of five years, on
hearing of vivisection had stated that it was "the
devil's own work." Mr. Seton inferred that it was his
belief that the words had been put into the child's
mouth. It was obviously a precocious little prig. Mr.
Seton wasted his time trying to convince an antivivi-
sectionist. It can't be done. Logic has no appeal
where unadulterated sentiment predominates. — Jour.
A. M. A., Feb. s, 1921.
largely, perhaps, owing to the slower development of
the evils of urbanization. The filth theory of disease
was that decomposition and fermentation of animal
and vegetable matter gave rise to poisonous gases, or,
as some thought, to living germs, which are carried by
the air and, falling on human beings, caused in them
the epidemic diseases. Hence, the principal aims of
early promoters of public health were clean streets
and yards, clean houses, removal of all "nuisances,"
the prevention of crowding, both of houses on the
land and of people in the houses, better house con-
struction, the building of sewers, the construction of
water closets or yard privies, and the provision of un-
polluted water. Good results attended these efforts.
Chapin reviews the progress made in preventive medi-
cine in the United States. He states that the bulk of
the medical profession still looks askance at the in-
vasion of the field of curative medicine by the state,
and the leaders and molders of public opinion do not
take kindly to medicine's becoming more of a govern-
mental function. Nevertheless, he says, it seems un-
likely that the movement is going to be checked and
it is a tremendous responsibility for those to whom is
given the opportunity to direct the movement aright
It is perhaps best that progress should be slow and
that we should feel our way. It is perhaps also good
that attention seems to be chiefly directed at present
to improving the clinic or dispensarj' and making it
available for all of the poorer portion of our popula-
tion. There is much to be done right there. To the
writers of press articles and to the compilers of health
al-ranacs, Chapin would say: "When facts are not at
hand, have the courage to say nothing. Let us beware
of the compulsory treatment of disease. That is an-
other rock on which the future of preventive medicine
may be wrecked. Education is better than legislation.
It is slower, but surer."
EVOLUTION OF PREVENTIVE MEDICINE
It has been less than a century, Charles V. Chapin,
Providence, R. I. (Journal A. M. A., Jan. 22, 1921),
says, that a permanent government organization for
health purposes has been maintained. There have
been three fairly well defined phases of this move-
ment. The first concerned itself chiefly with the en-
vironment, the second with the isolation of the sick,
and the third with personal instruction and with cure.
The modern health movement had its origin in Eng-
land nearly a hundred years ago. Interest in public
health developed more slowly in the United States,
Pennsylvania Stats DbpaktmBnt of Hiai,TH^-
The attitude of the department of health concerning
the illegal practitioner of medicine, is that which it
should take regarding the protection of the health of
the various communities — to wit that a man without
a sound fundamental medical education should not be
entrusted with the grave responsibility of life: that
when he takes this responsibility upon himself, disre-
garding the written laws of the commonwealth, it is
the function of the department, in conjunction with
the Board of Medical Education and Licensure, to see
that the community is protected, by enforcing the law.
This we have done and will do.
In its action the department wishes to be guided and
directed by the county medical societies, the members
of which know best the local conditions and are best
fitted to give information for the good of the public
A complaint having been entered, the department of
health will take it up.
The method of procedure is as follows :
A statement of facts must be made and sworn to.
These facts include : i. That the person accused has
no license : 2. That he has been practicing medicine or
is holding himself out to the public as a general prac-
titioner. This statement is sent to the department of
Health, after which they will take the necessary action.
The complainant, or those whom he represents, should
have witnesses who are willing to testify to these facts.
The penalty on conviction is a fine up to $1,000 or im-
prisonment up to one year, either or both.
The only difficulty in ridding a community of this
dangerous element, is incident to the apathy of those
who are most largely concerned.
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ELEVENTH CONFERENCE OF INDUSTRIAL PHYSICIANS AND SURGEONS
HELD UNDER THE DIRECTION OF THE DEPARTMENT OF LABOR AND IN-
DUSTRY OF THE COMMONWEALTH OF PENNSYLVANIA
BELLEVUE-STRATFORD HOTEL. PHILADELPHIA, DECEMBER 17, 1920
(Continued from the May issue of the Penn-
sylvania Medical Journal.)
THE REHABILITATION OF THE IN-
DUSTRIAL CRIPPLE
S. S. RIDDLE
Chief, Bureau of Rehabilitation, Pennsylvania Department of
Labor and Industry
HARRISBUItG
It is always a privilege and a pleasure to be
permitted to present before a session of indus-
trial physicians a review of the work that the
Bureau of Rehabilitation is attempting to per-
form in rendering physically handicc^ped per-
sons fit to engage in remunerative occupations.
Rehabilitation is, of course, an old story to the
members of the medical profession as physical
rehabilitation has been practiced with wonderful
results by your profession through the ages.
The work of the Bureau of Rehabilitation of
the Pennsylvania Department of Labor and In-
dustry has been organized, however, to begin
work where your work in a measure is termi-
nated. In other words, the Bureau of Rehabili-
tation takes the disabled worker after medical
and surgical skill have restored such worker to
his highest physical efficiency and endeavors to
adjust such worker to suitable employment, either
by training or immediate placement. Of course
contact of such handicapped workers with rep-
resentatives of the medical profession may fre-
quently be reestablished, even after such worker
is placed in employment or training, but action in
such cases when taken by the Bureau of Rehabil-
itation is by cooperation with the worker's per-
sonal physician, industrial physician of the plant
in which the worker was injured, physicians of
the Department of Labor and Industry or in
other state service. The Bureau of Rehabilita-
tion has had excellent cooperation from repre-
sentatives of the medical profession. The bureau
is empowered by its act to arrange for thera-
peutic treatment for physically handicapped per-
sons, but it may not use its funds to pay for such
treatment. Such treatment may be provided in
state-aided hospitals.
Pennsylvania as a commonwealth, through its
Department of Labor and Industry, has been
studying the problem of rehabilitation since No-,
vember, 1917, when the disabled from war di-
rected attention to the necessity for a rehabilita-
tion project.
Pennsylvania at that time began making plans
for rehabilitation of its war wounded, but the
passage of the Federal act for the vocational re-
habilitation of disabled soldiers, sailors and ma-
rines by congress made that great work a na-
tional activity.
Governor William C. Sproul sponsored the
Pennsylvania Rehabilitation Act of 1919 which
placed Pennsylvania in the vanguard of the
states in the humanitarian and economic project
of rehabilitating disabled industrial workers. A
Bureau of Rehabilitation was created in the De-
partment of Labor and Industry, with an appro-
priation of $100,000. That appropriation was to
pay administrativft costs of the bureau and from
that amount, direct payments could be made for
the benefit of disabled persons in two ways ; arti-
ficial appliances could be provided for physically
handicapped persons unable to purchase such ap-
pliances and, maintenance costs not in excess of
$15 per week could be provided physically handi-
capped persons during a period of training.
Since the state of Pennsylvania has invested
$100,000 in an industrial rehabilitation project,
it is proper to inquire whether such rehabilitation
project is a soynd economic investment. Statis-
tics show that each industrial employee in Penn-
sylvania produced on an average approximately
$5,000 worth of material wealth in 1919. Of
course, that is a general average. But on an ex-
tremely conservative estimate, if 500 handi-
capped persons aided by the Bureau of Rehabili-
tation, during its first year of operation, produce
during the remainder of their lives only $1,000
more of material wealth for the commonwealth
than they would have done had they not come
to the attention of the bureau, that additional
future wealth for the commonwealth may be
considered as approximately $500,000.
Such estimated return is on the $100,000 ap-
propriation to the Bureau of Rehabilitation made
by the Pennsylvania Legislature in 1919 in order
to start the rehabilitation work as a state project.
Rehabilitation has its economic as well as its
humanitarian phases. The problem is one of hu-
man engineering.
When the Bureau of Rehabilitation began its
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THE PENNSYLVANIA MEDICAL JOURNAL
June, 1921
active field work in January, 1920, it was con-
fronted with the problem of making the benefits
of the Rehabilitation Act available to physically
handicapped persons, as defined in the act, wher-
ever located throughout the more than 45,000
square miles of area of Pennsylvania.
To be successful, the bureau should function
in an isolated mining community, with a very
limited number of industries and occupations, as
well as in the heart of a great city where wide
variety of industries, occupations and facilities
for training provide a vast laboratory for ex-
periment and accomplishment of results.
The Bureau of Rehabilitation, to fulfill its pur-
poses should be of genuine service to all types of
industrial accident victims, coming under the defi-
nition of a physically handicapped person in the
act. The bureau should be of benefit to the illit-
erate foreigner, head of a family, and who, at
50 years, loses an arm or a leg or is otherwise
disabled and unwilling to move from the com-
munity where he was injured, as well as to the
bright young man or woman under twenty-one
who, although physically disabled, may have a
good basic education with capacity for mental
development and for whom a type of training
for a suitable task is not difficult to determine.
The bureau, under the act, is to aid in the re-
habilitation of "any resident or residents of the
commonwealth of Pennsylvania whose capacity
to earn a living is in any way destroyed or im-
paired through industrial accident occurring in
the commonwealth."
Rehabilitation is not to be construed to apply
to "aged or helpless persons requiring permanent
custodial care, or to any epileptic or feeble-
minded person, or to any person. who may not
be susceptible to such rehabilitation."
The Bureau of Rehabilitation, as an agency of
the commonwealth, has been organized to func-
tion, in every community of the state, by the es-
tablishment of branch offices, with traveling ad-
justers, at centers of high industrial accident
hazard. The central office of the bureau is at
Harrisburg, with branch offices at Philadelphia,
Pittsburgh, Wilkes-Barre, Pottsville, Altoona
and DuBois.
The development of the rehabilitation service
on a state-wide basis in Pennsylvania has been
gradual and, in part, experimental. When Penn-
sylvania started its rehabilitation work, there
were no records available of experience in other
states administering rehabilitation service on a
state-wide basis.
The Pennsylvania Bureau of Rehabilitation
developed its organization, as numbers of con-
tacts with disabled persons increased throughout
the state, rendering such development necessary.
Injuries sustained by workers in industrial
plants in Pennsylvania are reported daily to the
Bureau of Workmen's Compensation of the De-
partment of Labor and Industry. Information
from such reports is transmitted from the Bu-
reau of Workmen's Compensation to the Bu-
reau of Rehabilitation, giving a dally state-wide
survey of the persons the bureau should aid.
Publicity by cooperation of newspapers, public
addresses, circular letters and other means, es-
tablished contacts for the Bureau of Rehabilita-
tion with disabled persons. Cooperation of the
State Grange was obtained in disseminating in-
formation regarding the Rehabilitation Act
among the farmers of the commonwealth.
Every disabled person reported to the Bureau
of Rehabilitation at Harrisburg receives a circu-
lar letter, explaining the purposes of the Reha-
bilitation Bureau, also a copy of the act and a
questionnaire or registration blank to be returned
to the Bureau of Rehabilitation, in an addressed
envelope enclosed with the letter and question-
naire. Such questionnaire, properly filled out
and returned to the bureau, gives preliminary
information regarding the name, age and race
of the registrant. It also gives nature of injury,
knowledge of languages, industrial history, edu-
cational history, earning power before the acci-
dent and after, if employed, and indicates pref-
erences of the registrant for future occupation.
A duplicate of each questionnaire received at the
central office of the bureau is sent to the nearest
branch office in order that an adjuster may visit
the registered physicially handicapped person to
m£ike a generaJ survey of the social, economic,
educational and industrial conditions affecting
the accident victim.
The procedure of sending the questionnaire
by mail to disabled persons reported from all
.sections of the state has been shown to save time
and money and to be of great assistance to the
adjusters in the field. By sending such ques-
tionnaire to the disabled person, the bureau
eliminates the necessity of adjusters traveling to
make first contacts, with disabled persons in
isolated communities merely for the purpose of
obtaining preliminary information. The pro-
cedure of sending questionnaires is no longer
experimental. It works. Even foreigners and
illiterates carry the questionnaires to persons
who can read English with the result that such
persons consulted, enter the necessary replies
and return the forms to the bureau. It may be
explained that the state coat of arms is conspicu-
ously placed on the questionnaire which gives
the necessary official appearance to the docu-
ment, to send the foreigner to an interpreter and
the illiterate to an educated friend.
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CONFERENCE OF INDUSTRIAL PHYSICIANS
649
The adjuster of the bureau cooperates with all
possible agencies toward the end that the dis-
abled person may be reentered in suitable re-
munerative employment, either at once or after
proper training. Existing facilities adjacent to
the registrant's home are used when training is
necessary.
Experience of the bureau has shown that no
definite course of procedure can be laid down to
cover, in a universal way, any specific group of
physically handicapped persons. Every existing
facility is used in training and placement work.
The bureau has not, up to this time, found it
necessary or logical to attempt or recommen,d the
establishment of any centr^ized institution for
the exclusive training of the physically handi-
capped in industry. The ultimate aim of rehabil-
itation service is to get a disabled person into a
task which he or she can perform as well as a
jierson not physically handicapped. Therefore,
there should not be segregation of disabled per-
sons, excepting, perhaps in group employment
for the blind or in group sitting tasks for legless
persons. Some of the factors encountered by
the Bureau of Rehabilitation among its regis-
tered handicapped persons, to prevent in all
cases the application of vocational training, as
generally interpreted, are:
1. Age of handicapped person.
2. Lack of elementary education, lack of
mental development, illiteracy.
3. Domestic responsibilities with attendant
economic pressure.
4. Unwillingness of handicapped persons to
leave the localities in which they were employed
when injured.
Rehabilitation being defined as "the rendering
of a physically handicapped person fit to engage
in a remunerative occupation," the Bureau of
Rehabilitation decided that a great deal of its
work should center about the word "fit."
A worker who has been seriously injured and
permanently disabled by industrial accident has
usually more than his mere physical disability to
worry about. Therefore, the Bureau of Rehabil-
itation decided that if a physically handicapped
person is to be rendered fit to engage in a re-
munerative occupation that the rehabilitation ef-
forts must be applied in a universal way, not
only from a purely vocational or artificial ap-
pliance standpoint, but first, by helping to relieve
such disabled person so far as possible from
worriment caused by financial stress, physical
suflFering or other burdens.
In some cases, the bureau may discover a man
who has been injured and in immediate need of
therapeutic treatment. If the injured person is
without funds and if conditions are such that
therapeutic treatment cannot be arranged from
workmen's compensation benefits, without ex-
treme financial burden on the accident victim's
fafnily, the bureau arranges for such therapeutic
treatment, usually placing such person in state-
controlled or state-aided hospitals. The Bureau
of Rehabilitation, by opinion of the attorney-
general, cannot expend moneys directly from its
appropriation for such therapeutic treatment
but, as a state agency, is authorized to cooperate
with hospitals throughout the state. It has en-
countered no difficulty in obtaining therapeutic
treatment where necessary for cases registered
with the bureau.
If the bureau discovers extreme financial
stress, even though as a bureau, it may not ex-
pend its funds for charitable benefits, it makesf
every effort to arrange for the relief of such
financial stress of physically handicapped per-
sons by establishing contacts with local chari-
table organizations, churches, or any similar
agencies through which proper contacts may be
made for financial relief.
If the accident victim has suffered an amputa-
tion of an arm or a leg, and is financially unable
to obtain an artificial appliance, which is usually
a first requisite for return to suitable employ-
ment, the Bureau of Rehabilitation aids such
person to obtain a proper artificial appliance —
arm, leg or body brace — as a means to the end
of getting the industrial accident victim back into
self-supporting employment.
If the Bureau of Rehabilitation can aid the ac-
cident victim by investigating an appeal for
commutation of workmen's compensation for
the purchase of a small business or a similar
means for self-support, the bureau aids such reg-
istered person before the Workmen's Compen-
sation Board. Similarly, the bureau works at all
times on cases referred to it for attention by the
Workmen's Compensation Board by the referees
or by the Compensation Bureau. A representa-
tive of the Bureau of Rehabilitation attends
every meeting of the Workmen's Compensation
Board, wherever held in the state, to establish
contacts with physically handicapped persons
who may come to present their cases to the board
and in some phases of which the board may de-
sire action by the Rehabilitation Bureau.
If it be determined that the accident victim
can be benefited by a course of training in
school, in the industries or elsewhere, the Bu-
reau of Rehabilitation places such person in
proper training courses.
If such training cannot be attempted by the
physically handicapped person, because of finan-
cial limitations, the Bureau of Rehabilitation de-
termines the difference between such person's
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THE PENNSYLVANIA MEDICAL JOURNAL
June, 1921
income and estimated expenses, while pursuing
such course, and pays, from the appropriation of
the bureau, weekly maintenance to such person,
in amount to cover the difference by which liv-
ing expenses and school costs combined, exceed
the income of such physically handicapped per-
son, during training. In such case, the maxi-
mum amount" that may be paid by the bureau
from its funds, for a person in training, is $15.00
per week.
If a training course is not feasible for the dis-
abled person, the bureau makes every effort to
place such person in suitable remunerative em-
ployment.
In the work of placement, the Bureau of Re-
habilitation, for the purpose of discovering op-
portunities, cooperates with the branch offices of
the Bureau of Employment of the Department
of Labor and Industry in all sections of the state.
The Bureau of Rehabilitation to. last night,
had offered its services directly by letter to 1,142
persons, reported as disabled, and residing in 62
of the 67 counties of the state. Of those 1,142
persons, 742 were reported to the Bureau of
Rehabilitation by the Bureau of Workmen's
Compensation; 150 were discovered by adjust-
ers of the Bureau of Rehabilitation working
throughout the state ; TJ persons made direct ap-
plication to the bureau ; 8 were reported by em-
ployers; 19 by insurance carriers; 35 by em-
ployees of the Department of Labor and Indus-
try, other than those in the Bureau of Rehabili-
tation; and III contacts were made from other
scattered sources.
Seven hundred of the 1,142 persons to whom
the services of the bureau had been offered, had
registered up to last night. Of that number, 681
were men and 19 women ; 129 of the 700 were
illiterate and 20 were negroes.
Classification of the registrants into age
groups is interesting, indicating that the majority
of registered physically handicapped persons are
over 31 years of age. One hundred and four-
teen of the registrants are under 21 years of
age; 197 between 21 and 30; 150 between 31
and 40; 112 between 41 and 50; and 127 are
over 50 years of age.
The majority of the registrants are native-
born Pennsylvanians. Three hundred and
ninety-five of the 700 disabled persons regis-
tered, were born in Pennsylvania ; 59 were born
in the United States outside of Pennsylvania;
and 246 were born in foreign countries.
Parts of the body injured by accident to the
registrants, included 231 hands, 133 arms, 76
feet, 197 legs, 9 one-eye cases, and 28 totally
blind. Sixty-six of the registrants were afflicted
by injury other than loss of use of parts.
The Bureau of Rehabilitation, to last night,
had been of genuine assistance to 287 disabled
persons, throughout the state, registered with the
bureau and having a total of 410 dependents.
One Tiundred and thirty-seven of the 287 per-
sons aided are single, and 150 are married. The
Bureau of Rehabilitation assisted disabled per-
sons to obtain 158 artificial appliances. In some
cases, the total cost of such appliance was paid
by the bureau ; in some cases, the total cost was
paid by the employer ; in a number of cases, the
bureau and the employer or the disabled person
contributed toward the cost of the appliance.
Forty-seven of the 287 disabled persons aided
by the bureau are receiving regular weekly
maintenance payments from the appropriation
of the bureau during courses of training. Such
training courses include telegraphy; wireless
telegraphy; motor mechanics; preparator)'
course for mechanical engineering; traffic man-
agement ; salesmanship ; armature winding ;
commercial courses of various kinds, including
cost analysis and accounting ; Braille reading and
writing; piano tuning and carpet weaving for
the blind ; mechanical drawing and machine de-
sign ; teacher's course in a state normal school ;
watchmaking and other skilled occupations. Al-
most all of the persons the bureau has in train-
ing are under 25 years of age.
Sixty-seven of the persons registering did not
come under the Pennsylvania Act and 71 of the
registered persons declared that the services of
the bureau were not needed, principally due to
the fact that such persons were suitably em-
ployed when the services of the bureau were of-
fered to them.
The Bureau of Rehabilitation kept the number
of employees to a minimum until the load, es-
tablished by contact with disabled persons
throughout the state, indicated clearly the neces-
sity for additional employees in the field.
In the central office at Harrisburg, modem
filing systems have been installed for the com-
pilation of individual case records as well as for
analyzed mass statistics for all cases. By such
procedure, the number of employees in the cen-
tral office of the bureau has been kept to as small
a number as possible and increased only as
shown necessary.
Form letters have been developed and printed
for virtually all routine steps of correspondence
necessary in proceeding with cases. Develop-
ment of such form letters has saved a great
amount of time and kept the number of em-
ployees to a minimum by eliminating the dicta-
tion and transcribing of a great mass of daily
routine correspondence.
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CONFERENCE OF INDUSTRIAL PHYSICIANS
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EXPI,ANATION OF SLIDES SHOWN
This young man was injured in an industrial
accident. Infection developed, paralyzing both
his legs. You see him working at the typewriter
in a business school where he is taking a course
in shorthand and typewriting and general com-
mercial work. In many cases, such disabled
young men desire quick, intensive courses in
commercial work because they know of some
business opening available for them after a brief
period of training.
* * *
The man here shown lost a leg while employed
in the operation of a plant railway. The em-
ployer cooperated with the Bureau of Rehabili-
tation and this man now is competent to operate
a plant locomotive. He is the engineer of the
plant locomotive you see in the picture.
* * *
This man shown working at the rag carpet
loom lost his sight through an explosion in in-
dustry prior to the enactment of workmen's
compensation laws. His savings were reduced
to about $ioo when the Bureau of Rehabilitation
found him. The bureau is supporting him dur-
ing his course of training in weaving rag carpet
at a workshop of the Pennsylvania Association
for the Blind, which organization is doing splen-
did cooperative work with the Bureau of Re-
habilitation in aiding to rehabilitate blinded per-
sons to become self-supporting.
* * *
This man with the artificial left hand shown
here with his wife and children, lost his hand in
a cement block manufacturing plant. He was
provided with an artificial hand and employment
was found for him in a glass manufacturing es-
tablishment where he is now earning more
money than he did before sustaining his injury.
* * *
This young man lost his leg and is being in-
structed in the operation of the fencing machine
you see in the picture.
* * *
This man lost both legs above the knee and the
left hand is merely a stump. He is taking a
course in commercial telegraphy and his instruc-
tor shown with him in the picture is not charging
for his instruction because he lost a leg two
years ago. The company under whose direction
the man is studying is pleased with his progress
and because his artificial legs will make it diffi-
cult for him to get about in icy conditions of
winter, the company has promised to transfer
this man to work in the South during winter
months with opportunity to return North in
summer if he desires.
This young lady lost her hand while operating
a press. The Bureau of Rehabilitation has en-
tered her in school and has the promise of the
plant where she was injured that after training
she will be replaced in the clerical department in
a position her education and aptitude will fit
her for.
Note: Sixty slides were shown with verbal de-
scriptions given of each subject shown on the slide.
Dk. Patterson : We have had a most thrilling and
graphic illustration of the wise forethought of Com-
missioner Connelley and Governor Sproul in having
our commonwealth stand in the forefront of this most
useful salvage movement, and I am going to call on
Dr. John Bassin, Chief Surgeon of the New jersey
Rehabilitation Commission, to open the discussion on
Mr. Riddle's paper.
At the conclusion of the afternoon session, we .will
show some motion pictures illustrating rehabilitation
work.
DISCUSSION
Dr. John N. Bassin, Chief Surgeon, New Jersey
Rehabilitation Commission, Newark, N. J. : I think the
state of Pennsylvania. ought to be commended for the
splendid work it has carried on in this departmeQt, es-
pecially by its newly arrived baby, the Rehabilitation
Bureau. We are not so fortunate in New Jersey as to
feel that we had solved the problem of vocational re-
habilitation. As physicians, we have been taught that
the hand is mind trained; and it is always a question
in our minds as to whether or not, after all, it is not'
more prudent to begin with physical reconstruction of
the hand or any other injured member of the body
following an industrial accident before resorting to
the vocational aspect of rehabilitation.
Like your honorable commissioner, Mr. Connelley,
we, too, have a marvel of a Commission of Labor.
You all know Colonel Bryant, who has brought the
various bureaus of the New Jersey Department to
such a state of efficiency that when our rehabilitation
work began, this gentleman thought it practical to
establish clinics for physical reconstruction previous
to beginning vocational training, or actual placement
or employment. In New Jersey, the Workmen's Com-
pensation Bureau, the Employment Bureau in coopera-
tion with the rehabilitation clinics for physical reha-
bilitation constitute the major part of this work.
We have thus far successfully organized several in-
dustrial reconstruction clinics. To prevent duplication
of effort the tendency is to correlate the various
branches of the New Jersey Department of Labor with
the object of covering the rehabilitation program, the
Bureau of Workmen's Compensation, the Rehabilita-
tion Bureau, the Compensation Courts, the Social
Service Department, the Bureau of Factory Inspec-
tion and that of Vocational Guidance, Functional Re-
education and Employment tmder one roof. This was
actually accomplished in one year ; so that the factory
inspectors of the Department of Labor, knowing
pretty nearly every job in every one of the nine thou-
sand factories of the state, are in a position, after a
conference with the vocational officer and the surgeon
in charge, to find a place for the man, assuming that
the man cooperates. We thought we would reduce
the proposition to simple terms and eliminate red
tape, thereby reducing expenses because we have not
yet obtained $100,000 for the work, although it has
been found tmnecessary to pay a single bonus of fif-
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THE PENNSYLVANIA MEDICAL JOURNAL
June, 1921
teen or twenty dollars a week to any physically handi-
capped person.
To-day our results in over 1,000 cases encourage
continuation along these lines until this wonderful
state of Pennsylvania from which we can learn a great
deal, shall show us how it will approach the subject
of physical reconstruction with proportionately as lit-
tle expenditure of funds as New Jersey, which started
from the bottom.
Out of 1,000 cases supposedly previously cured, 555
required further reconstruction treatment previous to
vocational training. Most of our injured are not
young. Their ages range between 35 and 50 years;
and when one comes to a question of education, the
mental test and the social and economic atmosphere
of the individual in his home, it is an intricate problem.
It is a matter of getting the man trained as quickly as
possible and returning him to work.
Rehabilitation is a social problem, primarily. The
speaker is concerned principally with the physical re-
construction leading ultimately to a point of getting
the men back to their jobs or preventing them from
becoming mendicants.
The problem in connection with labor is not alto-
gether parallel with that concerning those injured in
ti&T. The cases are first referred to the clinic by the
courts for reconstruction, surgery or physiotherapy or
other means of rehabilitation found in other depart-
ments of medicine and surgery and used in the cases
of occupational disease.
Four hundred and forty-two fractures requiring fur-
ther treatment were included in the first thousand
cases. In most of these cases, it was found that a
great percentage of total permanent disability could be
substantially reduced by treatment which followed.
Of other traumatisms, lesions requiring further physi-
cal treatment, there were 321. Injuries to the organs
of special sense and to the nervous system and ab-
dominal and chest viscera, etc., are not included in this
classification. Experience teaches that unless one ob-
tains results within the first eight or nine days, the
outlook is not especially promising.
Outside of open and closed operative surgery,
physiotherapy was made good use of in 437 cases. We
are not anxious to operate but when the tissues are
cold and contracted perhaps months after the acci-
dent, when the patient has gone through a series of
after treatments, it is futile to depend on physio-
therapy alone. Physiotherapy has produced excellent
results immediately following the initial surgery or
secondary surgical stage.
It was found necessary to operate in 127 cases.
There were resection of joints, arthroplasties and bone
plastic work. The rest of the cases were carried to
a successful issue, the disability being reduced to a
minimum. In the final analysis, the 555 cases improved
in the light of recent advancement in surgery and
medicine and did not need vocational guidance for
employment. They have found employment them-
selves.
One hundred and sixty-one were completely restored
to health; that, by means of physical reconstruction.
Only 29 men had to be placed by the state's Employ-
ment Bureau, under the direction of Colonel Bryant,
of the State Department of Labor, in cooperation with
the Federal government.
We have not spent $300 of our appropriation for
actual treatment or bonuses. Everything was done
along the line of cooperation with every industrial, so-
cial and educational agency in the state, and nearly
every dollar of our allowance went in*o eauipme"t for
the clinics ; so that to-day we have a clinic in Newark ;
one in Jersey City, and one in CamdeiL Paterson and
Perth Amboy are soon also to have clinics.
The state is divided into five industrial zones, with
the possibility of further dividing them into sub-
zones. The work is done in cooperation with the
medical profession. It is not paternalism or charity,
but a matter of civic obligation of the state to indus-
trially injured citizens. It also is cooperative with the
"Safety First" movement along the lines of preventive
surgery and medicine. Good initial surgery in most in-
stances, should prevent deformities observed. The
profession has done wonderful work, but there are
still many industrial agencies that must come in and
help the industrial surgeon to obtain better results.
The pictures that I am going to show you are not
primarily intended for a medical audience. The ob-
ject on this occasion is to outline the general scope of
the work rather than to present individual cases.
So far as the work of the industrial physician and
surgeon is concerned, I believe that this association
should be especially commended because it is this asso-
ciation that has been stimulating and encouraging this
particular kind of work. This association is the ban-
ner bearer of the true methods of reconstruction
along the lines of physical as well as mental education
as preliminaries to the basic principles tmderlying the
whole process of vocational rehabilitation, which is
yet in its infancy.
Dr. Patterson: We will now have the pleasure of
hearing from Commissioner Connelley, of the Depart-
ment of Labor and Industry,
Commissioner Connelley: I am very glad to-day
to hear what our good friend from New Jersey has
said. Pennsylvania has, however, 9,000,000 people;
and for her industries, she is noted all over the world
as being one of the greatest states in the Union.
When we started rehabilitation measures, we called
twenty employment managers together, and asked
them to cooperate with us, mapping out our program
to them. The cooperation we sought was that of re-
placing the men in industry as soon as possible after
they had been rehabilitated "as nearly as the industrial
physician found possible, and had been given training
on the vocational side. We wanted their cooperation;
and, to a man, they have assisted us.
I believe that, as Dr. Bassin has said, the communi-
ties in the United States do not give the industrial
physician his due; because, when I look around and
see the work of such men as Dr. Sherman, of the
United States Steel Company, and others throughout
the country, who have repeatedly got men back into
paying positions, and possibly with an earning capacity
better than ever before, it does seem as if the world
should know more about what the industrial physician
is doing.
I feared some interference through the Federal gov-
ernment, but that fear has been dispelled. The money
that has been sent through Pennsylvania (to relieve
any doubt in the mind of the New Jersey gentleman),
I may say, has been well spent ; but when you con-
sider that what the United States still does for her
soldiers, and what these large corporations have done
for the men injured in their employ, you will realize
that what we have spent in Pennsylvania, as Mr. Rid-
dle has shown, when compared with the percentage
these men earn, it is small indeed. Wei are in the
throes of reconstruction, and are being assisted by the
United States government. I sincerely trust that
the industrial physicians of our country will look into
the matter and find out what the Federal government is
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CONFERENCE OF INDUSTRIAL PHYSICIANS
653
trying to do in the way of assistance. I believe, and
always have believed, that the states are better pre-
pared to do their work in this line, because they know
exactly what is needed. They are practical men.
They know what is required. In getting this work
from Washington, the people there, with all the best
intentions, do not know what is needed. There is a
great difference between the placement of one who is
under educational and vocational guidance and one
who is not, from the standpoint of the industrial physi-
cians and that of the manufacturers themselves.
The doctor from New Jersey has told us that there
were 187 cases that needed no vocational guidance.
They were rehabilitated and sent back to work. It is
true. In some cases they .did need this educational
work in Pennsylvania, but in many cases they would
not take it. We look at it as a case between the em-
ployer and the employee. We try to get the men back
where they can make a living, as is so often required.
The industrial physician — and I cannot help but repeat
my commendation of what the corporations have done
for this United States, to alleviate suffering and get
the man that was injured in their employ back into a
rehabilitated condition. You are doing such a won-
derful work here; and if we could only spread this
information to all laymen and industrial managers and
show them what you are doing in New Jersey, New
York, Pennsylvania and other states, I think we should
get somewhere.
Dr. Patterson : I now call upon Assistant Surgeon-
General John P. McDill, of the United States Public
Health Service, who will continue this discussion.
Assistant Surceon-General (R) John R. McDill.
United States Public Health Service, Chief Medical
Officer Federal Board for Vocational Education,
Washington, D. C. : I will speak more of the share
that the medical man has in the work than of the voca-
tional educational side. My interest, experience and
studies in the rehabilitation of disabled persons began
five years ago in Europe. Before we entered the war,
with Red Cross base hospitals, I succeeded in getting
into the Central Empire. My records of the work
there are published by the War Department as Medical
War Manual No. 5. The most instructive experience
of all has been that of the work of the Federal Board
for Vocational Education in " rehabilitating disabled
soldiers, sailors and marines which followed the work
of the army in physical reconstruction, including
physiotherapy and a curative workshop program. The
training by the Federal Board is not so much for a
job, but rather into a job, as employment is provided
at the end of training. Seventy thousand men have
been placed in training and each gets from $100 to
$150 a month according to the number of dependents,
for maintenance, together with his expenses while in
school, shop or factory, medical care and not to exceed
$250 worth of tools. This seems pretty extravagant.
The courses last from six months to four years and
cost the government about $2,000 a year per man. Two
thousand have finished their courses and 14,000 have
discontinued for physical or other reasons, mostly
physical, which is a reflection on the work. Not
enough men have yet been "rehabilitated" to draw any
conclusions as to the value of this gigantic experiment.
The courses include over 300 different trades, pro-
fessions and occupations. They run from a few
months to four years. Doctors, lawyers, musicians
and scientists and tradesmen are being trained in
thousands of schools, shops and factories.
The important thing is an adequate recent physical
examination before the man is put in training in order
to determine the feasibility of training a certain man
for a proposed occupation. The examination at the
time of the application for training does not answer
the above purpose if several months elapse before a
man actually enters training. There may be present
certain conditions that make a particular kind of
training not feasible, and this is a matter only a medi-
cal man may decide. It is exceedingly important to
have a recent and adequate physical survey of each
man before proceeding to place the man in training.
How shall you get that in dealing with the disabled in
industry? The Federal Board uses all the facilities
of the Public Health Service, and also pays a fee of
five dollars for every examination made by thousands
of other physicians. The Public Health Service has
over 2,000 salaried officers in the centers of population
and a representative in each county of every state and
working with them are 4,000 dentists, taking "care of
the teeth of the ex-service men.
But how is a state to handle the matter? I would
strongly advise that the state boards cooperate with
the existing state medical organizations. In Pennsyl-
vania you have a very strong Public Health organi-
zation, and, if I am correctly informed, with perhaps
2,000 doctors under the Commissioner of Health, who
carry out the work in the Health Department, and
whose services, I imderstand, would be available if re-
quired. That is something for the State Board of Vo-
cational Education to determine in conference with the
health authorities under section 4, I think, of your act
Observation of the man is required throughout his
training, by follow-up work, during which it must be
found out whether the training is the right one, be-
cause the number of physical breakdowns that the
Federal Board has is by far too many. These break-
downs have been because of a wrong course of train-
ing or by putting men into training without consulting
a medical oflicer or of training having been undertaken
too soon.
The Federal Board failed in its attempt to set up an
independent medical organization because salaries were
refused by congress and the surgeon-general came
to our assistance and offered to turn over as much of
his organization, as necessary, for the work. Unfor-
tunately for the state of Pennsylvania, for reasons
that will not exist much longer, I understand, it was
thought better not to have salaried officers of the
United States Public Health Service throughout the
state ; so there are at present only two or three sal-
aried officers outside of those assigned by the Federal
Board, in this state. But before you are well into
your work, there will be full-time salaried officers in
every community, and the surgeon-general has ex-
pressed his desire to place the services of his officers
at the disposal of State Boards for Vocational Edu-
cation.
Your medical reports will come not only from doc-
tors in private practice but from hospitals, and partic-
ularly from the industrial surgeons. There will be no
worry about the quality of most of these reports; es-
pecially those from industrial plants and first class in-
stitutions; but if a man has been discharged from
treatment for some time, an additional report on his
present condition will be needed before risking his
health and the state's money in a course of training.
The real problem in my mind is how to get across to
the medical profession something that, I believe, is a
new obligation of medicine to its patients. Our con-
ception of our duty to the patient in the past has been
that when we have done all that medicine and surgery
can do, our duty has been done, but gentlemien^here^ I ^,
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654
THE PENNSYLVANIA MEDICAL JOURNAL
June, 1921
is a great deal more that we owe. There are certain
questions of vital importance to each patient's future
welfare that only a doctor can answer. When we have
done all we can for a patient in private practice we
send him a bill and feel or hope that we have done all
that could have been done ; but we should tell that pa-
tient, "You are, or are not handicapped in following
your present occupation on account of your physical
condition." In other words, we should translate any
temporary or permanent physical disability remaining
at the end of treatment into a vocational handicap, and
say, "On account of your condition resulting from dis-
ease you are disabled to a certain extent." The next
step is to determine the degree and give an opinion
whether this disability can be overcome by education
and training, perhaps combined with more medical
treatment: Then the patient may ask, "It is worth
while to do it?" The answer is, "Yes, and after
training is completed, you should be able to carry on
your occupation in a completely normal manner, and
never be dropped out because you are not able to com-
pete with others in that line who are not handicapped."
That would be the ideal result of a course of training
and the Federal government is now engaged in trying
to make it come true.
My experience and study of the last five years have
convinced me that the medical profession and its in-
stitutions are falling short of their full' duty to those
of their patients who have suffered from disease or
injury, who have attained the greatest improvement
-that medical care and skill can provide, and who yet
:are left with some disability which impairs their earn-
ing power or employability.
Medical advice and medical supervision combined
with vocational training, can still do much for these
handicapped persons. Public interest is awakened to
the value of the rehabilitation of substandard citizens,
a great opportunity for service is at hand, and the
medical profession's share in this work will enable it
to fulfill its complete functions to its patients.
My opinion is based on a study in this country and
abroad since early in 1916, of methods of economic res-
toration of persons, who as a result of their disease or
injury, have been handicapped in earning a living at
their life vocations. The most instructive part of this
experience has been gained in the last two years, with
the United States Public Health Service in its medical
work for the Federal Board for Vocational Education
in placing 70,000 disabled ex-service men in the train-
ing which was thought best calculated to remove the
vocational handicaps resulting from their physical dis-
abilities. This training is given in over 2,000 schools,
10,000 shops and factories and 100 hospitals. It is ex-
pected that 300,000 ex-service men and women will be
given or offered training by the Federal government
in the next two years.
The magnitude of this temporary task which is an
individual and not an institutional job, however, pales
into insignificance when compared with that of rehabil-
itating all persons disabled in industry or otherwise.
This work will be administered entirely by state
boards, stimulated by an annual grant of funds from
the Federal government, but it will be years before it
will be operating on the large scale contemplated by
the law.
It has been proved by the work among the ex-
soldiers that the movement cannot succeed without the
closest cooperation of the best talent in the medical
profession because the plan involves decisions and ac-
tions by medical men of importance equal to or greater
than by those engaged on the educational side of the
work. Is it not the duty, therefore, of the medical
profession and its institutions to at once prepare to
carry out its share in performing this great tmder-
taking.
In the minimum standard proposed for hospitals, the
section concerning complete case records might be
amplified by requiring answers to the following ques-
tions, the same should be a part of all clinical records :
(a) Has the patient a resulting physical or func-
tional disability after treatment has been completed,
and is it {>ermanent or temporary?
(b) Is this physical disability a vocational handicap
in regard to his or her former occupation or proposed
occupation ?
(c) Can this vocational handicap be overcome by
vocational training or education, perhaps combined
with further treatment ?
(d) Is such training feasible, in view of the present
physical or mental disability?
(e) If training is feasible, would the person be able
to carry on in the proposed occupation after the com-
bined physical and educational training has been com-
pleted?
Only a medical man can answer the above questions
which vitally concern a patient's future.
If economic rehabilitation is indicated as above, the
patient should be urged to consult a vocational adviser.
Dr. Patterson : This important subject is now open
for general discussion. It seems to me that there is
nothing more important than the rehabilitation into
useful citizenship of one who has had the misfortune
to meet with a disabling accident. We will ask you to
come forward and give your name and address.
Dr. Steim : I am glad to be able to say something
on this subject, but from the standpoint of the in-
dustrial surgeon or physician, rather from that of a
citizen and taxpayer.
This is a subject which is entitled to consideration
by everybody, for that reason I am talking from the
standpoint of a citizen and taxpayer in the state of
Pennsylvania.
I believe that Mr. Riddle and his bureau are entitled
to every consideration they can possibly get from each
citizen, since the matter of salvaging and training into
productive channels such ability as can be salvaged
after disabling injury is one of very great importance
to each one of us.
Mr. Riddle seems to be under considerable stress as
to how to justify the expenditure of that $100,000 ap-
propriated. To those of us who have had a year or
two's experience in connection with rehabilitation of
disabled soldiers, it seems that $100,000 is a pitifully
small sum to do anything with in that line ; and I know
that all citizens of the state will be willing to con-
tribute toward any part of $500,000 a year when they
know the extent, the scope and the continuously con-
structive value of this work.
We can contribute a great deal in other ways than
just by money. I am speaking of everybody now, and
not as an industrial physician. The question of reha-
bilitation, which has been so miKh emphasized to-day,
is a question of deciding how much or perhaps rather
what sort of trailing a mental or physical cripple can
assimilate with the most benefit to himself and the
world at large. That can only be determined by com-
plete and fundamental knowledge of the individuaPs
heredity, his social environment and what his past
training in every direction has been, in short, what he
has left when he comes to be rehabilitated.
The examiner cannot decide this alone. He most
take some one else's word for a large part of it. He
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June, 1921
CONFERENCE OF INDUSTRIAL PHYSICIANS
655
must take the word of the disabled person himself to
a large extent. The abnormal mental attitude of the
cripple must be taken into consideration. He does not
know what he wants and still less what sort of train-
ing is best for him. Maybe after an extensive course
of training has been instituted he changes his mind
and the greater part of the training is lost.
Everybody can give helpful information along these
lines, neighbors, his former foreman, his minister, if
you like. Everybody who knows the cripple or knows
anything about his history can bring that knowledge to
the attention of the Rehabilitation Bureau and can also
bring to the attention of each industrial cripple the fact
that we now have in the state of Pennsylvania a Re-
habilitation Bureau.
Publicity all along the line is what this bureau re-
quires most, in order that it may efficiently carry on
the important work which it has tmdertaken.
Miss Laudek: If you had been in Washington
when the rehabilitation bill was discussed, you would
know the record of the league. The American Asso-
ciation for Labor Legislation published a monograph
on the subject in which you will find a record of the
league's action in behalf of rehabilitation for indus-
trial cripples. So we were instrumental in the first in-
stance in having the law passed.
Mk. Riddle: When we go to see a man, we believe
that we should have a physician's statement regarding
the man's condition when he has sustained a serious in-
jury. We have no way of knowing what the man's
condition is. We must have some medical advice. We
cannot pay for it. We establish contact with a physi-
cian and on a definite form that the adjuster has to
have filled out there is a place for the statement of
the personal physician, the hospital physician, the in-
dustrial physician or a physician of the Department of
Labor and Industry. This must be filled in before
there is any thought of therapeutic treatment The
blank is as follows:
PHYSICIAN'S STATEMENT
(To be filled in by a phyucian consulted by the adjuster on
the case, the personal physician of the applicant, hospital
physician, the industrial surgeon of the plant where the ap-
plicant was injured, or a physician of the Department of
Labor and Industry or in other state service.)
What is the applicant's general condition ?
cant ?
If so, what?
Remarks, suggestions as to treatment, etc.
Is the applicant fit to return to work or undertake
training ?
Has applicant lost use of any members?
What members ?
Was loss of use due to amputation or other cause?
If other, what?
If loss was due to amputation, please give exact loca-
tion of amputation
Date of loss Is the scar fixed or
movable ?
Character of stump for direct or indirect weight bear-
ing ?
Power of stump Usefulness of stump
Painless?
What artificial appliances are required ?
If no artificial appliances are used, why not?
Are any being worn ? If so, what ?
If leg, are crutches used ?
Do you recommend therapeutic treatment for appli-
(Any erasures or alterations should be initiated by the physi-
cian signing this statement. Please read the report over
carefully before signing.)
Physician's signature
Address
Date
This form is to be signed by the physician. In that
way, we do not judge ourselves whether a man should
have therapeutic treatment. It is a question in the
minds of the members of the bureau whether the state
should jump into the medical end of rehabilitation,
and we also believe that the physician who has at-
tended the man is the best able to judge of his condi-
tion. So we get in touch with every physician pos-
sible, and get their exact attitude and recommenda-
tions; and in that way, we bring in the medical phase
in each case in which a man has been recently injured
or is believed to have a definite need for further
therapeutic treatment.
Dk. Bassin: I wish to bring out a point here. It
has always seemed in New Jersey that the Bureau of
Workmen's Compensation can solve the financial as-
pect of this work better than any other agency at pres-
ent existing in either New Jersey or perhaps in Penn-
sylvania. It is imderstood that a certain sum of money
is allotted to every man injured for a certain degrree
of total or partial disability. The insurance carrier or
self insurer is obliged to pay that under the law. Why
look elsewhere for funds, if the state's appropriation
is inadequate ? Why ' not reduce the medico-legal
question to a business plane? As individual physicians
and surgeons it is unethical for us to do that; but in
group medicine and surgery, I think it is proper. This
is what we undertook to do a year ago. The manufac-
turers were thus approached: "Here is an elbow that
is so per cent, totally disabled." "Here is an ankle 25
per cent, totally disabled, permanently." "You are not
obliged under the law to pay any more money for fur-
ther treatment, excepting a lump sum for total per-
manent disability. Suppose we take the 50 per cent,
injury and reduce it to a 25 per cent, disability and
thereby save you $500? How does that appeal to
you?" They would then naturally question: "How
do we know that you will accomplish that?" "Give
us an opportunity and we will do our best." The mat-
ter was taken up with the Commissioner of Labor,
who ruled that we were to undertake the treatment
and charge up to the carrier. If we were to success-
fully obtain the anticipated results, thus not alone
helping the injured man, but actually saving money for
the carrier, it would be desirable ; otherwise we were
to charge up the expense for treatment to the reha-
bilitation fund. This course was adopted with the re-
sult that the commission has well earned the money
the manufacturer paid for treatment, at the same time
actually helping the carrier reduce his overhead ex-
pense and in the final analysis helping to restore the
injured man to health and to return him to the best job
his handicap would permit. Fortimately this arrange-
ment worked so satisfactorily that thus far, in not a
single instance was the state called upon to defray the
expense of treatment as previously mentioned.
Mr. Riddle: Of course when we get recommenda-
tions for therapeutic treatment from the physician, we I
get in touch with the insurance carrier. We have yet
O
656
THE PENNSYLVANIA MEDICAL JOURNAL
June, 1921
to find one carrier who will not give the man the. best
treatment if convinced that his liability can be re-
duced by increasing the physical capacity of the man.
In regard to workmen's compensation, if we could
rely on that as solving the economic problem, we
should be highly pleased. Out of the 700 cases that
have come to the attention of the Bureau of Reha-
bilitation, 344 were injured before the Rehabilitation
Act of 1919 was passed; and a great many before the
Workmen's Compensation Act was passed. Many
have not a cent in the world and many have received
all the compensation coming to them. Rehabilitation
also applies to agricultural cases which do not come
under the Compensation Act. The armature winder,
and the blacksmith shown on the slides never got any
compensation. You know the number of dependents
the average man has? Maximum compensation for an
injured man with seven or eight children, up to 1920,
was $10 a week, and since then it has been $12 a week.
That is not adequate to carry such a man through,
even a short period of training, without earnings.
The economic problem is a serious one. The educa-
tional facilities we have little difficulty in discovering.
The principal problem is the economic one. Cases
come that are in dispute before the Compensation
Board for one reason or another. The man is not
getting any compensation during such interval. He
will probably get it later, but we must act immediately.
■ Commissioner Conneu.Ey: We look on the Com-
pensation Bureau as purely judiciary. We have law-
yers who are on the board, who adjudicate cases. The
insurance carrier disputes many cases, and they are
adjusted by the medium of these men. I take it that
the Compensation Boards are no more capable of di-
recting vocation than they are of doing that which
lies in the power and ability of the physician, to tell
when the patient is fit to do a certain piece of work.
As Mr. Riddle says, the cases are in many instances
retroactive. That is the reason why we had to do in
Pennsylvania just what we have stated.
Dr. Bassin : I do not wish to be misunderstood.
Vou are doing splendid work. In New Jersey, we
have medical examiners with the Compensation Courts.
In Pennsylvania you have lawyers who will often com-
promise with either the doctor or the lawyer of the re-
spondent.
Commissioner Connelley : In answer to Dr. Bassin,
I would say that we are trying to do this thing as eco-
nomically as possible. We know what the extravagance
of the government has led the country into. Pennsyl-
vania is paying one third or one fourth of the money
to the United States government for its existence. We
have a governor who is a business man. He runs his
administration on business principles, and we are try-
ing to do the very best we can ; but sometimes spend-
ing money is the most economical way to get through
and accomplish what you are after. I do not doubt
that New Jersey, starting as it has started, is doing a
splendid piece of work; but the industrial physician,
the Compensation Bureau, and the Department of In-
spection of New Jersey differ little from those in
Pennsylvania. We, however, consider that the Com-
pensation Board is judiciary; because it decides the.
amount of money to be paid and whether the claims
are proper or not. We are after economy, but not at
the expense of the people we are trying to rehabilitate.
Dr. L. H. Botkin, Carnegie Steel Company, Du-
quesne: It seems to me that this resolves itself into a
little controversy between two states. I came here, as
a member of a committee representing a large indus-
trial plant, to get sbrae information as to what wc
could do to better the injured men of our own plant
I think that the state of Pennsylvania, as I under-
stand it, is doing a wonderful work ; but its most won-
derful work, to me, is a second consideration, which
has not been mentioned here to-day — and that is, that
when the industrial plants of this state know that
there is an efficient department in the state of Penn-
sylvania that is looking after them and their cripples,
they are going to do better by those cripples them-
selves. It is not a question with us, as to the better-
ment of the physical condition of the men; but our
man is never let loose to go out until everything has
been done that can be done for him. There is no
question of that Every cripple, with but two excep-
tions in 30 years, has been not only given employment
but kept in employment He has been furnished with
artificial limbs to use during the term of his life.
Whenever, in my opinion, the artificial limb is worn
so miKh that he needs a new one, he gets it; or if
the artificial limb gets broken, it is replaced. Neither
is it a question of vocational education; because the
company keeps a school in which they study, their
time being paid for at the wages that they are earn-
ing. They also keep a night school, for the education,
not only of the cripple, but of any one in the plant
who wants more education along any line, mechanical
or otherwise. Just now, Dr. Bassin made one of the
grandest statements I have ever heard in connection
with my experience with crippled men. Every crip-
pled man that I have ever seen was a disheartened
and discouraged man, to begin with. Now it is a ques-
tion of mental attitude in that man. We must give
him confidence that the state and the company are
looking after his welfare and are going to build him
up in the best possible manner to make him an inde-
pendent workman.
This committee hoped to get something here that
would help them in the vocational training along dif-
ferent lines — possibly along different lines from what
we have been using ; so that the men could go out any-
where and get a job as workmen of different kinds,
because they are fitted for it We want to fit a man
who is injured in our plant along some line of voca-
tional training that will enable him to be an independ-
ent man.
This whole thing has been a revelation to me. It is
wonderful work; but I believe that both the state of
New Jersey and the state of Pennsylvania are doing
their best work along that line; and the employers
know where their cripples are being rehabilitated, and
that they are going to be asked to cooperate and
help in the betterment of these men. I have the as-
surance from Mr. Riddle that he is going to give us
proof of this, and I feel sure that Commissioner Con-
nelley will help in giving us some better ideas than
what we already have, concerning the betterment of
the cripples that are necessarily made in a great in-
dustrial plant.
Dr. Patterson: Is there any further discussion?
If not, we would ask everyone to be sure to register;
so that we may send to each person present the Pro-
ceedings, when published. At the close of the meeting
this afternoon, we will have the first showing of a
new film taken by the Women's Division of the United
States Department of Labor, just issued from Wash-
ington. We will now adjourn, to meet promptly at
2: 15 this afternoon for our last session of the day.
Adjourned at l : 30 p. m.
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June, 1921
CONFERENCE OF INDUSTRIAL PHYSICIANS
657
AFTERNOON SESSION
The meeting was called to order by the chairman at
2 : 30 p. m.
Dr. Patterson: The meeting will kindly come to
order, and those in the back of the hall take seats.
If there is any one subject that is important, it cer-
tainly is the "Transportation of the Injured." Many
people are hurt at places miles distant from hospitals,
yet require hospital treatment. So we will open our
afternoon session by having an address by Dr. R. H.
Sayers, Chief Surgeon of the Bureau of Mines, De-
partment of the Interior, Washington, D. C, who will
speak to us on this subject. I take pleasure in pre-
senting to you Dr. Sayers.
TRANSPORTATION OF THE INJURED
R. R. SAYERS, M.D.
Chief Surgeon, United States Bureau of Minea; Passed As-
sistant Surgeon United States Public Health Service
WASHINGTON, D. C.
During the past few years the important prob-
lem of transportation of the injured has gone
through some marked changes. These changes
are due in the main to the same things that have
revolutionized transportation in other Hnes — the
telephone and motor vehicles, the latter being es-
pecially important. Lieutenant Colonel F. S.
Breton, of the British Royal Medical Corps, has
described in a very interesting manner, in his
book, "The Great War and the Royal Army
Medical Corps," the effect of these changes.
As to the mining industry, an example might
be taken from the old prospectors who 20 years
ago lived in a cabin in the Crow Foot Mountains
of Montana about 20 miles from the nearest
town. (Slide No. i.) If one of them was in-
jured, his pardner cared for him as best he could
for several days ; then, when it became necessary
to transport him to a physician, this probably
was done on an Indian travois (Slide No. 2)
made by cutting two poles 15 to 16 feet long,
laying them side by side, and connecting them
by two crossbars, one 6 feet from the end and
the other 6 feet farther back. The bars were
fastened to the poles with nails, bolts or tied in
place with cords. Between the crosspieces lac-
ings of ropes or a blanket were fastened for a
litter. One end was then attached to a horse by
the saddle girths similar to shafts ; the other end
dragged on the ground. Two days were required
for the trip, as it was very tedious.
To-day if a prospector's pardner is injured or
sick, the prospector telephones to a physician
who motors out and gives the patient attention
within a less number of hours than it took days
formerly. Further, if hospital treatment is ad-
visable, a motor ambulance is sent out and the
patient transferred to the hospital within a mini-
mum length of time. Another example of the
effect of the telephone and motor vehicle was re-
cently brought to my attention. A man working
2,000 feet below the surface in the North Star
mine, Grass Valley, California, dropped a piece
of timber and broke his ankle. He hopped on
one leg to a nearby telephone, called up the sta-
tion tender and told him what had happened.
The skip used for hmsting men was lowered and
the injured man taken to the surface. A motor
ambulance and surgeon had been summoned
from the hospital one mile away by use of tele-
phone and were waiting at the collar of the shaft.
In just 35 miputes from the time the man was in-
jured, he was in the hospital, his broken ankle
being roentgen rayed after having been set and
placed in a plaster cast.
The problem of underground transportation
of injured men is usually very much involved.
This can best be illustrated by considering the
workings of some of the larger mining proper-
ties in the United States. For instance, the
Homestake Mining Company (Slide No. 4) of
Lead, South Dakota, has 5 shafts varying in
depth from 800 to 2,200 feet and has over 60
miles of underground workings, all of which
are connected. The North Butte mine at Butte,
Montana, is over 3,600 feet deep (Slide No. 5),
and the Leonard, Tramway, Anaconda, Never-
sweat and any of the other 20 odd mines of the
Anaconda Copper Company on Butte Hill
(Slide No. 6), are all from 1,000 to 3,000 feet
in depth, with miles of extensive workings, many
of which are connected, and many of which are
accessible only through steep, narrow openings.
On the Calumet and Hecla Copper Company's
property (Slide No. 7) in Michigan, are located
the deepest shafts in the United States. The
workings of the lead and silver mines of the
Coeur d'Alene (Slide No. 8) region of Idaho,
are deep and extensive, as are those of the cop-
per mines of Arizona and New Mexico and the
gold mines of California (Slides No. 10 and 11).
The slides shown up to the present have been of
metal mines of this country and bring out the
importance and difficulties of transportation of
injured in such mines. While coal mines of the
United States are not so deep as the metal mines,
their workings may be as extensive or even
more so.
To illustrate the transportation problem and
at the same time show conditions in coal mines,
let us follow a miner from his home to his work
and suppose that he is injured in order that we
may further show the care he receives. The
home (Slide No. 12) of the miner chcsen for
the illustration is in Ellsworth, Pennsylvania,
and is a fairly good home with sanitary sur-
roundings, a home that shows it to be cared for
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THE PENNSYLVANIA MEDICAL JOURNAL
June, 1921
both inside and out. The miner leaves bis home
and walks to the mine carrying his lunch with
Iiim and enters the mine, and this entrance to the
mine is well constructed of concrete (Slide No.
13). He walks down a man way to the working
place or room (Slide No. 14) and examines the
roof, by tapping it with a pick handle" to see if
it is safe. There are no props to support this
roof or to prevent loose rocks from falling. The
miner although he realizes the roof is not en-
tirely safe, decides to risk it and goes to work
mining with a pick (Slide No. 15). The roof
falls and the miner is partly buried by the rock
and coal from the roof (Slide No. 16). This
accident is not an actual case but one prepared to
illustrate what might and often does happen. As
it is a hypothetical case, we may suppose his in-
juries to be anything we wish. Let us consider
that this man has a lacerated wound of the thigh
with arterial hemorrhage and is unconscious.
Njow miners usually work in pairs, so we
will consider that the injured miner is found by
this pardner or 'buddie," who immediately re-
moves the coal and rock from the injured man,
examines him and applies a tourniquet over the
artery on the point of pressure between the
wound and the heart to stop the hemorrhage.
He also applies a first-aid dressing to -the wound.
His next duty is to get the injured man to a place
of safety, as more rock and coal may fall. If he
is in a low seam of coal, he will use the one-man
drag carry. This may be done by tying the in-
jured man's wrists together or (Slide No. 17)
by using a loop of cloth or belt passed around
the shoulders of the patient and over the car-
rier's neck (Slide No. 18) ; then by crawling,
he drags the injured man to a place of safety.
I wish to call your attention to the fact that the
bearer has had to decide why, when, how, and
where to transport his patient. His reason for
transportation was to get his patient to safety
and to the doctor ; "when," in this case, was im-
mediately after stopping the arterial hemorrhage ;
and "how" was determined for him by the low
roof, as in a three-foot seam ; "where," only
until he was sure of safety, which may have been
a few feet or many. As soon as he has reached
the entry or manway where he can stand up-
right, he may use "across the shoulders" or "fire-
man's carry" (Slide No. 18) ; this will probably
be the method of transportation chosen, as his
patient is unconscious and the method is less
tiresome to the bearer than many others. This
method of carry has been shown in almost all
moving picture houses as a method used by the
soldiers in the World War. If the patient be-
comes conscious, he will object to the use of this
method, as the blood flows to his head, and the
bearer will use either pickaback (Slide No. 19)
or carry in arms (Slide No. 20). The carry in
arms method is very useful in injuries to the
feet and legs, but is more tiresome for the
bearer than either of the other methods.
If a second man is available, a two-, three-, or
four-handed seat may be formed. If either the
two- or three-handed seat (Slides No. 21 and No.
22) is used, the free hand may be used to sup-
port the injured patient (Slide No. 23) or the
injured extremity.
The above methods of carrying an injured
man are only suggested for use where more help
is not available.
When the patient has been placed where he is
safe and fairly comfortable, it is advisable to se-
cure ample assistance and materials rather than
to try to carry him alone or with the assistance
of only one other man.
Stretchers are almost indispensable in the
transportation of injured men. If we suppose
that our man is in a coal mine, an army stretcher
(Slide No. 24), or litter as it is sometimes
called, will probably be aviailable. This consists
of two long poles with a bed of canvas and the
poles held apart by hinged iron bars; or a
stretcher similar to the army type may be impro-
vised (Slide No. 25) by using two drill steels or
poles 7^ to 8 feet long and a blanket or piece of
canvas the same length. After spreading the
blanket out, place one pole about one foot from
the center, fold the short side over the pole and
place the second pole on the two thicknesses
about two feet from the first pole ; then fold the
remaining part of the blanket over the second
pole towards the first. When the injiired person
is placed on the stretcher, the folds of the blanket
or canvas are locked by friction.
Another very satisfactory improvised stretcher
can be made by using poles similar to those de-
scribed above and two or three coats or jumpers
(Slide No. 26). The sleeves are turned inside
out and the two poles passed through them ; the
flaps are then turned inside out and the two
poles passed through them; the flaps are then
turned down around the poles and buttoned
underneath.
Had our patient had an injury to the back, a
dislocated hip, or a fractured pelvis, a special
improvised stretcher splint would have been
used. This consists of two long boards 4"xi"x8'
and three short ones 4"xi"xi8". The long ones
should be placed parallel to each other about 4
inches apart and the three short ones leashed to
the long ones at a level with the patient's shoul-
ders, hips, and ankles (Slide No. 27). After
padding the two long splints, the patient may be
secured to the splint by cravat bandages about
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June, 1921
CONFERENCE OF INDUSTRIAL PHYSICIANS
659
the extremities and body (Slide No. 28). This
stretcher is very useful in bringing injured men
down vertical or steeply inclined manways.
If our miner had been injured in a metal mine,
the Stokes navy stretcher or the Homestake
stretcher would probably have been used. The
Stokes navy stretcher (Slide No. 29) is a wire
woven basket made to fit a man's form and is
equipped with straps to secure the patient in the
stretcher. He may then be raised or lowered in
a vertical position without injury. The Home-
stake stretcher (Slide No. 30) is made of a solid
plank about 7 feet long and i inch thick and cut
to correspond somewhat to the human form. It
has a footboard on which the patient may stand
when being raised or lowered. Of course he
must be securely strapped to the stretcher before
transportation is undertaken.
The stretcher drill recommended by the United
States Bureau of mines is practically the same
as that used in the United States army, the
American Red Cross and other military and
allied organizations. It is well to study a dia-
gram of the drill as shown (Slide No. 31), as it
shows the various duties of each man much bet-
ter than can be described by words. There are
four men, bearers, in the squad and the captain.
You will notice (Slide No. 32) that the men
are facing so that the patient will be carried feet
foremost. This is the proper way to carry the
patient except when going up stairs or up hill,
when he should be carried head foremost.
If we had supposed the miner to have been in-
jured during a mine fire or explosion from
which poisonous gases were produced as some-
times happens, it might have been necessary for
the stretcher squad and captain to wear self-
contained oxygen breathing apparatus (Slide
No. 33), in order to rescue the injured man.
They would carry extra oxygen breathing ap-
paratus to be placed upon the injured man (Slide
No. 34) to protect him from the poisonous
gases. This method has been used at many mine
disasters and has been the means of saving lives
which would otherwise be lost.
While carrying an injured man on a stretcher
is a good method of transportation any carry be-
comes tiresome if the distance is a few thousand
feet, as often is the case in mines. Further the
injured man suffers much due to missteps, caused
by the rough roadway and poor lighting found
under ground. To avoid the above objections
.some mines are equipped with ambulance cars
for transporting injured men, when under-
ground. An example of this is found at the
Seneca mine of the Calumet and Hecla Com-
pany (Slide No. 34). This ambulance car is
nicely upholstered and equipped with springs.
Another type (Slide No. 35) used by the
Homestake Mining Company of Lead, South
Dakota, is similar to a two-wheeled cart, is pulled
by hand and not intended to run on the car
tracks. It is equipped with springs and covered.
In some cases it may be necessary to take the
man out where water, dirt or snjall rock might
fall on him. The cover is some protection from
these.
A practical method of improvising an under-
ground mine ambulance is to equip an ordinary
mine car, used regularly for hauling the coal out
of the mine, with four springs. The springs are
attached to the upper edge of the sides of car
near the corners and the stretcher suspended in
the car from these springs (Slide No. 36). This
method can be used in most of our coal mines.
The springs should be placed with the stretcher
so that both may be obtained at the same time.
To summarize: The reasons for transporta-
tion are to get the injured man to a place of
greater safety, to make him more comfortable,
to prevent further injury through handling and
finally to get him where he may receive proper
treatment.
How to transport, or the method of trans-
portation, may be one-man, two-man, stretcher
squad, or car transportation — any one or all of
which may be used for one or more injured
persons.
When to transport an injured person will de-
pend upon the nature of the injury (for he often
must receive proper first-aid or emergency treat-
ment prior to transportation), whether the pres-
ent location of the patient is safe or not, and the
availability of assistance for transportation, and
the availability of capable and efficient equipment
and personnel for treatment.
Dr. Patterson: I am sure we are greatly indebted
to Dr. Sayers for this extremely interesting descrip-
tion of the "Transportation of the Injured." The sub-
ject is open for discussion, and I am going to call first
upon Dr. G. H. Halberstadt, of the Philadelphia and
Reading Coal and Iron Company, Pottsville, Pa., to
open the discussion.
DISCUSSION
Db. George H. Halberstadt, Philadelphia and Read-
ing Coal and Iron Company, Pottsville : The organiza-
tion and instruction of first-aid corps by the Philadel-
phia ^nd Reading Company occurred in 1904.
The army drill regulations were taken as a basis for
teaching. The army changed the method of bearers
of the litters later but this was not adopted as it was
thought that four men on the handles were preferable
to two.
There are 700 men in 70 corps constantly in training
for this work. In addition at each colliery there is a
rescue corps, trained to work in the helmet and to use
the pulmotor, oxygen inhalers, etc.
When summoned, the first-aid corps carry the dress-
ings case, containing hermetically sealed packets of
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the; PENNSYLVANIA MEDICAL JOURNAL
June. 1921
sterile gauze, picric acid gauze, absorbent cotton, gauze
and cotton bandages, tourniquets, etc.. When possible
the injuries are always dressed before the patient is
moved.
The Hoff litter is the simplest and most practical.
The canvas bed is covered with a rubber blanket and
then a woolen one. This excludes the air from below,
and a few blankets over the patient keep him reason-
ably warm. When impossible to use the litter the men
are instructed to carry the patient either by one, two
or three bearers.
In the gangways and tunnels the patient is trans-
l>orted in a mine car. The litter is suspended on four
springs that hang from the top of the sides of the car.
The United States Bureau of Mines showed some
slides to-day that were given them by the Reading
Company long before the bureau took up first-aid in-
struction.
The Hoff litter is the simplest and best for all pur-
poses— always assembled — the poles, spreaders and
canvas instantly available. When not in use it takes
up a small space and can be kept clean. All litters
that have to be assembled for use are undesirable.
At all collieries there are inside and outside dressings
stations, where any adjustments can be made before
the case is sent to its destination. The company's
medical department consists of a surgeon-in-chief and
sixty-three surgeons. A surgeon is always summoned
as soon as an accident is reported. He makes any
changes in the dressings, if necessary, and with first-
aid men accompanies the case to the destination. All
cases requiring it are sent to a hospital.
For years we have been at odds with the United
States Bureau of Mines on their method of use of
the oxygen breathing apparatus. Oxygen to be of
most service should be taken through the nose. The
Draeger helmet furnishes this method of respiration.
The oxygen is supplied in sufficient quantity for the
man to work or walk at a given gait — a fast walk.
When this speed is exceeded for a time it is necessary
for the rescuer to halt in order that the supply of oxy-
gen may catch up. The United States Bureau of
Mines trains their men to clamp the nose and take in
the oxygen through the mouth, which is physiolog-
ically wrong. I believe the reason for their adoption of
this method was that of their men ran into a mine,
and when he found respiration difficult instead of rest-
ing while the supply caught up with his demands, tore
off the helmet and was suffocated by mine gases be-
fore he could be rescued. The helmet may have some
terrors but in our experience, when the men wear it,
and are under proper control it is perfectly safe for
respiration.
Before the introduction of motor ambulances the
collieries were all supplied with horse-drawn vehicles
of a modified army pattern. They carried four litter
patients or two litters and five seated. All motor am-
bulances are of the same pattern as those formerly in
use. Horse-drawn ambulances are held in reserve for
use when weather conditions render the motors un-
available.
The fractured and dislocated spinal cases are put on
two splints, 5 feet long lashed 6 inches apart and cov-
ered with a folded blanket leaving an interspace. The
.Stokes litter by reason of its construction and bulk is
impractical for mine use. The first-aid boxes for
mine use are made of pine. This is the only wood
that will stand mine conditions. Metal will not an-
swer the purpose.
Dr. Pattehsok: Thank you, very much. Is there
any further discussion? We should like to hear from
some of the railroad surgeons whom we have the
pleasure of having with us.
Dr. J. S. Carpenter, Jr., Pennsylvania Railroad
Company, Pottsville : I think Dr. Halberstadt has cov-
ered the subject In the railroad work at Pottsville,
the ambulance carries the men, when practicable; and
if not, we use the Hoffman litter. We have all sur-
face work. The engine itself brings the men in, when
they are at any distance from the hospital. In that
way, our transportation problem is covered very well
Dr. Patterson : Dr. Heilman, haven't you something
to say?
Dr. J. B. Heilman, Pennsylvania Railroad Com-
pany, Harrisburg: We have nothing new to add to
what has been said. Some years ago, we adopted a
large, heavy stretcher, but we have found that the
army stretcher is the most efficient stretcher for gen-
eral purposes.
Dr. Patterson : We have time for more.
Dr. Heilman : One thing that has interested me has
been the matter of competitive drill. I have not been
entirely convinced that the competitive drill is prac-
ticable for railroad work. There is a large labor
turnover, and it is difficult to keep the teams together;
and in the training which these men get, there is so
much time devoted to preparing for competition that
I doubt whether it is worth while. I should like to
hear the opinion of other railroad surgeons on this
point. The Bethlehem Steel Company and the coal
companies are satisfied to use it
Dr. Halberstadt: Each week a given time is al-
lotted for practice dressings under direction of the
corps captain. Throughout the year all the men in
each division are assembled at night for instruction by
the surgeon-in-chief. In September, each year, all the
men, 700 in number, meet for the annual competitive
drill. Each division draws a problem and the win-
ning corps enter for the final test In July the corps
are g^ven nine problems, injuries to all parts of the
body, artificial respiration, handling and transporta-
tion. Each division draws one problem and competes
with its own corps. The winners enter the final. It
is needless to say there is more practice work done
during the months of July, August and September
than all the rest of the year.
Training railroad men is much more difficult than
training miners, as it is impossible to get them long
enough to accomplish much with them.
Dr. Patterson : If no one has anything to add, I
will ask Dr. Sayers to close the discussion.
Dr. Sayers: I have very little to say. In regard
to the oxygen-breathing apparatus. Dr. Halberstadt
stated that you can work no faster than it will feed.
That is true of all types of oxygen-breathing appara-
tus, however. There have been developed recently,
within the last four or five years, other forms of ap-
paratus. These have automatic valves, which will fur-
nish oxygen as fast as you wish to use it. Of course
Doctor Halberstadt knows about these, but I do not
know whether the others know it.
(To be continued in July Journal.)
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June, 1921
TRUTH ABOUT MEDICINES
661
TRUTH ABOUT MEDICINES
MECHANISM OF SHOCK AND EXHAUSTION
George W. Crile, Cleveland (Journal A. M. A., Jan.
15, IC20) says that the man in acute shock or exhaus-
tion is able to see danger, but lacks the normal muscu-
lar power to escape from it; his temperature may be
subnormal, but he lacks the normal power to create
heat; he understands words, but lacks the normal
power of response. In other words, he is unable to
transform potential into kinetic energy in the form of
heat, motion and mental action, despite the fact that
his vital organs are anatomically intact. His mental
power fades to unconsciousness; his ability to create
body heat is diminished until he approaches the state
of the cold-blooded animal ; the weakness of the vol-
untary muscles finally approaches that of sleep or
anesthesia ; the blood pressure falls to zero ; most of
the organs and tissues of the body lose their function.
It is evident, therefore, that in exhaustion the organ-
ism has lost its self-mastery. Self-mastery is achieved
only by the normal action of the master tissue — the
brain. This subject is gone into at some length by
Crile. He concludes finally, that the brain is an organ
of intense metabolism. The brain cells may be
conceived as having their protective and nutritive cyto-
plasm evolved to function at a distance. The energy-
transforming function of the brain has such high
selective value in the biologic sense as to confer a
selective value also on the structure and functions of
the liver and of the blood ; for if the brain cells thus
stripped cannot transform energy fast enough to drive
the muscles speedily enough to escape from the enemy,
then the liver and the blood will perish as well as the
brain. The more completely the liver and the blood
and the lungs and the kidneys keep the brain cells free
from the impairing by-products of their active metabol-
ism, the cleaner pair of heels will the pursuing enemy
see. The brain cannot work continuously, but a re-
versible process is necessary at regular intervals to
restore it. This process in the higher centers is called
sleep. The more intense the activation, the more
needed is sleep. The brain is the only organ that
sleeps conspicuously. Of great significance is the fact
that the entire man spends one-third of his time wait-
ing for the brain to restore itself — to put itself again
in the position of being able adaptively to transform
potential into kinetic energy.
"GROUP PRACTICE"— A MENACE OR A
BLESSING
A most important innovation, commonly described
as "Group Practice," has appeared in this country
during the last two or three years. It was referred
to incidentally by Dr. Billings in his discussion of
"The Future of Private Medical Practice," in The
Journal last week (February sth). This week we pub-
lish a plea for group medicine by Dr. Leonard, who
is connected with a recently organized group (the
.Academy of Clinical Medicine) in Duluth. Groups
under various names, such as clinics, academies, etc.,
arc being organized over night, as it were, here, there
and yonder, in towns of 10,000 or 15,000, as well as
in the larger cities. The development of modern medi-
cine, and especially of scientific laboratory diagnosis,
may make necessary some such cooperative plan as
these groups are intended to provide. Equipment,
laboratory, roentgen ray and the like, which the aver-
age practitioner is not able to provide or to utilize
satisfactorily, may thus be cooperatively provided.
But what of the outcome of this new development?
What of the physicians outside the group? Some evi-
dently are seeing the advantages and are forming
other groups — perhaps in some instances forced to do
so in self-defense I Will not this mean group against
group ? May it not be one more step toward the com-
plete elimination of the general practitioner — of the
family adviser — of him who heretofore has reflected to
the public the altruistic motives of the medical pro-
fession? Does it mean that the family physician is
being replaced by a corporation ? Will commercialism
or professional altruism control the management of
these corporations, or groups if they are not incorpo-
rated? In thinking over this matter it is important to
look ahead and see what influence this new develop-
ment may have on the public. How will the average
layman view it? Will he not prefer state medicine?
We are asking, not answering, the questions — present-
ing but not attempting to solve the problem ; for if we
mistake not, it will prove to be a serious ont.— Jour.
A. M. A., Feb. 12, 1921.
HARMFUL MEDICAL ADVERTISEMENTS
Quackery is one of those by-products of human na-
ture and psychology that thrives in all climes and has
persisted in some form or other throughout the pass-
ing years. Unfortunately, it is not confined to the
inerudite or the so-called lower strata of society. De-
ception makes its gains among all manner of persons.
The Journal has repeatedly pointed out the insidious
ways in which the nse of nostrums is perpetuated and
even facilitated by the medical profession. Sometimes
this occurs unwittingly ; not infrequently, a defensible
excuse cannot be offered. Least of all is there justi-
fication for those inaccuracies and improprieties of
statement with which medical publications, supposedly
intended to lead rather than mislead the profession,
all too often deceive their readers. The questionable
statements of a chance contributor cannot always be
verified or controverted. .A. well conducted journal
must remain an open forum for the discussion of de-
batable questions in science. Fraud thus meets its
antagonists under conditions in which error can be
condemned and the truth may prevail. But the adver-
tising columns are like a closed book. They are all too
often protected by pay. In any event, custom has ren-
dered them free from easy attack. As a particularly
blatant illustration of the harm that can come from
present-day tolerance of low standards in such forms
of publicity, a recent advertisement on the front page
of a widely read foreign contemporary — the Berliner
klinische Wochenschrift — may be cited. In bold type
it urges the abandonment of cod liver oil in the treat-
ment of rickets and other nutritive disorders of infancy
and childhood, and urges the substitution of a natural
mineral water (containing arsenic) in the management
of the conditions specified. Cod liver oil has won an
almost indispensable place for itself in the therapy of
rickets. The high esteem in which it has been held in
this respect as the result of years of empiric experience
is finding its justification in the current researches on
nutrition. The advice g^iven in the advertisement cited
is not merely a parody on scientific investigation : it is
an insult to the intelligence of the medical profession •
at present. — Jour. A. M. A.. Jan. 22. 1921.
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662 THE PENNSYLVANIA MEDICAL JOURNAL . June. 1921
THE PENNSYLVANIA ^^^^ therefore "this data" is a blood-curdling
barbarism. He evidently must have read a re-
I^PT\T/^ Af TOTTI?\rAT '^^"* Chia^o clinical lecture, in which the title
1 M.M^LJl\^r%.Li jyj\JM\iy^U .peaks of "adnexae," which might be called a
„.,.,, r ' r ~. TT TTT : duplicated plural, similar in its fault to the
Published monthly under the supervision of the Pubhcation -J t ■ tf r > e • i
Committee of the Trustees of the Medical Society of the Sute Cherubims of SOme Speakers of inCOrreCt lan-
ennsy vana. guage. Their failures in writing foreign words
Editor always remind one, if a careful student, of the
FREDERICK L. VAN SICKLE, M.D Harrisburg j^j^j ^f ^^.^^^^ ^^^^^ ^^ ^^^ j^ears from the
PRANK F. D. RECKORD**^*. .*"*". Harrisburg tongucs of returned soldicrs of the World War.
Auooiat* E4itor» English is a good enough speech for North
ipsEPB mcFa«land, M.D Philadelphia American teachers and writers of surgery.
Geokgi E. PrAHLKR, M.D Philadelphia ,,,, ,,..,/•• i '
Laww«c« LiTcunKLD, M.D., Pittsburgh Why try the dead and the foreign tongues, when
i.'"s*t*war/°Ro'dman; M.D.', ■.■.■.■.■.■.". ■.■.■.■.■.■.■.■.■.".■.■.■.Phiiadeiphw most of US do not Understand the spelling or
b«»aS; ^'y^'■^°■:^V^\\:V^\\V.\■:.\\\\■^^ grammar of "those kind" of words? Failure
PubUcation Committee to appreciate Keen's suggestions in language
T*-^^"?f"i"*' ^xP^ Chairman .Reading makes surgical literature akin to a good deal of
Thkodorz B. ArPEL, M.D., Lancaster , ° , , . - . P , .
Frank c. Hammomd, M.D Phiiadeiphu hasty surgical education. It IS a sign of unde-
.„ ~. ~. r r~; ' ; velopment in surgical minds.
Alt communications relative to exchanges, books for review, . "^ < ,, ■ < ■
manuscripts, news, advertising and subscriptions are to be ad- A mere CUttCr IS nOt alwayS a real SUrgeon :
dressed to Frederick L. Van Sickle, M.D., Editor, ai» N. . i . ^ i i «i. ^
Third St., Harrisburg, Pa. uor IS a school teacher, who says between you
The Society does not hold itself responsible for opinion, ex- ^nd I," a Worthy product of Philadelphia's
pressed in original papers, discussion^ communications or ad- method of Selecting the Board of EduCation bv
vertisements. ^ o ^ ^ -
— employing common pleas judges to discnm-
Subscription Price— $3.00 per year, in advance. j^ate between candidates. It is too much in its
Z .Q21 results like the university trustees of a certain
•' ' town, one of whose learned professors declares
to an audience that "between you and I" this is
EDITORIALS so. J. B. R.
PROFESSOR KEEN ON MEDICAL
AUTHORSHIP
Dr. W. W. Keen, Editor of the encyclopedic
Surgery known to all surgeons, has evidently
seen, in looking over many manuscripts sub-
mitted by surgeons scattered over the world's
surface, many specimens of poorly written Eng-
lish. In a recently published series of clinical
lectures he speaks his mind. He has been a
teacher of surgery to so many medical pupils
that his introductory instructions on surgical
authorship will be given heed. Keen truly as-
serts that much technical writing is done in bad
English. He slyly attacks the bad Latin which
creeps past the author and the proofreader;
but a graduate of Brown University, such as he
is remembered to be, soon catches it.
He avers that the English of some authors of
the present day is obscure, inelegant and ver-
bose. He advises laying aside one's manuscript
for a few weeks and then rereading it. No bet-
ter suggestion could be made to a writer, who
wishes to see his own bad grammar, undigested
.statements and false logic. Professor Keen re-
minds us that "data," so common now in nevvs-
. paper and medical English, is a plural noun
like, for example, memoranda and adnexa and
STATE MEDICINE
The medical profession ought to face the
facts concerning the possibility of the establish-
ment of some form of state medicine and com-
pulsory health insurance at some future time.
So far as Pennsylvania is concerned the legis-
lature, thanks quite largely to the activities of
our Medical Legislative Conference, left the
subject as it found it, but the movement is not
dead.
Dr. Victor Vaughn, chairman of the Council
of Health and Public Instruction of the A. M.
A., says, "There is a' widespread movement for
state medicine and compulsory health insurance
which the medical profession should oppose.
On the other hand it has been pointed out that
if the organized medical profession leaves the
initiative in those matters to other groups the
medical profession will be placed on the de-
fensive. That is a bad position." Foch said.
"No campaign is ever won by the side on the
defensive," and he said it while he was holding
the allied armies on the defensive. But he was
preparing for his offensive. Is the medical pro-
fession preparing its offensive in this campaign?
It has been often pointed out that, as medi-
cine is practiced to-day, only the wealthy or the
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EDITORIALS
663
very poor can get the benefit of the best in diag-
nosis and treatment. The great middle class,
the common people of whom Lincoln said, "God
must love them. He made so many of them,"
cannot afford to pay for the diagnostic care
given "without money and without price" to the
down and outer. And the great middle class is
beginning to get wise to the situation. The med-
ical profession cannot afford to permit its only
position on this great question to be one of op-
position to change. We must as a profession
Iiave a positive program and we must work for
it. Will that program be the establishment of
small, well-equipped community hospitals jn
each community of say 10,000 people, such hos-
pitals with laboratories, x-rays and operating
facilities open to every physician in the com-
munity? If not that — what? There must be
an answer.
As someone has said, "The community has a
stake in demanding high quality of medical
service for the health and well being of every-
one is affected. The community should there-
tore bear a share in the provision of tools which
the medical profession needs to work with."
Have we not a right to believe that the young
men who are leaving country practice for a
career in the cities (the average age of the phy-
sician in country practice is above 50 years) will
return again to the smaller communities if they
are assured of finding laboratories, x-ray ap-
paratus and other hospital and dispensary facil-
ities there ? Have we not a right to believe that
such a move would improve the practice of med-
icine and thus redound to the lasting good of the
"common people"? C. R. P.
ARGUMENTS AGAINST NOISE
There has been a great deal of agitation by
the police authorities in some of the larger cities,
in an endeavor to reduce to a minimum unnec-
essary noise. Philadelphia is now passing
through police vigilance of this kind, especially
in regard to the unnecessary noise upon the part
of the driver of the automobile. There are other
factors producing unnecessary noise, that should
be brought under better control. There are at
least four good reasons why every physician and
every other good man should wage war against
unnecessary noises:
I. Because in a certain and an increasing
number of sensitive and "well" people such
noises distinctly aid in carrying them over the
easily-passed line from comparative health
among the sick and "unfit for service," thus
surely increasing the sick rate.
2. Because they decidedly destroy the vital
and restorative powers of the sick, and thus
clearly increase the death rate.
3. Because they dull and brutalize the nerv-
ous systems of those who can, and do, learn to
withstand their pathogenic influences.
4. Because they serve to make the sensitive
and cultured, who are able to do so, separate
themselves in their search for quiet from the
masses, who must endure, thus serving to in-
tensify the license of the noise-makers, by les-
sening the checks upon their crimes. The
separation of the community into classes is
exaggerated in this way, and these growing
wider apart, make impossible desirable helpful-
ness, sympathy and mutual understanding of
each other. Noise is undemocratic; it should
be un-American. F. C. H.
MEDICAL OBLIQUITIES
The faculty of thinking, speaking and writing
straight in medicine seems to be a rare quality
and one that is hard to find. This is becoming
more and more apparent when we compare
medical utterances with those of other profes-
sions and even trades. The tradesman sells his
goods largely on his ability to present them in
an attractive light ; the lawyer, the minister and
the educator must of necessity present their
ideas in such a manner as to make them seem
desirable, but the doctor seems to have devel-
oped a habit of oblique medical expression, if
not of oblique medical thought. As a result
the country is flooded with quacks and cults,
superstitions and misinformation, that need not
have developed had the doctors been given to
more direct. habits of thought and .speech.
"Obliquity," says the dictionary, "is the qual-
ity possessed by lines which are neither parallel
nor at right angles; moral error." In these
days of keen business activity and rivalry, when
every effort is being made by men and women
to think, speak and write straight upon subjects
which pertain to their business, so that they may
"sell" their ideas, physicians have no right to
endanger their noble profession by oblique
thinking. The results achieved by those who
take the time and trouble to think and write in
parallel lines or at right angles, emphasize the
necessity of some method by which the medical
profession of to-day and of the future may de-
velop this faculty in such proportion as to
achieve results commensurate with their im-
portance to the community.
When we compare the literary activities of
medical men with those of other professions,
and note the sameness and lack of vigor and
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THE PENNSYLVANIA MEDICAL JOURNAL
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force in the presentation of medical ideas, we
are surely impressed with a contrast which is
not on the credit side of medical literature.
Straight statement of fact is necessary in medi-
cine and is more important than it is in any
other profession, and yet simple unembellished
statement of fact is rarely seen, presented in
such forceful and attractive manner as will pro-
duce results.
Could we but awaken the medical men of the
state to their duty of increased literary activity,
to their duty of thinking, speaking and writ-
ing straight on medical affairs, we believe that
the prestige which Pennsylvania possesses in
medical history would be greatly increased.
WHEN SHALL THE SURGEON OPER-
ATE IN CASES OF APPENDICITIS?
This is as interesting a question, as several
years ago, notwithstanding the voluminous lit-
erature that has appeared upon the subject.
The following seems worthy of consideration in
a general survey of the subject. The first acute
attack of appendicitis belongs to the physician.
This attack may (a) pass by without complica-
tion, in which instance there is no occasion for
surgical interference; or (b) earlier or later,
with alarming symptoms of general or local
nature ( fever, rapid pulse, pain, dullness on per-
cussion, rigidity) it may go on to perforation
and abscess formation. Such an abscess either
(A) leads to progressive and threatening gen-
eral peritonitis, or (B) it remains circum-
scribed and becomes encapsulated, the first se-
vere symptoms continuing without important
change.
The conditions (b), (A) and (B) indicate
surgical treatment as do all chronic recurrent
forms of appendicitis. The question appears
still to be undecided. Some surgeons advocate
operation in all patients as soon as the diagnosis
is made.
The above seemingly furnishes a clear and
concise rule for the guidance of those who are
in doubt as to when surgical interference is in-
dicated. F. C. H.
A HOPEFUL SIGN
For many years the subject of the centraliza-
tion of national health affairs by the govern-
ment of this country has been discussed, but with
no solution up to this time. Recently, however,
ihe subject has been revived in the public press
through a discussion of this subject by the Phy-
sician to the President. In the minds of many
there has been the thought, frequently expres.sed
in words, that the babies and the sick in the
United States should have as much protection
as the live stock on the farm and that these
activities should be supervised by a Secretary
in the Cabinet of the President.
The getting together of the many organiza-
tions now in operation dealing with the subject
of health, sanitation, prevention of disease and
all activities therein related, should be the aim
of the present administration as the best possible
way of producing real results and gaining the
active cooperation of every one interested in
the subject.
. Another subject that should receive the atten-
tion of such a centralized head of the govern-
ment is the practice of the healing art in all
its branches. Granted the right of states to
regulate the examination and licensure of all
who desire to follow any of the branches in-
cluded in such practice, there still remains much
that might be accomplished in correlating the
plans by which a more equitable reciprocal rela-
tion between state boards could be brought
about, as well as aiding in advising better plans
of procedure that would thereby bring together
the discordant views of those whose duty it is
to present new laws or amend those now upon
the statute books of every state.
"SOCRATES REDUX"
MEDICAL INDUSTRIAL EFFICIENCY
With our desk piled full of papers and un-
answered letters, there was some satisfaction in
learning from the scraps of conversation that
came to us through the partly open door, tiiat
Socrates had found an auditor in the waiting
room and was sufficiently entertained not to re-
quire our attention.
But the satisfaction was neutralized by the
interest we soon found in the conversation, and
we were really glad when the wind blew the
door wide open and let us into it, in a passive
way. Starting at the point in the dialc^^ue at
which the wind assisted us, this is what we
heard :
"I tell you that efficiency is the word of the
times. It is in adhering to it, in its strictest
sense, that the future hope of industry lies."
The speaker, whose manner was didactic and
dogmatic as well as sententious at times, paused
and Socrates, as usual, began by asking a ques-
tion.
"I don't understand it. What does it mean?"
"Well, it can be perfectly well understood by
one phase of what the 'Cosmos Steel Works'
has just started. According to their new rules.
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no one is to be employed unless he be in perfect
health. If he passes a satisfactory medical ex-
amination, he will be given a trial month, in
order to see what he can do, and prove his abil-
ity to maintain a standard day's work as pre-
scribed for his department. If he fails, out he
goes to make room for someone who is able to
do it; if he succeeds, he is given regular em-
ployment and advanced or otherwise as he
merits."
"What is the nature of the medical exam-
ination ?"
"It consists first of a psychological test, then
of a rigid examination both physical and chem-
ical, just as though he was a candidate for life
insurance. You see that through these means
the company will be free from liability for acci-
dents that might accrue from mental defects,
from loss of time that might result from illness,
and will be saved the payment of many pen-
sions."
"Do I understand that this applies to all new
employes ?"
"Not a new hand will be accepted unless he
first obtains the doctor's certificate."
"How about the office, does it apply there
too?"
"I understand that it applies throughout.
There ought to be no discrimination."
"No, I don't think there ought."
"It is the greatest thing that has ever been
undertaken. As you know, at this time they are
turning off fifty per cent of the hands. Only
men known to be in the best of health will be
retained. There are a lot of men in the estab-
lishment that have been there a long time and
are known to suffer from various ailments, that
it is desirable to get rid of ; the new system gives
the opportunity."
"You are a stockholder in the steel works,
aren't you?"
"Yes, I am, and I was consulted in regard to
the matter and gave the best advice I could, es-
pecially in regard to the medical examinations,
which I can tell you will be thorough."
"Would you recommend such a system for all
industries ?" ,
"Undoubtedly. As I said, I believe it is the
hope of the future."
"How far would you apply it ?"
"I think it should be universally adopted."
"Do you mean by 'universally adopted' that
it is appropriate for all industrial, commercial,
educational, financial and similar enterprises?"
"Exactly."
"Well, it's a great system. But how could it
work? If everybody who could not pass as a
first-class life insurance risk were to be ex-
cluded from work and was shut out of the shops,
the stores, the offices and the schools, who would
do the work? How many physically and men-
tally perfect men do you suppose there are?
What would become of the great army of the
rejected? Who would support the early cases
of Bright's disease, of diabetes, and of incipient
tuberculosis? I really don't see that a man
should be denied work because he has the early
signs of a disease that may not kill him for many
years. Much of the world's best work has been
and is being done by men more or less advanced
in chronic and ultimately fatal maladies. What
can a man do if no one will give him work while
he can still work? It is bad enough to know
that final incapacity stares him in the face with-
out having his present livelihood taken away be-
cause that day is sometime coming."
"Such people must look out for themselves."
"Where are they going to look ?"
"That js up to them."
"You are mistaken, it is up to us. We will
have to take care of them."
"I don't understand what you mean."
"Well, I'll tell you. When everybody works,
everybody has money; when few work, few
have any. The more people we keep from work-
ing, the poorer we will be because we who have
a little will have to take care of those who have
nothing."
"I don't follow you."
"No? A while ago I met Humphry Warner.
You know him, he has been your patient for a
long time. Well, ten years ago he was my pa-
tient, so I know something about him too. He's
out of luck now, and likely to die of a broken
heart if something worse does not happen to
him first — suicide, for instance."
"You absolutely astonish me. What is it ?"
"Efficiency !"
"What do you mean ?"
"Just that. Ten years ago Warner was made
chief clerk in the purchasing department of the
Cosmos, and being a brilliant fellow, it was only
a short time before he made himself indispen-
sable, and last year would have been made the
purchasing agent if nepotism had not prevented.
The 'Atlas Company' heard all about it, and of-
fered him fifty per cent more salary, so he left
the Cosmos and went with them. In three
months the affairs of the Cosmos were in such
shape that they were after him to come back at
any price. After a long period of negotiation
he finally consented, with the promise that he
should be made the purchasing agent within a
year.
"Now the Atlas has an invariable rule that if
an employe leaves them, he is never under any
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THE PENNSYLVANIA MEDICAL JOURNAL
June. 1921
circumstances to be taken back again, so you see
he had to bum his bridge behind him, which he
did. He left the Atlas Company, and came to
the Cosmos. The first thing he found himself
up against was an unexpected medical examina-
tion, which he and the officers thought a kind of
joke. It wasn't. The doctor found that he had
a little sugar in his urine and refused him a cer-
tificate, and then he was politely told of the new
rule, and that although under the circumstances
it was most regrettable, it would be impossible
to take him into the company's service. Of
course he cannot go back to the Atlas, he cannot
work for the Cosmos, it has become noised
about that he is in bad health, and so he sud-
denly finds himself without a position, with a
large family on his hands, a home only partly
paid for, supposed bad health to contend with,
and no prospects."
"It is most unfortunate. I must see him at
once."
"What good will that do? Will you tell him
that you are the principal cause of his troubles ?"
"No, but I will explain to him the necessity
of taking the utmost care of his health, and point
out to him the folly it would be for a great cor-
poration to have a sick man in charge of an im-
portant department."
"Do you think that he has been an 'efficient'
worker in the past ?"
"Undoubtedly, and one of the very best the
company had."
"Did you ever examine his urine?"
"No, it was never necessary."
"Well, I happen to know that he had had a
little sugar in his urine now and then for at least
ten years, and I judge that he may continue to
have for the next ten years. In my judgment
if a man has been able to do what he has done,
he might as well go on doing it as long as he is
able, only, of course, it would not be 'efficient.'
It will be more 'efficient' to have the purchasing
department of the Cosmos all mixed up as it is
at present, and to let Warner die of a broken
heart, or develop real diabetes from worry and
disappointment, or commit suicide. Multiply
Warner's case by a thousand, or a hundred, or
even by ten and you will have a clear idea of
the immense benefit that medical efficiency in
industrial life is going to be to the community."
MEDICOLEGAL
VACCINATION
The Superior Court has handed down recent-
ly a number of decisions which are of interest
to the medical profession. The act of June i8.
1895. is entitled "An act to provide for the more
effectual protection of public health in the sev-
eral municipalities of this commonwealth." This
act provides for the vaccination of children at-
tending school.
The school directors of Mill Creek Township,
Erie County, were convicted of a violation of
this act, and appealed to the Superior Court.
The question raised by the appeal was whether
or not Mill Creek Township is a municipality
within the intent and meaning of the act of as-
sembly before referred to. In delivering the
opinion of the court affirming the conviction.
Judge Orlady says :
"In giving the meaning intended by the legis-
lature to the word 'municipalities' as used in the
title of this act, and the subsequent legislation
depending upon it, we are not controlled by re-
fined distinctions as to the origin of the term or
its technical meaning as given in particular
cases. * * * The facts in this case are
clearly stated, and when we consider the aim
and purpose of the legislature, there can be but
one meaning ascribed to the term 'municipalities'
as used in the act referred to. The purpose of
the legislation is clearly defined in its title — to
provide for the more effectual protection of the
public health.
"We have in this state, townships and school
districts having a population equivalent to that
of many cities, and to hold that this act would
be operative in one and not in the other, when
its sole purpose is to prevent the spread of com-
municable diseases throughout the common-
wealth, and which are always liable to affect
both, would be unreasonable. * * *."
As said in Stull v. Reber, 215 Pa. 156, "The
act is not a penal statute. It is a broad general
act relating to the health of the whole popula-
tion of the commonwealth. * * * It is an
act touching very closely common rights and
privileges, and, therefore, especially requiring
a common sense administration."
The same question was raised in the case of
the Commonwealth v. Butler, which was de-
cided by Judge Linn of the Superior Court. In
this case the defendant refused to have his son
vaccinated, and he was refused admission to the
.schools. The father was then prosecuted under
the School Code for failure to require the at-
tendance of his son in school.
These two cases remove the last vestige of
doubt relative to the vaccination law of 1895.
ILLEGAL PRACTICE OF MEDICINE
In the case of the Commonwealth v. Read.
President Judge Orlady of the Superior Court
affirmed the conviction of the defendant, who
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PROPAGANDA FOR REFORM
667
for the past 30 years has been conducting a place
of business at four different locations on South
Street, Philadelphia, and vending patent medi-
cines, roots, herbs and mixtures. He adver-
tised as "Dr. Read, Specialist," "Dr. Read, Ex-
pert Optician," and "Dr. E. Parker Read,
Specialist in Diseases 'of Both Sexes." He ad-
mitted that "he was not a graduate of any med-
ical school, and he had received no certificate of
licensure from the Bureau of Medical Education
and Licensure of the Commonwealth of Penn-
sylvania. The court decided that the defendant
by his conduct brought himself unquestionably
within the terms of the act relating to the li-
censure of physicians; that he engaged in the
practice of medicine, that is, he held himself
out to the public as one instructed and skilled in
the healing art.
In the case of Commonwealth v. Dailey, the
Superior Court in an opinion by Judge Trexler,
affirmed the conviction of an osteopath who had
prescribed drugs for the use of his patients and
held himself out to be a physician, upon the
ground that his license under the act of March
19, 1909, which authorized him to practice os-
teopathy, did not entitle him to practice medi-
cine and surgery. B. J. MyeRS.
PROPAGANDA FOR REFORM
Diphtheria Antitoxin and Diphtheria Baciixi. —
The well established curative properties of diphtheria
antitoxin must not be confused with its possible value
as a prophylactic against the disease. Attempts have
been made to apply diphtheria antitoxin locally in the
pharynx and nares with the hope of eradicating the
objectionable micro-organisms that may have found
lodgment there. Recent investigations to determine
the effect of diphtheria antitoxin in preventing lodg-
ment in and growth of the diphtheria bacilli in the
nasal passages of animals were entirely negative (Jour.
A. M. A., Jan. i, 1921, p. 41).
Pharmaceutical Barnums. — The exploiter of nos-
trums to the medical profession, realizing that at least
a pretense must be made of giving the composition of
medicaments offered to the physicians, declares that
his clay poultice has for its base "anhydrous and levi-
gated argillaceous mineral." This sounds much more
imposing than "dry and finely powdered clay," and
satisfies by its very sonorousness. Now comes a prod-
uct exploited chiefly to members of the dental pro-
fession, but also, it seems, to physicians. These are
"activated" tablets which are "an anodyne, analgesic,
febrifuge sedative, exercising (sic) antineuralgic and
antirheumatic action." Their composition is stated to
be "An activated, balanced combination of the mono-
acetyl-derivative of para-amidophenetol together with
a feebly basic substance in the alkaloidal state from
Thea-Sinensis." This means nothing more than
acetphenetidin (phenacctine) and caffein (Jour. A. M.
A., Jan. I, 1921, p. 42).
More Misbranded Nostrums.— The following prod-
ucts have been the subject of prosecution by the fed-
eral authorities charged With the enforcement of the
Food and Drug Acts: Dermacilia Eye Remedy and
Ointment (The Dermacilia Manufacturing Co.), the
first falsely claimed to be an effective treatment and
cure for sore eyes of all forms, the second falsely
claimed to be effective for all skin and scalp affection
and for all kinds of eczema. Rogers's Liverwort, Tar
and Canchalagua (Williams Manufacturing Co.),
falsely and fraudulently recommended for treatment
of consumption, asthma, whooping cough, influenza,
etc. Valesco (Alhosan Chemical Co.), falsely and
fraudulently recommended as a remedy for tubercu-
losis, asthma, pneumonia, etc. (Jour. A. M. A., Jan. i,
1921, p. 52).
Serums and Vaccines in Therapy. — In the develop-
ment of serums and vaccines, scientific investigation
and experimentation have preceded clinical tests of
those products which have proved of permanent worth.
Whenever the clinical use of serums and vaccines' has
prpceeded beyond well established facts determined by
laboratory research, the result has usually been disap-
pointing. To submit a serum or vaccine for clinical
trial without successful preliminary laboratory in-
vestigation of its probable worth is an imposition on
the profession. The success of diphtheria antitoxin
and antityphoid vaccine has prejudiced the profession
and public in favor of vaccines and serums so that they
arc willing to accept a new serum or vaccine simply
because it is a serum or vaccine. In his introduction
to a series of articles on serum and vaccine therapy
which is now being published by the Council on Phar-
macy and Chemistry, Flexner points out that in only
a few instances has the anticipation been realized that
a curative antiserum for each disease would be dis-
covered. The history of antipneumococcus serum af-
fords a striking example of the difficulties and pitfalls
that are encountered in the development of remedies
of this class. Thus far only one therapeutically ac-
tive serum. Type I, has been developed, and this serum
is not effective against infections by other types of
pneumococci. Despite this, we are being offered to-
day for clinical use "polyvalent" antipneumococcic
serums recommended by the makers for the use in all
types of pneumococcus infection (Jour. A. M. A., Jan.
8. 1921, p. 115).
Parathesin Not Admixtb) To N. N. R.— The Coun-
cil on Pharmacy and Chemistry reports that the local
anesthetic ethyl paramino-benzoate was first intro-
duced as "Anesthesin" or "Anaesthesin" ; that the
product is not patented in the United States, and that
it may be manufactured by any firm which chooses to
do so. In order that a common name for the drug
might be available, the council coined the short, easily
remembered and descriptive name "Benzocaine." As
the terra "Anesthesin" had become a common name
for the drug, the council also recognized this as -a
synonym for benzocaine. While the council had pre-
viously recognized the brand of benzocaine manufac-
tured by the H. A. Metz Laboratories, Inc., under the
name "Anesthesin," this firm requested recognition of
the product as "Parathesin." Ars the use of one sub-
stance under several names causes confusion and re-
tards rational therapeutics, the council's rules provide
against the recognition of proprietary names for non-
proprietary, established drugs. For this reason, and
because the legitimate interests of the manufacturer
may be safeguarded by appending his name or initials
to the common name, benzocaine or anesthesin, the
council refused recognition to the designation "Pa-
rathesin."— {Jour.
A. M. A.. ^•ov.^^.,lJ)^^.^^.(i35^0gle
The Medical Society of the State of Pennsylvania
OFFICERS' DEPARTMENT
WALTER F. DONALDSON, M.D.
Secretary
8014 Jenkins Arcade Building
Pittsburgh, Pa.
THE PROGRAM
The Committee on Scientific Work have com-
pleted plans for your enlightenment and enter-
tainment at Philadelphia, October 3-6. The pro-
gram is replete with scientific, economic and so-
cial features worthy of the high standards of
former years, and is destined to attract nation-
wide attention, with a consequent large attend-
ance. Symposia in every section offer their
popular appeal.
Ninety per cent of the scientific exhibit space
was sold May i. Hotel reservations may soon
be at a premium. Apply for yours now. All
sessions and exhibits will be held in the Bellevue-
Stratford Hotel.
THE 1921 HOUSE OF DELEGATES
The component societies are reminded that
they are entitled to representation in the House
of Delegates in the proportion of one delegate
for each one hundred members or fraction there-
of in good standing on July i. Two alternates
must also be elected for each delegate, and the
names of the delegates and alternates forwarded
to the Secretary's office not later than July 31.
Elect live, interested members who will go to
Philadelphia for the first meeting of the House
— Monday afternoon, October 3.
MEDICAL DEFENSE
The latest application for defense in a suit for
alleged malpractice was concerned only as a con-
sultant, but is threatened as a codefendant with
the attending physician and the hospital. This
member is in good standing, and his dues were
paid before March 31.
FALSE PRETENDERS
In this department of the May Journal we
commented favorably on a suggestion that medi-
cal societies should contribute financially, if nec-
essary, to the successful prosecution of unli-
censed and illegal practitioners of the healing art.
In Mercer County the Pennsylvania Department
of Health has recently begun the prosecution of
a group of osteopaths aHeged to be practicing
osteopathy without license, and in certain in-
stances, practicing medicine and surgery. The
Health Department has retained an attorney to
assist the Mercer County District Attorney, and
the Mercer County Medical Society has engaged
to assist in the prosecution one of the best at-
torneys in Mercer County.
It is to be hoped that the startling contrast in
the preparation for practice required of an osteo-
path and that required of a doctor of medicine
may be emphasized during the trial, and that at its
conclusion, respect for the laws of the common-
wealth and for the rights at least of babies and
children, victims of diphtheria and other acute
diseases, may be instilled into the minds of the
hordes of illy-prepared licensed and unlicensed
drugless therapists at the present time practic-
ing throughout the state.
LEADERS
1930 Per Capita
i^zi Per Capita
Tax Paid
Tax Paid
Co«»i/.v
Dec. 31, 1920
May 16. I9ii
Per Cent
Lehigfi
83
100
inalc
Elk
22
26
Il8</r
Greene
22
25
114^
Montgomery
138
146
106^
York
118
122
I03Tr
Berks
127
130
102^0
Luzerne
234
238
102%
Dauphin
147
150
I02'c
Lycoming
102
104
102%
Beaver
59
60
lOll
Mercer
73
74
101%
Chester
75
76
101%
Crawford
55
55
100%
Huntingdon
36
36
100%
Wyoming
13
13
100%
Juniata
II
II
100%
Sullivan
8
8
100%
Allegheny
1,135
1.139
100%
Columbia
47
47
100%
Armstrong
60
60
100%
THE 1921 MEMBERSHIP LIST
The 192 1 list of officers, committeemen and
members of the sixty-three component county
medical societies will appear in the July Jour-
nal. Every effort is being made to have the lists
and the appended information accurate and up-
to-date. At this writing — May 16 — our paid
membership for the current year is 98% of the
total membership for 1920 on December 31. Of-
ficers of the several component societies are
urged to bring in the few deHnquent members.
■Digitized by VjOOQIC
June, 1921
OFFICERS' DEPARTMENT
669
not only that the list may be complete, but that
all such may be enrolled in time to preclude all
possibility of misinterpretation of the $2.50 six-
month per capita tax to the State Society for all
bona fide new members uniting with the com-
I)onent societies between July i and the last of
the year 1921.
CHANGES IN MEMBERSHIP OF COUNTY
SOCIETIES
The following changes have been reported to May
15th:
Allegheny: New Member— Francis W. Halstead,
Bakerstown. Transfer— Robtit A. Kilduffe, Pitts-
burgh Hospital, Frankstown Ave., Pittsburgh, from
Delaware County.
Berks: Resigned — Octavia L. Krum, Wernersville.
I'm/A— Samuel L. Kurtz (Jeff. Med. Coll., '54), of
Reading, President of the Medical Society of the State
of Pennsylvania in 1891, found dead in bed, April 22,
aged 88.
Blair: Transfer — Charles W. Delaney of San Jose,
California, to the Medical Society of California.
Chester : Reinstated Member — ^Jeremiah V. Reeder,
Phoenixville. Resigned— FrtAerkk M. Hollister, of
Brocton, Mass. rrowj/^r— Franklin C. Brush, of
Phoenixville, to Montgomery County.
Clarion : Z>ea«A— Richard S. Keeler (Coll. of Phys.
& Surg., Baltimore, "85), of St. Petersburg, recently,
aged, 60.
Columbia: Removal — Clark S. Long, from Main-
ville to Benton.
Dauphin : New Member — Bayard T. Dickinson, 343
N. Front St, Steelton. Death— Uartin L. Wolford
(Jeff. Med. Coll., '80), of Harrisburg, April 28,
aged 69.
Fayette: Death — Daniel A. Chapman, of Republic,
April 5.
Indiana : New Member — Francis Reilly, Claghome.
Lawrence: Reinstated Member — Patrick J. Brice,
New Castle.
Lehigh : New Members — Roland W. Bachman, 301
N. Second St.; John F. Eckert. 438 N. Sixth St.;
John W. Noble, 36 N. Jefferson St.; John Lear, 1038
Hamilton St., Allentown; William A. Riegel, Cata-
sauqua; Alan L. Difenderfer, Harrison B. Kern,
Slatington.
McKean : Reinstated Member — Allen A. Van Slyke,
Mt. Jewett.
Mercer: New Member — Burgoyne L. Tinker, West
Middlesex. Removal — Joe Funderburgh, from Mercer
to Toledo, O. ; William M. Writt, from New York to
Farrell. Retired from practice — Arthur E. Brown,
Greenville.
Mifflin : Removal^Chnrles H. Brisbin, from Chal-
font (Bucks Co.) to Lewistown.
Montgomery : New Members — Perry W. McLaugh-
lin, Ammon G. Kershner, Norristown.
Northampton : New Member — Earle B. Schlier, 534
Ave. D., Bethlehem. Resigned — Allen O. Kisner, Beth-
lehem.
Philadelphia: New Members — Bernard B. Neu-
bauer. Medical Arts Bldg. ; Francis X. McCarthy, 6008
Germantown Ave.; Henry L. Klein, 708 N. Fortieth
St.; Clarence A. Patten, 319 S. Sixteenth St.; Joseph
P. Garvey, 3639 Spring Garden St. ; Grace Tankersley,
(transferred from Delaware Coun^ Medical Society),
1831 Chestnut St.; Harold L. Bottomley, Samaritan
Hospital; George Bevier, 34th and Pine Sts. ; Chris-
tian Bauer Kyle, 703 W. Erie Ave.; Joseph W. Rob-
erts, 1426 North Eighteenth St.; Howard K. White,
460 Green Lane; Isaac J. Muldawer, 2023 South
Fourth St.; Charles Theodore Cutting, 112 N. Broad
St.; Abraham I. Baron, 2422 N. Twenty-Ninth St.;
Joseph Charles Yaskin, 1719 N. Fifty-Second St.;
John O. Bower, 2033 Walnut St.; Lourain Edward
McCrea, St. Agnes Hospital; W. A. Jolley, 140 N.
Broad St.; Frank W. Burge, 4226 Walnut St.: John
Edward Loftus, 605-6 Medical Arts Bldg.; Egbert T.
Scott, 5827 Haverford Ave.; G. Baringer Slifer (re-
instated), 1707 Ritner St.; Everett A. Tyler, 2104
Chestnut St.; Elmer J. Berlin, 1702 Oregon Ave.;
William M. Joyce, 1919 South Broad St. ; Morris L.
Yubas, 907 Pine St.; Joseph P. Besser, 3134 Diamond
St.; Frank W. Konzelman, 3638 North Twenty-First
St.; Robert P. Sturr, 1823 Spruce St.; Herbert Reid
Hawthorne, 606 N. Thirteenth St.; Walter M. Miller,
5100 Spruce St; Henry Newton Speer, 727 S. Fifty-
Fifth St, Philadelphia. Deaths— Charlts A. Koder
(Jeff. Med. Coll., '82), of Philadelphia, April 9, 1921 ;
S. A. Sterritt Metheney (Jeff. Med. Coll., '94), of
Philadelphia, March 26, 1921, aged 52; George L. Mc-
Coy, of Philadelphia, April 6, 1921.
Schuylkill: £>ea*/i-— Ralph W. Montelius (Jeff.
Med. Coll., '76), of Mt Carrael, April 19, aged 6;.
Somerset: Resigned — Beverly W. Briscoe, Addison.
TioCA : New Member— h. L. Hobbs, Blossburg.
Warren : New Member — ^Thornton M. Shorkley,
Tidioute. Resigned — Clarence A. Bonner, of Wor-
cester, Mass., formerly of Warren.
Westmoreland: New Members— Joseph L. Sowash,
Irwin; Joseph D'Alessio, Monessen; David R. Shep-
ler. West Newton. Deaths — William Marshall Barron
(Univ. of Pitts., '92), of Latrobe, April 14, from ty-
phoid fever, aged 59.
PAYMENT OF PER CAPITA ASSESSMENT
The following payment of per capita assessment has
been received since April 16. Figures in first column
indicate county society numbers ; second column, state
society numbers:
For 1920
May 10 McKean 45 7199 $5.00
For 1921
Apr. 16 Clinton 20 6797 5.00
Beaver 54-57 6798-6801 20.00
Venango 53 6802 5.00
Warren 16-36 6803-6823 105.00
Potter 4-8 6824-6828 25.00
York 121 6829 5.00
Cambria 110-112 6830-6832 15.00
Warren 37 6833 5.00
Apr. 18 Franklin 40-44 6834-6838 25.00
Center 26-28 683(^6841 -'15.00
Northampton 1 13-127 6842-6856 75.00
Montgomery 144 6857 5.00
Philadelphia 2014-2016 6858-6860 15.00
Apr. 19 Jefferson 38-45 6861-6868 40.00
Venango 54 6869 5.00
Blair 81-82 6870-6871 10.00
Chester 76 6872 5.00
Tioga 33 6873 5.00
Apr. 20 Wyoming 13 6874 5.00
Washington 122-123 6875-6870 10.00
Cumberland 40 6877 5.00
Lackawanna 161-169 6878-6886 45.00
Apr. 21 Westmoreland 135-140 6887-6892 30.00
Franklin 45-47 6893-6895 15.00
Fayette 104-115 6896-6907 60.00
Apr. 22 Monroe lo-ii 6908-6909 10.00
Venango 55 6910 5.00
Erie 114-115 6911-6912 10.00
Lehigh 90-100 6913-6923 55.00
Clinton 21 6924 5.00
Apr. 23 Luzerne 208-213 6925-6930 30.00
Allegheny 1117-H34 6931-6948 90.00
Potter 1-3. 9-14 6949-6957 4500
Apr. 25 Venango 56 6958 5.00
Warren 38 6959 5.00
Dauphin 146 6960 5.00
Warren 39-40 6961-6962
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670
THE PENNSYLVANIA MEDICAL JOURNAL
June, 1921
Apr. 26
Clearfield
58
6963
$5.00
Lawrence
57
6964
5.00
Westmoreland
141-144
6965-6968
20.00
Columbia
46
6969
5.00
Apr. 27
Wayne
25
6970
5.00
Apr. 28
Luzerne
214-219
6971-6976
30.00
Venango
57
6977
5.00
Clinton
22
6978
SCO
Apr. 29
Washington
124
6979
5.00
Blair
83-84
6980-6981
10.00
Clarion
32
6982
5.00
Susquehanna
1S-19
6983-6987
25.00
May 2
York
122
6988
5.00
Warren
43-44
6989-6990
10.00
Montgomery
145
6991
5.00
May 3
Somerset
41-42
6992-6993
10.00
Cambria
"3
6994
5.00
May 4
Dauphin
147-148
6995-6996
10.00
Clearfield
59
6997
5.00
May 5
Dauphin
149-150
699*-6999
10.00
Westmoreland
14S-146
7000-7001
10.00
May 6
Warren
41-42
7002-7003
10.00
Montgomery
146
7004
5.00
Luzerne
220-221
7005-7006
10.00
May 7
Westmoreland
147-148
7007-7008
10.00
Beaver
58-59
7009-7010
10.00
Columbia
47
701 1
5.00
Northampton
128
7012
5.00
Erie
116-117
7013-7014
10.00
Clinton
23
7015
5.00
Potter
15
7016
5-00
May 10
Lawrence
58
7017
S-oo
Beaver
60
7018
5.00
Delaware
86
7019
5.00
McKean
42-43
7020-7021
10.00
May II
Indiana
61
7022
5.00
May 12
Franklin
48-so
7023-7025
1500
May 13
Bradford
51
7026
5.00
May 14
Mercer
74
7027
5.00
FREDERICK L. VAN SICKLE, M.D,
Executive Secretary
212 North Third St., Harrisburg, Pa.
THE MEDICAL LEGISLATIVE CONFER-
ENCE OF PENNSYLVANIA
The final meeting after adjournment of the
legislature was held in Philadelphia, May 13th,
with as full an attendance of the members as
during the time of more active work of the con-
ference.
The reports of the Secretary, Treasurer and
the other members of the conference proved the
worth to the members of the profession, as evi-
denced by their contributions, as well as the ef-
fective work done by the conference. Detailed
reports on each bill before the Senate or House
of Representatives were not considered neces-
sary, but we take pleasure in presenting the fol-
lowing report of the President of the Confer-
ence:
REPORT OF THE PRESIDENT OF THE MEDICAI<
LEGISLATIVE CONFERENCE OF PENNA.
Gentlenien: As president of the conference I
respectfully submit the following report :
The uppermost question during the past year
has been Compulsory Health Insurance.
The Commission on Health Insurance held a
number of meetings at which various members
of the conference were present and made telling
arguments against the adoption, in this state, of
Social Insurance.
Mr. Lewis, of the Commission, informed me
the medical men had, by their arguments, con-
vinced him that the medical aspect of this ques-
tion was detrimental to the people affected by its
workings.
The Commission appointed to consider the
subject, reported to the legislature. Two reports
were made, one, the majority, was signed by
nine members rejecting the proposition, and a
minority report advocating its adoption, was
signed by two members.
There was no bill passed by the legislature
continuing the Commission or appointing a new
one, and consequently the question of Compul-
sory Health Insurance will be a dead issue for
some time to come.
The antivivisectipnists were not in evidence
during the session of .the legislature nor were
the antivaccinationists, consequently no legisla-
tion on these subjects had to be met.
The. members of the osteopathic cult are no
doubt satisfied with their status in the state, for
they had no bills introduced in their behalf.
The House Bill 23, known as the Chiropractic
Bill, was the one which caused us so much work
and anxiety. This bill in the form introduced
in the House, would have legalized all the unli-
censed chiropractors in the commonwealth and
would have established a Board of Chiropractic
examiners. It had low educational qualifications
and would have opened Pennsylvania to the
products of all the chiropractic schools in the
country. Its main object was to legalize all those
practicing this cult at the present time and who
are doing so in defiance of the law.
After a very strenuous time and much effort
this bill died a seemly death in the Committee on
Health and Sanitation of the Senate.
Bill 856, introduced by the Department of
Education, had for its object the centralization
of various examining boards, under one Board
of Licensure. The conference decided to take
no action on this bill.
There were a number of bills which were en-
dorsed by the conference and some others which
were opposed by it.
The conference was ready and willing to as-
sist the Department of Health in all its efforts
to have legislation passed for the health and wel-
fare of the people.
The president of the conference madenjumer-
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June, 1921
OFFICERS' DEPARTMENT
671
ous trips to Harrisburg and on a number of
these trips was accompanied by the secretary.
There were several hearings given by the
Committee of Health and Sanitation of the Sen-
ate and the House and these were attended by
members of the conference as well as members
of the profession.
The legislative work was very arduous and
required a great amount of time and effort.
Tribute should be paid to the men who did
yeoman work in bringing about such good re-
sults. Dr. Van Sickle stood always ready to
respond when called upon and Dr. Krusen was
kept busy with his part of the program and,
needless to say, did it well.
Every member of the conference responded
when called upon for help, and aided greatly in
accomplishing the results.
The profession in general showed its interest
when the financial call was made, and when the
necessity for interviewing the members of the
legislature arose, the men throughout the state
acted quickly and effectively.
The conference published four bulletins dur-
ing the session. These were sent to the secre-
taries of the county societies and kept the profes-
sion informed of the work. These bulletins
were compiled by Dr. Van Sickle and Mr.
Haight.
In future the medical profession should take
its rightful stand in politics and show the men
who are charged with the conduct of political
matters, that it can and will care for its own in-
terests, as well as safeguard the health of the
people.
It should take an active part in the selection
of men for the legislature who can be depended
upon to pass only such medical legislation as will
be beneficial and constructive.
Mr. Robert Haight, who was selected as the
legislative adviser, did splendid work. He was .
ever ready with advice and suggestions and the
results accomplished are, in no small way, due
to his untiring efforts.
Dr. Steedle and Dr. Miller, chairmen, respec-
tively, of the House and Senate Committees on
Health and Sanitation, deserve the gratitude of
the medical profession of Pennsylvania, for the
very important role they played in the. work at
Harrisburg during the recent session of the leg-
islature and the successful results obtained were
due, in a great measure, to the assistance these
gentlemen rendered the conference.
Respectfully submitted,
G. A. Knowles.
Philadelphia, May /j, ip2i.
PHILADELPHIA HOTELS AND GARAGES
AVAILABLE FOR THE ANNUAL
SESSION
THE ALDINE, Chestnut and Nineteenth Streets.
Single room, $2.50 and $3.00; with bath, $4.50
and $5.oa Double room, $3.50 and $400; with
bath, $6.00 and $7.00. Hotel contains 350 rooms;
25 to 30 rooms available.
THE ADELPHIA, Chestnut and Thirteenth Streets.
Single room with bath, $5.00, $6.00 and $7.00.
Double room with bath, 2 beds, $9.00 and $10.00.
Hotel contains 365 rooms; 25 single and 100
double rooms available.
THE BELLEVUE-STRATFORD, Broad and Wal-
nut Streets. Outside rooms with bath — single,
$7.00 and $8.00; double, $9.00 and $10.00. Inside
rooms with bath — single, $4.00 and $5.00; double,
$7.00. Parlor, bedroom and bath, $20.00, $23.00
and $25.00. Hotel contains 734 rooms.
THE COLONNADE, Chestnut at Fifteenth Street.
Single room, $2.00 and up; with bath, $3.50.
Double room, $4.00; with bath, $6.00. Hotel con-
tains 150 rooms.
THE CONTINENTAL, Ninth and Chestnut Streets.
Single room, $2.00, $2.50 and $3.00; with bath,
$3.00, $3.50 and $4.00. Double room, $4.00 and
$4.50; with bath, $5.50, $6.00 and $7.00. Hotel
contains 400 rooms.
GREEN'S HOTEL, Eighth and Chestnut Streets.
Front rooms with bath — single, $3.30 and $5.00;
double, $5.00. Front rooms without bath — single,
$2.50; double, $3.30 and $4.00. Inside rooms with
bath— single, $3.50; double, $3.30 and $4.00. In-
side rooms without bath — single, $2.00 and $2.30;
double, $5.00. Hotel contains 320 rooms.
THE LORRAINE, Broad and Fairmount Ave. Sin-
gle room, $2.30; with bath, $3.00 and $4.00.
Double room, $4.00; with bath, $3.00 and $6.00.
Hotel contains 270 rooms.
THE LONGACRE, Walnut Street, west of Broad.
Single room with bath, $4.50 and up. Double
room with bath, $6.00 and up. Parlor, bedroom
and bath (two persons), $7.00 and up. Hotel con-
tains 183 rooms; room for 100 persons with two
in a room.
THE MAJESTIC, Broad Street at Girard Avenue.
Single room, $2.50 and up; with bath, $4.00 and
up. Double room with bath, $5.00 and up; with
twin beds, $6.00 and up. Hotel contains 600 rooms.
THE NEW HANOVER. Twelfth and Arch Streets.
Single room, $2.50 and up; with bath, $4.00 and
up>. Double room with bath, $5.00 and up; with
twin beds, $6.00 and up. Hotel contains 200 rooms ;
room available for 30 or 60 persons.
THE RITTENHOUSE, Chestnut and 22d Streets.
Single room, $2.50 and $3.00; with bath, $4.00.
Double room, $3.30 and $4.00; with bath, $6.00.
Hotel contains 200 rooms.
RITZ-CARLTON, Broad and Walnut Streets. Double
room, outside, with bath and twin beds, $10.00.
Hotel contains 200 rooms ; 20 dauble rooms avail-
able.
THE ST. JAMES, Walnut Street and Thirteenth.
Single room with bath, $4.00 to $7.00. Double
room with bath, $7.00 and $8.00. Hotel contains
200 rooms; 100 rooms available.
THE VENDIG, Thirteenth and Filbert Streets.
Rooms with bath — single, $3.00; double, $7.00.
Hotel contains 216 rooms ; 30 rooms available.
THE WALTON, Broad and Locust Streets. Rooms
with bath — single, $5.00; double, $7.00. Hotel
contains 330 rooms; 50 rooms available.
THE BELGRAVIA, Eighteenth and Chestnut Streets.
Rooms with bath — European plan — single, $3.00;
double, $7.00. American plan — single, $8.00; dou-
ble, $14.00. Hotel contains 200 rooms.
GREEN HILL FARMS, City Lane and Lancaster
Road. (Suburban garage attached.) Outside
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672
THE PENNSYLVANIA MEDICAL JOURNAL
June, 1921
rooms, private bath, twin beds, $5.00, $6.00, $7.00
and $8.00. 150 rooms available.
GARAGES LOCATED IN CENTRAL PART
OF CITY
ADELPHIA GARAGE, 134 N. Juniper St. Capacity
150 cars. Can accommodate 15 cars.
AMERICAN GARAGE, 14" Locust Street. Capacity
150 cars. Can accommodate 10 to 15 cars.
BELLEVUE-STRATFORD GARAGE, 1407 Locust
Street. Capacity 200 cars. Can accommodate 50
cars.
CAMAC STREET GARAGE, 255 S. Thirteenth St
Capacity 250 cars. Can accommodate 75 cars.
CENTRAL AUTO GARAGE, 314 S. Camac Street.
Capacity 75 cars. Can accommodate 7 to 10 cars.
PENNSYLVANIA GARAGE, 329 S. Broad Street.
Capacity 500 cars. Can accommodate 100 cars.
NEW HANOVER GARAGE, 1125 Cherry Street.
Capacity 70 cars. Can accommodate 25 cars.
MEAT FOR THE HOSPITAL
By a Member of the Department of Food Economics
Armour and Company
Probably there is no class of caterers who have a
harder problem than the person who plans for the hos-
pital meal. Here they plan for the hard working help,
the brain worker, and the convalescent or the sick
person with the finicky appetite, as well as all the vari-
ous special diets. Here more than anywhere else a
knowledge of the use of the various cuts of meat is
desirable. Here appetite appeal is very important
The successful dietitian is one who can use the same
kind of meat many times and have it look and taste
dilTercnt Nothing is less appetizing than to have the
meal come to the table day after day looking and tast-
ing just like the previous meal.
With these thoughts before us let us consider the so-
called cheaper cuts of meat with the wide variety they
make possible. The round, rump, shanks, plate, flanks
and chuck constitute three quarters. of the weight of
the entire carcass. Because the demand is for the
loins and steaks that need no special skill in prepara-
tion, the heavier cuts are less expensive. While the
long fibre which is characteristic of these cuts requires
skill to prepare, so far as nourishment is concerned we
find that there is practically no difference. For in-
stance we find that a pound of medium fat beef rump
contains 1400 calories of fuel value and a chuck 1,105.
Having established a logical reason for these cuts
being cheaper and realizing that there is practically no
nutritive difference between them and the higher
priced cuts, let us consider what skill is necessary to
make them palatable.
One principle of cookery which will always govern
is to subject the meat to the greatest heat first. Brown
thoroughly the entire outside surface. This will keep
in the natural juices of the meat. Then heat and add
whatever liquid you have decided to use. Cover the
pan tightly, reduce the heat and allow the meat to
cook slowly until tender. During the entire process of
cooking, after the liquid has been added, the tempera-
ture should be below the boiling point.
The seasoning of any dish is important to make it
palatable. The enormous shipping facilities of to-day
enable us to procure an endless variety of spices, htrbs
and seasonings. These make possible so many com-
binations that one seldom needs to use the same flavor
twice. Thus two meat dishes, althotigh they are made
from similar cuts need not taste the same.
For some who do not care for the piquant flavor of
the spices, or in cases where the carbohydrate content
of the vegetable may be desirable, the vegetables may
be added to the meat and cooked with it In the case
of children or others who think they don't like certain
vegetables such as carrots or onions, the vegetables
may be removed from the juice before the meat is
served.
Next is the appearance of the dish. If you have
ever had a long siege of illness you can sympathize
with the person who will turn away leaving his meal
untouched or the one who will eat it under protest It
is so easy to make a little change in the appearance of
a dish. Have the portion neat and the garnishings
fresh and clean. There is every reason why the hos-
pital should be genuinely concerned over the appear-
ance of a tray no matter how strict the diet of the
patient.
Such points are important also when serving the
meals of the workers, as they help to eliminate waste.
.\ hard working man or woman will eat all the food
on his plate if it is well seasoned and appetizing in its
appearance.
"CHIROPRACTIC"
A Pennsylvania physician sends us some advertising
leaflets issued by a "chiropractor" in his vicinity. The
leaflet is one of those that are printed by the hundred
thousand and sold to individual chiropractors, having
the purchaser's name printed on the leaflet to give a
personal touch. Our correspondent comments :
"I am enclosing an example of the flagrant nonsense
which the public is being handed and is accepting. The
man whose name is printed on this circular as the
chiropractor was a schoolmate of mine. He finished
his education in the grammar school, while I kept on,
not earning a penny until I became twenty-four years
of age.
"On the day I left my home and office in July, 1917,
for the army this man, who is now a 'chiropractor,'
was perched on a ladder across the street painting a
house. Six months later, in camp, I received my home
newspaper containing his noisy advertisement ^He
had acquired the prefix 'Dr.' and was flourishing. At
the present time he boasts of two offices, a flourishing
'practice' and an automobile. In my home town of
50,000, five more chiropractors have established offices
within the past three years and are doing business."
We are not sure that any comment is necessary ; the
letter is an editorial in itself. However, it may be
worth while to point out that the profession that is
devoted to the relief and cure of human ailments is the
only one that will permit men without technical knowl-
edge to ply their vocation with impunity — provided
these ignoramuses speciously plead that they are rep-
resentatives of a new "school" of healing. It is not
conceivable that a man whose only training was a six
months' correspondence course would be put in charge
of a locomotive. It is equally inconceivable that a man
with a few weeks' reading of law would be admitted
to the bar and entrusted with cases that might involve
large financial interests. But a street cleaner or a
garbage collector can take a six months' "course" in
"chiropractice" and be permitted by the commonwealth
t.) hold himself out as competent to treat the most com-
plicated piece of mechanism known — the human body.
— Jour. A. M. A., Jan. 15, 1921.
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County Medical Societies
REPORTERS OF COUNTY SOCIETIES:
Adams — Henir Stevrart, M.D., GeltysbiiTg.
Allegheny — Lester Hollander, M.D., Pittsburgh.
Akmstkonc — Jay B. F. Wyant, M.D., Kittanning.
Beaver — Fred B. Wilson, M.D., Beaver.
Bedfokd — N. A. Timmins, M.D., Bedford.
Bexks — Clara Shetter-Keiser, M.D., Reading.
Blair — James S. Taylor, M.D., Altoona.
Bradford — C. L. Stevens, M.D., Athens.
Bucks — Anthony F. Myers, M.D.. Blooming Glen.
Butler- -L. Leo Doane, M.D., Butler.
Cambria — John W. Bancroft. M.D., Johnstown.
Carbon — Jacob A. Trexler, M.D., Lehighton.
Center — James L. Seibert, M.D.. Bellefonte.
Chester — Henry Pleasants, Jr., M.D., West Chester.
Clarion — Sylvester J. Lackey, M.D., Clarion.
Clkareield — J. Hayes Woolridge, M.D.. Clearfield.
Clinton — R. B. Watson, M.D., Lock Haven.
Columbia — Luther B. Kline. M.D.. Catawissa.
Crawford — Cornelius C. Laffer, M.D., Meadville.
Cuuberland — Calvin R. Rickenbaugh. M.D., Carlisle.
Dauphin — F. F. D. Reckord, M.D., Harrisburg.
Delaware — George B. Sickel, M.D., Chester.
Elk — Samuel G. Logan, M.D., Ridgway.
Erie — Fred E. Ross, M.D., Erie.
Fayette — George H. Hess, M.D.. Uniontown.
Franklin — John J. Coffman. M.D.. Scotland.
Greene — Thomas B. Hill. M.D., Waynesburg.
Huntingdon — John M. Keichline. Jr., M.D., Petersburg.
Indiana — C. P. Reed, M.D.^ Indiana.
T«i»e»sok— W. J. Hill, M.D., Reynoldsville.
JUHIATA — Benjamin H. Ritter, M.D., McCorsville.
Lackawakka — Harry W. Albertson, M.D., Scranton.
Lancaster — Walter D. Blankeoship, M.D., Lancaster.
Lawrence — William A. Womcr. M.D.. New Castle.
Lebanon — John C. Bucher, M.D. Lebanon.
Lehigh — Frederck R. Bausch, M.D., Allentown.
Luzerne — Walter L. Lynn, M.D., Wilkes-Barre.
Lycoming — Wesley F. Kunkle, M.D.. Williamsport.
McKean— Fred Wade Paton, M.D., Bradford.
Mercer — M. Edith MacBride. M.D., Sharon.
Mifflin — O. M. Weaver, M.D.. Lewistown.
Monroe — Charles S. Flagler, M.D., Stroudsburg.
MoNTCOMERV — Benjamin F. Hubley, M.D., Norristown.
Montour — John H. Sandel, M.D., Danville.
Northampton — W. Gilbert Tillman, M.D., Easton.
Northumberland — Charles H. Swenlt, M.D., Sunbury.
Perry — Maurice L Stein, M.D., New Bloorafield.
Philadelphia — John J. Repp. M.D., Philadelphia.
Potter — Robert B. Knight, M.D., Coudersport.
Schuylkill — George O. O. Santee, M.D., Cressona.
Snyder — Percy E. Whiflfen. M.D., McClure.
Somerset — H. Clay McKinley, M.D., Meyersdale.
Sullivan — Martin E. Herrmann, M.D., Dushore.
Susquehanna — H. D. Washburn, M.D., Susquehanna.
Tioga — John H. Doane. M.D., Mansfield.
Union — Oliver W. H. Glover, M.D., Laurelton.
Venango — John F. Davis, M.D., Oil City.
Warren— M. V. Ball, M.D., Warren.
Washington — Homer P. Prowitt, M.D., Washington.
Wayne — Edward O. Bang, M.D., South Canaan.
Westmoreland — J. F. Trimble. M.D.. Grcensburg.
WvoMiNf. — Herbert L. McKown. M.D., Tunkhannock.
York— Gibson Smith, M.D.. York.
June, 1921
COUNTY SOCIETY REPORTS
ALLEGHENY— APRIL
The regular monthly scientific meeting of the Alle-
gheny County Medical Society was held on April 19,
1921, at 8:30 p.m., in the Pittsburgh Free Dispensary
Building, 43 Fernando Street, Pittsburgh, Pa. The
president. Dr. Carey J. Vaux, was in the chair. At-
tendance : 133.
Dr. R. J. Behan took up the "Presentation of a Case
of Lymphatic Drainage of Ascites Through Paraffined
Veins." The consideration of drainage of ascitic fluid
was taken up in reference to hypertrophic cirrhosis of
the liver, with resultant stasis of the portal circula-
tion. The writer divided the operative measures for
the relief of this condition into two classes: first,
measures which aim to promote better circulation in
the liver ; second, mere drainage of fluid. A complete
review of the literature of these procedures followed
and the salient features of the Morrison, Talma, Rob-
erts, Schiassi, Mayo, Narath, Lamboth, Handley, Pat-
terson and Routte operations were discussed. As a
further development of the lymphatic drainage Dr.
Behan recommends the following method, which de-
pends for its success upon the drainage of the ascitic
fluid into tissue spaces. The author uses paraffined
veins as the medium for drainage and used it success-
fully in two cases. About 12 inches of the internal
saphenous vein is removed ; this is immediately
threaded on a glass rod of suitable size and put
through the stages of preparation, which pathological
specimens are subjected to for sectioning. Finally it
was imbedded in paraffin. This vein was then placed
in boiling water and, while still hot, the glass rod was
removed. Three sections were now made of the vein.
One section was placed between peritoneum and fatty
perirenal tissue; the second between peritoneal cavity
and fascia covering pelvis ; the third was attached to
the peritoneal cavity on one end and to the subcutane-
ous tissue about Poupart's ligament with the other. In
this manner efficient drainage of ascites was obtained
when other methods previously attempted failed.
Dr. F. A. Rhodes, "Presentation of a Case of Re-
section of Intestine for Mesenteric Embolism, and a
Case of Ruptured Spleen." Dr. Rhodes presented a
case of rupture of the spleen caused by traumatism in
a boy eight years of age. The injury was followed by
symptoms of shock and vomiting and a passage of
considerable mucous from the intestines. The parents
of the patient refused operation, but as the condition
of the child got. worse within 48 hours, he was oper-
ated on and a half-inch rupture of the hilus of the
spleen was found. A splenectomy was performed, and
the boy made an uneventful recovery. The second
case for presentation was a patient in whom a resec-
tion of intestine for mesenteric embolism was per-
formed. The patient, aged 47, a physician, took ill
suddenly with intense pain of the lower quadrant of
the abdomen. This was followed by vomiting, ab-
dominal distension and tympany. Intestinal obstruc-
tion was the preliminary diagnosis, 4nd 25 hours later
a laparotomy was performed. A gangrenous ileum
was found. Seven inches of it, with its mesenteric at-
tachment was removed, the bowel drained above and
an end to end anastomosis performed. Patient was
discharged well in 19 days. The speaker took up the
question of hemorrhagic infarcts into the mesentery,
and studying literature he found SCO cases on record
diagnosed after laparotomy. After reviewing the his-
tory, etiological factors and symptomatology of mes-
enteric infarcts he placed the mortality of cases from
8s to 94 per cent. Dr. J. J. Buchanan complimented
Dr. Rhodes on the success of this operation. He re-
called two cases of this type both of which terminated
fatally, in both of which a large amount of intestine
was involved. Dr. G. R. Wycoff in the discussion of
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Dr. Rhodes's paper reported one case of hemorrhagic
infarct into the mesentery, in which he removed 48
inches of the intestine; patient died within two days
after operation. Dr. Rhodes in closing the discussion
laid particular emphasis on the removal of all of the
mesentery involved in the process of gangrene.
Dr. I. L. Ohlman presented a case of "Double Pyo-
Nephrosis" in a man aged 44, married, father of eight
healthy children. Outside of measles and typhoid fever
patient had never been ill. About ten months ago,
however, he developed some pains referable to his
stomach, when empty, and was seeking relief from this
when a great deal of albumen present in the urine
prompted the attending man to send patient to the
writer. After roentgen ray study of the case' it was
discovered that both pelves of the kidney could hold
at least 52}^ c.c. of sodium bromid solution, and both
ureters were dilated. The presence of bacillus coli
communis was demonstrated from both kidneys.
Suprapubic cystotomy for good drainage was insti-
tuted.
Dr. Shaul George took up the question of "Essential
Gastric Hemorrhage with Fatal Issue and Autopsy."
He presented a case which occurred in a man 45 years
of age; occupation, laborer. Patient took ill suddenly
with marked hematemesis which was followed by a
collapse and symptoms of shock. Patient was re-
moved to the hospital and diagnosis of malignancy
was suspected. He was anemic, restless and delirious,
weighed 124 lbs., his pulse about 108, subnormal tem-
perature, no tympany completed the picture. The ad-
ministration of morphin, normal horse serum, citrated
blood and transfusion was carried out The patient's
symptoms continued for nine days, during which time
the red blood counts had reached one million per cc,
on which day patient died. An autopsy revealed no
gross changes in the stomach, but a microscopic study
of sections from the mucosa showed the presence of
Diaulafoy ulcers of the stomach. After reviewing
the literature on this subject Dr. George closed his
paper. In the discussion Dr. A. R. Matheny reported
a similar case where a gastrotomy was performed.
Vicarious hemorrhage was stopped by the use of Mon-
sell solution. This case recovered and left the hos-
pital in a comparatively short time. Dr. J. I. Johnston
lost two cases of vicarious hemorrhage from the stom-
ach. One followed drinking of hydrochloric acid, in
attempted suicide. No diagnosis was made in the two
cases; in neither instance was there an autopsy per-
formed. Dr. J. D. Singley remarked that the impor-
tance in Diaulafoy ulcers of the stomach is the fact,
that etiologically they are due to multiple septic emboli
in the mucosa. Dr. R. Kilduff emphasized the con-
trast of the clinical and pathological findings. Dr.
George, in closing the discussion, thought that should
he see another case of a similar nature he would ad-
minister a weak solution of silver nitrate through a
stomach tube.
"The Treatment of the Shaft of the Femur by the
Pearson Method of Caliper Extension with Demon-
stration of the Fracture Bed and Report of Cases,"
by Drs. John D. Singley and Morris A. Slocum. In
the presentation Dr. Singley reported 9 cases treated
by the Pearson method with uniformly good results
which he summarized in the following manner: There
is lack of shortening, no infection, slight amount of
bowing, it is comfortable both to patient and attendant
and adaptable to any fracture in the shaft of the
femur. The apparatus and bed was demonstrated,
using a dummy for the patient. Drs. R. E. Brenne-
man, R. Robinson, G. F. Berg, A. R. Matheny, J. A.
Ruben, J. D. Singley and M. A. Slocum entered into
the discussion, practically all of them agreeing on the
useful character and nature of this apparatus.
"Clinical Notes on Three Cases of Thoracic Aneu-
rism" was presented by Dr. W. W. G. Maclachlan.
The notes furnished were of three cases previously
reported at the Allegheny County Medical Society.
In the discussion Dr. Maclachlan stated that the
medical treatment used in this clinical entity has not
been sufficiently strenuous, since very little short of
iodides has been used. The actual cause in the forma-
tion of an aneurism is the deposit of spirochseta pallida
in the wall of the vessel, formation of granuloma, and
the giving away of the necrotic material in the arterial
wall. To kill the spirochseta in situ is the rational
form of treatment; fibrous tissue will replace the
necrotic wall of the vessel, and carry on the function.
The first case was a secular aneurism of the upper
portion of the arch of the aorta. Twelve injections of
arsphenamine and three years' treatment with mercury
and iodides is keeping this patient perfectly well. The
second case showed a large projecting aneurism of the
chest wall. This patient was given 15 treatments of
arsphenamine. He refused mercury and, although he
is relatively well at present, he will die soon of aneu-
rism. The third case, similar to the second case, had
IS injections of arsphenamine and two years of mer-
cury. Patient died while at work a few days ago.
No conclusions could be drawn from these few cases,
but Dr. Maclachlan feels certain that a great deal of
benefit can be given patients suffering from aneurism.
This communication was discussed by Dr. Lester Hol-
lander, who referred to the frequency of arterial wall
changes in syphilitics observed with roentgen ray ex-
amination. Dr. J. I. Johnston concurred in the
thoughts expressed by the paper.
"Laboratory Aids in the Diagnosis of Gonococceal
Infection." In this presentation Dr. Robert Kilduff
spoke of two laboratory methods. He laid particular
stress on the proper preparation and staining of films
in direct smears. The serological diagnosis of gonor-
rhea was also carefully considered.
Lester HollanoEk, Reporter.
BERKS— APRIL AND MAY
At the meeting of the Berks County Medical Society
held April 12th, Dr. Guthrie of Sayre, Pa., addressed
the society on "Practical Psychology as Applied to the
Modern Hospital." An abstract of his address fol-
lows :
In hospitals there should be cooperation by man-
agers, staff and nurses. The mental welfare of the
patients should receive the same consideration as their
physical condition receives. The reception of the pa-
tient should always be friendly and he should be
spared the sight, sound or smell of anything objec-
tionable. Sometimes a patient will be frightened by
the proximity of a postoperative, typhoid or gastric
lavage case. Operative cases should not be moved
into a ward until they are no longer annoyed by
laughter or music. If any patient complains, his com-
plaint should be investigated and, if found to be cor-
rect, the condition should be remedied; but, if the pa-
tient develops into a chronic fault-finder, he should be
removed from the ward.
Every detail should receive careful attention, in-
cluding drinking water and the bed pan. Nurses
should practice the golden rule to patients. A smile
always wins out, and attention should be given cheer-
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COUNTY SOCIETY REPORTS
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fully. Good food, well cooked, should be served hot
to every patient in sufficient quantity. A delicacy will
promote the flow of the digestive juices.
The public should be treated kindly and properly.
Such signs as "Silence" and "No Talking" do harm
and ought not to be around. In cases of serious ill-
ness the friends of the patients should be shown every
courtesy, including light refreshments. Statements
should not be sent immediately after a death.
Patients should be treated more as individuals and
less as cases. The spirit among hospital workers must
be the best if we are to maintain good hospital morale.
The society considered it a rare opportunity to hear
an address of this kind, referring to the common
sense rules of hospitals.
At the May meeting Dr. R. J. Henderson presented
the following paper. He illustrated the subject by
presenting three interesting cases of this disease which
had been benefited by the treatment. Dr. Henderson
had charge of the physiotherapy department of the
Walter Reed Hospital at Washington during the war.
PHYSIOTHERAPY IN THE TREATMENT OF
ANTERIOR POLIOMYELITIS
J. R. HENDERSON, M.D.
Reading, Pa.
The purpose of this paper is to formulate a brief
outline of the present status of physiotherapy in the
treatment of anterior poliomyelitis, or infantile paraly-
sis. No attempt will be made to offer anything new
to those intimately familiar with this method of treat-
ment. On the contrary, I shall endeavor to present
only that which has been established and accepted by
various workers and tested and modified in my per-
sonal experience.
Infantile paralysis is an acute disease, due to a
toxin or microbic infection which suddenly attacks the
ganglion cells in the anterior roots of the spinal cord.
The disease usually attacks children from one to five
years of age, comes on suddenly, mostly at night or
when the child is asleep, and the diagnosis is generally
made when the paralysis appears, which is from a few
hours to several days after the onset
Most of us in the past have been taught that either
all of the motor cells supplying a muscle have been
destroyed and recovery is therefore impossible, or if
the cells are not destroyed, the muscle will recover by
itself and treatment outside of braces possibly is un-
necessary. This is'a most pernicious doctrine, has led
to lamentable neglect in the treatment of this disease,
and has been at least partially responsible for many
children being maimed and crippled for life.
It might be well to review our anatomy in this con-
nection. We know that because the motor cells sup-
plying a single muscle do not come from a single spot
in the spinal cord, but arise from a scattered nucleus
and derive motor fibers from several spinal roots,
the focus of the disease may destroy some cells, in-
jure others, and yet leave some cells in the nucleus
uninjured. Sherrington (an English writer) says:
"The position of the nerve cells sending motor fibers
to any one muscle is a scattered one extending
throughout the whole length of the spinal segments
innervating that muscle. In the limb regions many
muscles receive their motor fibers from as many as
three consecutive spinal roots and the bodies of the
nerve cells innervating those must, therefor*, inside
the cord extend through the length of three whole
segments of the cord as a continuous columna group
and, in each transverse level of the cord, these cells
must lie commingled with nerve cells innervating many
other muscles." There is also another possibility, and
that is that at the various transverse levels there are
embryonic cells which are only awaiting stimulation
to develop them and take up the work of the cells
which have been destroyed. The main reason I think
why these embryonic nerve cells are prevented from
functionating is because the fibrous or scar tissue sur-
rounding them, due to the inflammatory process, re-
mains tmabsorbed.
The tissue in the neighborhood of the affected area
presents the usual symptoms of an ordinary inflam-
matory process anywhere else, there being nothing
characteristic of poliomyelitis. At the end of the in-
flammatory process there is either a complete neutral-
ization of the toxic element, with absorption of the
fibrous tissue and restoration to normal, or' else if the
cells have been damaged beyond recovery and the scar
tissue remains unabsorbed, yre have a more or less
permanent paralysis with early atrophy. The cold
flaccid limb, the paralysis and atrophy, while they are
' an important part of the clinical manifestations of this
disease, are the unavoidable consequences of the lesion
in the spinal cord. Therefore it can be readily tmder-
stood that any and all treatment applied to the para-
lyzed muscles, is not and cannot be followed by much,
if any, permanent good.
Motion and groMrth are physiological processes and
imder the direct control of their respective trophic
centers. Without the restoration of the trophic cell
and its axis cylinder, there can be no recovery of mus-
cular function. Massage, electricity, heat and pas-
sive motion applied to the paralyzed extremities do
not cause regeneration of the trophic centers, and are
useful only in so far as they help to keep up local
nutrition and develop the few muscle fibers which may
be getting some stimulus from a partially destroyed
trophic cell.
The thing which concerns us is this: is it possible
for the regeneration of the trophic cell to take place,
and if so, how? Regeneration being a physiological
process, it does not follow that the particular motor
cell which may have been destroyed, is regenerated
and, if we recall the facts that the position of the nerve
cells sending motor fibers to any one muscle is a scat-
tered one and that at each transverse level of the cord
• these cells lie commingled with other nerve cells in-
nervating other muscles and also the probability that
we have embryonic cells in the spinal cord waiting
under proper conditions to take up the work of the
destroyed cells, we may get an idea as to how re-
generation may take place by substitution. The treat-
ment of this disease, or I should say the treatment
of the clinical manifestations of the disease, has been
sadly neglected. There is no particular treatment of
the acute symptoms that I know, other than rest,
nursing and hygiene. But I do claim for the post-
febrile and present paralytic stage that there is a par-
ticular method of treatment which will produce favor-
able results, the greatest drawback being the length of
time required. As you all know, nerve tissue regen-
erates more slowly than any other tissue of the body,
therefore, to obtain results, one must be most persis-
tent as it is not a matter of a few weeks, but months,
and even years in some cases, to obtain the maximum
benefit. I do not believe there is any case of infantile
paralysis which is entirely hopeless, the amount of
benefit to be obtained in any individual case depending
first, on the amount of trophic nerve cells in the spinal
cord which are destroyed ; second, on early treatment ;
third, on persistent treatment.
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The particular method of treatment which I wish to
bring to your attention for the relief of the postfebrile
or paralytic stage, is the application of heat. The local
application of heat has always been recognized as a
valuable empiric method of treatment. Perhaps the
most important physiologic action of heat is to pro-
duce hyperemia. The latter is nature's own remedy
and occurs with the regularity of a natural law.
Among the effects of hyperemia are: relief of pain,
respiration property of dissolving blood coagula, exu-
dates in joints, tendons, etc.
Heretofore the different methods employed for
raising the temperature of the subcutaneous tissues
has had one drawback, that is injury to the skin and
not until it was demonstrated that satisfactory results
could be obtained by the use of diathermia, which is
a high potential, oscillating electric current, was there
any known practical method by which the subcutane-
ous tissues could be heated without causing injury to
the parts. It is by the proper application of this
method that we cause a heating of the subcutaneous
tissues through and through. It is not the electricity
that brings about the regeneration; it is the physio-
logical process which is inaugurated as the result of
the heating of the deeper tissues which causes the ab-
sorption of the fibrous material and the stimulation of
the embryonic cells which finally brings about re-
covery.
As accessory forms of treatment, massage and the
application of interrupted galvanism and sinusodial
currents does much in maintaining the local nutrition
of the muscles. Braces are also necessary to prevent
deformities, but any or all of these last mentioned
methods in themselves will not cause regeneration of
nerve cells. Clara Shetter-Keiseb, Reporter.
DAUPHIN— APRIL
At the regular monthly meeting of the Dauphin
County Medical Society, held in the Harrisburg Acad-
emy of Medicine, with Dr. C. R. Phillips, president, in
the chair, Dr. George R. Moffitt, bacteriologist, of
Harrisburg, gave a most interesting and profitable
illustrated talk upon his recent experiences in Poland.
Major Moffitt in abstract told of the desolation of the
industrial plants from which the Russians had taken
all the machinery and the Germans had taken all the
metal, even the roofing, and the panes of glass from
the windows.
Of the hospital work, Dr. Moffitt told of the crowded
conditions and of the starved condition of many of
the patients.
"The peasants would drive to the hospital," he said,
"bringing two or three more patients, and when the
doctors told them that the hospitals were filled to over-
flowing, they would simply lift the patients to the
ground and drive away. The leading doctor of one of
the big hospitals and his wife had given up their beds
and were sleeping on piles of straw. In one hospital
for children there were thirty beds and ninety chil-
dren. Sometimes the only treatment for smallpox,
which existed in the most virulent form, was by paint-
ing with iodine. Not a single American died of ty-
phus under the treatment given by the American doc-
tors.
"Almost 850 children were in one hospital which
was in the path of the Bolshevik army. The task of
moving these children to places of safety was a big
one but was safely accomplished.
"The accuracy of the Bolshevik artillery," said Dr.
Moffitt, "was accounted for when it became known
that eight out of ten officers in that army were Ger-
mans, trained through the war.
"The Home Guards of Poland were women. They
followed the custom of the armies of men and sang
as they marched. The. singing was in four part har-
mony and was especially beautiful. In Germany much
heavy manual labor is done by the women."
Dr. Moffitt was at one time cut off from supplies
and in making his way back to Warsaw, he found out
that "a pack of cigarets was as good as a $10 bill for
a tip." Frank F. D. Reckobo, Reporter.
DELAWARE— APRIL
The April meeting of the Deleware County Medical
Society was held at Chester Hospital, on April 14th,
Dr. George H. Cross presiding. The paper of the eve-
ning was presented by Dr. George M. Dorrance, Phila-
delphia, his subject being "Plastic Surgery of the
Face."
Dr. Dorrance first considered the question of scar
formation and the reasons why scars stretch, so that
what looks to be a beautiful cosmetic result shortly
after operation presents a totally different picture a
few months later.
He called attention, from an anatomical standpoint,
to the influence o( the fascia and underlying muscles
on the surface contour of the body. When these are
divided the contraction of the muscles and fascia, as
well as the elastic fibres in the skin, tend to gradually
stretch the new fibrous tissue composing the scar.
Pathologically, in a wound, there is an exudate be-
tween the edges of the wound with an infiltration of
round cells and leucocytes. This exudate gradually
undergoes organization and many new-formed ves-
sels are seen in this granulation tissue. As a result
one finds a certain amount of induration around and
beneath a wound, acting as a kind of "natural splint."
As time goes on this exudate is absorbed and the
fibrous tissue, contracting as it does, obliterates the
vessels. The pink scar then becomes white. Gradu-
ally the contraction in each direction stretches this scar
and the wide depressed scar results.
Realizing these facts, success in preventing this ef-
fect may be attained by carefully suturing the mus-
cular layer, and then markedly everting the edges of
the wound so that fascia is in apposition to fascia and
strong union results. Later the eversion is reduced
by the contraction and a good cosipetic result is ob-
tained. Good results are dependent to a large extent
on operative work done at the proper time. In these
secondary plastic operations six to twelve months
should be allowed before operating. Massage is of
much value in postoperative treatment.
In discussing the tubed pedicle graft Dr. Dorrance
referred to the loss of flaps in plastic work after
burns, after x-ray treatment for cancer and in syphi-
litics. This can be prevented by taking flaps from
healthy areas and transferring them by the tubed
pedicle method. Flaps can be moved quite a distance-
by this method. Dr. Dorrance's paper was well illus-
trated by lantern slides, and was very instructive and
enjoyable. Georce B. Sickel, Reporter.
HUNTINGDON— APRIL
The Huntingdon County Medical Society met at the
Hunting^pn Club rooms, Thursday, April 14, 1921,
with the vice-president. Dr. Fred Hutchinson, in the
chair, and the following members present : Drs. Simp-
son, Richards, Harman, Frontz, St. Clair, Morgan,.
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COUNTY SOCIETY REPORTS
677
Sears, A. H. Evans, Reiners, Schum, Koshland and
Keichline.
Dr. Frontz reported for the Committee on Public
Policy and Legislation and urged us all to stand by
the State Society Legislative Committee, which is do-
ing a splendid work for the public as well as the pro-
fession. The Chiropractic Bill was referred back to
the House Committee and passed finally with changes
which were endorsed by the State Society. Dr. Finne-
gan's bill is meeting with a great deal of opposition
from practitioners who are not in favor of spending a
few years in preparation.
We are going to motor to Cresson July 14th.
John M. Keichline, Reporter.
LANCASTER— MAY
ANNUAL BANQUET
The annual banquet of the Lancaster City and
County Medical Society was held on the evening of
May the 4th, at the Stevens House, Lancaster, and
was one of the most successful affairs the society has
ever held. It has been customary to hold our banquet
in January, but the county men protested that this was
their busiest season of the year and a time when the
roads were all but impassible, so on motion May was
chosen as the opportune time.
Dr. J. D. Hershey, of Manheim, was toastmaster on
this auspicious occasion and sixty-seven members and
guests partook of a most excellent dinner.
Dr. Hershey first introduced Dr. E. J. Stein, presi-
dent of the society, who asked the members for their
complete cooperation both to their local society and to
the State Society. He said that in the next two years
the society would in all likelihood have its own per-
manent home. Dr. Stein pledged himself to continue
the high caliber of speakers that have addressed the
society in the past and said that during his term of
office some new speakers would appear.
The toastmaster next introduced the president-elect
of the Medical Society of the State of Pennsylvania,
Dr. Frank G. Hartman. Dr. Hartman chose as his
subject, "The Relationship of the Lancaster City and
County Medical Society to the Medical Society of the
State of Pennsylvania." The earliest record of any
physician in Lancaster County is that pertaining to
John Henry Neff, a native of Switzerland, who located
along the Conestoga, east of Lancaster, in the year
1750. He was known as the "old doctor" and had a
brother also a physician, who located at about Neffs-
ville, which is possibly named after him or some
branch of his family. At about this time appears one
Henry Zimmerman, who located in East Earl Town-
ship, and the Zimmermans or the English equivalent,
Carpenter, are descendants of this man. The "old
doctor," i. e., Dr. Neff, had many students and direct
heirs and enjoyed a very extensive practice. John
Eberly, a student of the old doctor, became Profes-
sor of Medicine at Jefferson Medical College and a
most talented physician. Dr. Henry Carpenter, re-
membered by some of the older men, was the fifth di-
rect descendant of Dr. Henry Zimmerman. Dr. Hand,
an officer in the Continental Army, resigned and lo-
cated here in 1774, but was soon recalled to the army
and left as his heritage many students. Dr. William
Smith, possibly a student of Dr. Neff, was convicted
of being a vagabond and a beggar and was ordered to
be given ten lashes at different places until he was
driven over the county line. Dr. Edwin A. Atlee, a
student of Dr. Hand, located in Columbia, later went
to Middletown, and then graduated from the U. of P.
Dr. Samuel Humes served as city treasurer for a term
and was a gifted physician and surgeon, and Drs. John
L. Atlee, grandfather of the present John L., and
Henry A. Carpenter were both students of his. Dr.
Atlee graduated from the U. of P. in 1820 and Dr.
Carpenter from the Penna. Medical College in 1841.
Drs. Francis S. Burroughs, Geo. B. Kerpin, Alexander
and Patrick Cassidy and John Lehman were prominent
in their day and stood for the highest in medical prac-
tice.
A meeting of all the physicians of the city and
county was called to meet the 7th day of February,
1823, to meet at Strasburg, and upon meeting a com-
mittee was appointed to draft a constitution and by-
laws and a meeting was called for Lancaster on the
following Monday. A further committee was named
but no other meeting was held because of jealousy in
the ranks. More than twenty years ^lapsed when upon
Jan. 14, 1844, a meeting was held in Lancaster and an
organization effected. At this temporary meeting Dr.
W. L. Atlee was called to the chair and Dr. Humes
acted as secretary. At a later meeting Dr. W. L. Atlee
was elected president. Dr. Atlee read the first paper
which was a report of the removal of an ovarian cyst
by laparatomy. In 1848 Dr. Atlee presented a com-
munication to organize a state society, and this same
year twenty-five districts and counties sent representa-
tives to the Methodist church in this city and a tem-
porary organization was formed. At this session a
resolution was adopted calling on the lawmakers to
protect the public from the ignorant and uninformed
who were practicing various forms of healing. The
next year Dr. Samuel Humes was elected president of
the State Society and five men from Lancaster were
among the officers. From 1861 to 1866 the society met
irregularly, but after the war it took on new life and
continued to flourish until to-day we have one of the
best of the component societies.
Other speakers were Dr. Leon Herman, of Philadel-
phia; General Shannon, of Columbia; Dr. J. J. Gil-
bride, of Philadelphia; Mr. H. Martin, of Manheim;
Drs. Walter Keylor, T. C. Shookers and S. S. Rine.
The banquet will long live in the memory of all the
members and guests as one of the most pleasant af-
fairs ever held in this community.
Walter D. Blankenship, Reporter.
LUZERNE— MAY
The essaybts at the regular meeting of the society
held May 4, were Doctors L. A. Sheridan and John
Howorth, whose subjects were "Congenital Dislocation
of the Hip" and "Uretero-Calculi," respectively. Both
papers were of great interest and brought out much
discussion. The intense interest in congenital dis-
location of the hip by the profession in this country
since the visit of Dr. Lorenz in 1902 caused much
modification and simplification of the technique by
men of this country since then.
The condition should be diagnosed and treated early
in life, so as to limit changes which take place in the
bony and ligamentous structures as time goes on, and
to obtain a better result. The greater prevalence of
the condition in females is probably due to anatomical
differences between the male and female. Unilateral
is more common than bilateral.
Dr. Sheridan presented a case of bilateral disloca-
tion treated at the age of seven years. The adductor
tendons had to be divided subcutaneously and both
hips were replaced by the method of Ridlon. The re-
sult was excellent, the child being able to play "hop
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THE PENNSYLVANIA MEDICAL JOURNAL
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scotch," roller skate, and walk with comparative ease
for long distances.
Dr. Everett presented a case of osteochondritis of
both hips, diagnosed by the late Dr. H. Augustus Wil-
son, of Philadelphia. He advised no other treatment
than that of nutrition, massage, etc., and correction of
deformities which might arise.
Dr. Howorth's paper dealt with a not uncommon
condition. The x-ray is not infallible in the diagnosis
of uretero-calculi, as calcareous deposits in arteries,
phlebotiths, exostosis on the ischium, calcified glands
and foreign substances in the bowels cast shadows in
the region of the ureter. Besides, some calculi do not
cast a shadow. Cystoscopy and ureteral catheteriza-
tion are often necessary to determine the real condi-
tion, which may be combined with the x-ray. The
symptoms of ureteral calcuU are not always constant
and may vary greatly, simulating other conditions
often, as duodenal ulcer, appendicitis, obstruction of
the bowel, or even ruptured ectopic gestation. The
passage of a ureteral stone may take from several
hours to several days, and sometimes its passage is
impossible. Dangers to the kidneys should be guarded
against.
Medical treatment consists of relieving the spasms
with morphine, papaverine, or benzyl benzoate, and
diuretics as acetate of potash in repeated doses and
large amounts of fluid to aid in passage of the stone.
Seventy-five per cent of all calculi are passed without
further interference within three to six months from
the first symptoms. Catheterization of the ureters, di-
lating the ureteral orifices, the introduction of ureteral
sounds and the injection of sterile oil will often be
sufficient. In impaction in the pelvic portion with
stricture of the meatus, cutting and dilatation of the
orifice may be necessary. Operative procedures are
indicated in excessive urinary retention sufficient to
endanger the kidneys, or stone too large to pass, or
multiple stones.
The siunmer outing meeting was voted to be held
June 22d, at Pocono Manor Inn.
Walter L. Lynn, Reporter.
Adjourned to meet July 14th, at the Mercer Sani-
tarium, guests of Dr. W. W. Richardson.
Edith MAcBkine, M.D., Sec'y-Reporter.
MERCER— MAY
Th^ members of the Mercer County Medical So-
ciety held their regular meeting on Thursday, May
I2th, a clinic at Buhl Hospital, from 10 a. m to noon.
Drs. A. M. O'Brien and John F. Spearman performed
surgical operations. Dr. Allen P. Hyde showed a
number of x-ray plates. Luncheon was served at the
Sharon Country Club at i o'clock. There were forty
members present and eleven, guests, including Ray-
mond E. Whelan, M.D., and Chas. D. Hauser, M.D.,
of Youngstown, O., and nine dentists. A business
meeting and program followed. Dr. P. P. Fisher
gave an interesting talk on his postgraduate work at
White Haven Sanitorium, and Dr. Whalen read an
excellent paper on "Focal Infections and Their Sig-
nificances." This paper was discussed by all the mem-
bers. C. D. Hauser, M.D., and the dental surgeon, J.
D. Whiteman, D.D.S., of Mercer, who is president of
the Pennsylvania State Dental Board of Examiners,
made some able remarks on this subject.
Dr. B. L. Tinker, West Middlesex, was elected a
member, and the application of Dr. Frederick C. Pot-
ter, of the Mercer Sanitorium, was read. Edith Mac-
Bride was elected delegate to the Pennsylvania State
Society meeting, with Paul T. Hope and W. B. Camp-
bell, alternates. Geo. W. Kennedy was named for
candidate for District Censor.
MONTOUR— MAY
The regular monthly meeting of the society was held
at the State Hospital for the Insane, Danville, on May
2oth, and was called to order at 2:30 p. ra., by the
president. Dr. R. A. Keilty, with a fair represenution
of the members and 25 visitors present; the visitors
coming from Williamsport, Watsontown, Lewisburg,
Northumberland, Sunbury, Shamokin, Bloomsburg and
Danville.
Drs. F. D. Glenn and L. R. Chamberlain, of the staff
of the State Hospital, were elected to membership.
After other routine business had been disposed of, the
scientific program was taken up, and consisted of an
excellent and well prepared "Symposium on Syphilis
of the Central Nervous System," prepared by the staff
of the State Hospital
Dr. R. A. Keilty opened with an able paper on the
"Pathology and Serologic Reactions" of these condi-
tions. He began with some thought on the history of
syphilis and then told of the manner of its invasion.
He said that syphilis was a specific disease, produced
by the treponema pallidum, and that this is now ac-
cepted as its etiological factor; that in the beginning
the disease was local; that there was a portal of en-
trance, the chancre, with localized reactions in the
adjacent lymph nodes, and that the invasion of
the treponema is associated with a reaction on the part
of the individual against this invasion. The progress
of the invasion is a slow one, requiring days or prob-
ably weeks, and that this is due to the slow migration
of the organisms. When the natural defenses are
overcome, the disease becomes a true bacteremia, viru-
lent in its insistence and widespread invasion, but low
in toxemia. As the resistance to the invasion of the
disease is overcome, the disease becomes systemic
Syphilis is not a destructive disease, as is the case
with tuberculosis, but is productive, building up with
fixed tissue types of cells through which we have de-
posits in the later stages, as, gummata, etc., which tend
to involve the meninges and small blood vessels, espe-
cially about the base of the brain. It was shown
that heredity does not count for as much in this dis-
ease as was formerly supposed, that the spread of the
disease was chiefly by contact and that the influence of
a syphilitic father upon the offspring was far less than
that of the infected mother.
In the serologic tests, made at the laboratories of the
Geisinger Memorial and State Hospitals, Danville, it
was interesting to note that in a number of cases of
frank positive spinal fluid reactions, the blood reac-
tions were negative. In a few cases of cerebrospinal
syphilis the blood reactions were positive and the
spinal fluid reactions negative.
Dr. G. B. M. Free followed with a 'splendid paper
on the "Symptomotology" of mental diseases resulting
from syphilis. He said that the diseases of the central
nervous system, usually recognized as due to the
treponema, are paresis, cerebral syphilis and tabes.
Paresis may be divided into three periods or stages:
(i) the prodromal, (2) the period of full develop-
ment and (3) the terminal period. The most impor-
tant symptoms of the prodromal period are the ocular-
motor and teodon reflex disturbances. The Argyl-
Robertson pupil is a valuable sign of the beginning of
paresis, as it frequently occurs early in the disease.
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COUNTY MEDICAL SOCIETIES
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Next comes the pin-head pupil ; then variations in the
size of the pupil, one dilated and the other contracted.
The patellar reflex may be normal, exaggerated, or
lost on one or both sides; the exaggerated is most
common. In this stage we have the beginning of
speech defects, with slight tremor of the muscles about
the mouth and face, and the tremenlous handwriting.
The mental symptoms of the prodromal period are a
gradual change of character, with failing of the men-
tal and physical powers. The patient cannot apply
himself to his work and mental and physical applica-
tion soon bring on fatigue ; the memory becomes poor
and the morale of the patient becomes demoralized.
A remission in the symptoms may occur in this stage,
during which the patient may return to his home and
business. Such remission may last a year, seldom
more than two years, during which the only evidence
of the disease may be the inactive pupil, the slight
tremor of the hands, and the exaggerated or lost knee
jerk. These sig^ns do not subside.
In the fully developed or second stage the above
symptoms become more marked. The tremor, espe-
cially of the mouth and tongue, are more in evidence,
the speech defects increase, musclar weakness is no-
ticeable and the walk becomes ataxic. Characteristic
of paresis are the so-called paretic attacks, which may
vary from a slight syncope to a severe apoplectic or
epileptic seizure. The apoplectic seizures resemble
true apoplexy, but the resulting paralysis soon passes
off, in fact may disappear in a few days. The men-
tal symptoms of this stage are merely an exaggeration
of those of the first period. The memory fails ut-
terly, the patient may not be able to find his room or
his bed; he becomes disoriented in all fields.
Juvenile paresis is a form of paresis which occurs
frequently, but is often unrecognized. The disease
usually occurs in children, one or both of whose par-
ents had syphilis; it can be noticed from twelve to
fourteen years of age. The early sjrmptoms may be
largely motor, such as clumsiness in walking. With
this is combined disturbances of speech ; the child be-
comes dull at school, and all the usual signs of paresis
develop.
In the terminal or third stage there are more marked
physical symptoms. The tremor is constant and the
ataxia increased until it is dangerous or impossible for
the patient to walk. He soon becomes bed-ridden and
control of the sphincters is lost. The dementia be-
comes so profound that the patient may not know his
name, and of his conversation there is only here and
there a sound or word to suggest the remains of his
former delusions.
Cerebral syphilis may also be divided into three
types: the meningitic, the endartertic and the gum-
matous. The lines of demarcation between these types
are not sharp ones.
The mental disturbances of brain syphilis are those
of organic brain disease, but in subjects predisposed to
insanity the syphilitic cachexia may induce ordinary
forms of insanity. These are most frequently of the
depressed varieties, grouped under the general name
of melancholia.
Tabes. True tabes, or locomotor ataxia, is a neuro-
logic and not a mental disease. There is early a loss
of coordination, which is at first shown by unsteadi-
ness when the patient walks in the dark. The gait is
characteristic. In walking he raises his feet high,
throws them forward and brings them down in such
a way that the whole sole strikes the floor at the same
time. The patellar reflex is lost early. The eyes show
the contracted and the Argyl-Robertspn pupil, double
vision, dimness of vision from optic atrophy, and
paralysis of the ocular muscles.
Dr. H. V. Pike concluded the symposium with a
lucid presentation of the "Differential Diagnosis." He
stated that in making a diagnosis of syphilis of the
central nervous system there should be kept constantly
in mind the following facts:
(i) The absence of a history of specific infection
is without importance, as the lesion may be so slight
as to escape observation. There may be no secondary
symptoms and, furthermore, the development of symp-
toms referable to the central nervous system quite fre-
quetly does not appear until many years have elapsed.
(2) The mental picture is by no means constant and
may stimulate those of many of the functional psy-
choses.
(3) The Wasserman reaction of the blood should
be considered only as confirmatory evidence; a posi-
tive reaction may occur without involvement of the
central nervous system or it may be negative when in-
vasion has taken place. In doubtful cases, examina-
tion of the spinal fluid should be made.
(4) Neurosyphilis presents definite neurological
signs which, when taken in connection with the men-
tal symptoms and serological findings, will generally
render a conclusive- diagnosis fairly easy.
Dr. Pike then conducted a clinic in which he pre-
sented eleven cases, emphasizing and illustrating, in
quite an instructive manner, the various stages and
types of insanity due to syphilitic infections and
lesions.
Dr. J. Allen Jackson, in opening the discussion,
stated that ten per cent of the cases of insanity com-
ing to the hospital were due to this disease. He em-
phasized the fact that the disease is due to a specific
germ and that few or no cases really recover ; usually
it is only a matter of time until the inevitable end
comes. He declared the hope lies in early, active
treatment, intensive treatment, before the nerve
changes set in since after that period little can be done.
Dr. J. B. Cressinger, Sunbury, continuing the discus-
sion, stressed the need of early recognition and early
active treatment. He also warned against too active
treatment, especially in the later stages and with the
arsenicals, since real harm would likely be done.
A number of others joined in the discussion, some
seeking information, and others expressing apprecia-
tion of the privilege of being present, warmly com-
mending those who so ably presented the program,
and thanking the society for the invitation which had
been extended to them. J. H. Sandel, Reporter.
PHILADELPHIA— MARCH
Stated meeting held March 23, 1921. The president,
Dr. George Morris Piersol, in the chair.
A paper on "Modem Methods in the Diagnosis of
Renal Disorders," was read by Dr. Ross V. Patterson,
of Philadelphia, in which he said that the study of a
patient suspected to be the subject of renal disease in-
volved, for the most part, the use of methods of com-
paratively recent development. The general concep-
tion of renal disease has veered from an anatomical
to a functional basis. Until comparatively recently,
for want of a better plan of classification, the clinical
endeavor was to group forms of renal disease into sev-
eral anatomical types, according to postmortem find-
ings. The clinical investigation consisted in ordinary
urinary examinations, often yielding findings inter-
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THE PENNSYLVANIA MEDICAL JOURN'AL
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preted as indicating renal disease when none existed
or, perhaps, quite as often failing to reveal such dis-
ease when present and well advanced. Toxic symp-
toms, edema, arterial sclerosis and hypertension, ane-
mia and cardiac hypertrophy were associated findings
upon which considerable diagnostic dependence was
placed. In the chronic forms only well advanced cases
were recognized, and most of them were beyond
amelioration. The more recent tendency to develop a
functional estimate has made for earlier recognition
and given more confidence and exactitude to both diag-
nosis and treatment. The importance of a functional
conception of renal disease becomes apparent when it
is realized that anatomical lesions are incorrigible; a
rational plan of treatment by a regulation of the diet
is one in which the demand made upon the kidney is
lessened to within its decreased functional capacity.
Unless the nature and degree of functional impair-
ment are ascertained, we have no definite basis upon
which to base either prognosis or treatment.
Diagnosis includes the recognition of both the na-
ture and the degree of a disorder. Anatomical lesions
have an importance in proportion to the functional im-
pairment which they occasion. Kormal kidneys are
capable of exercising a functional capacity several
times greater than is necessitated by the demands
made upon them under ordinary circumstances. Their
accommodation limits enable them to meet, without
overstrain, unusual, exceptional and variable condi-
tions, in which waste prodtKts, in varying amounts,
gain access to the blood. Despite the constantly
changing burden of waste products, the composition
content percentages remain fixed, or vary only within
narrow limits. One of the early evidences of kidney
disease may be found in a retention of the chlorides
in the blood and tissues with a diminished elimination
in the urine. The normal urinary chloride content is
1.8 per cent; the amount may be reduced to 0.5 per
cent or less in disease. With impairment of renal
function and consequent blood retention, the total non-
protein nitrogen may reach 100 or 200 mg., or more,
per 100 c.c. of blood. Blood urea is chiefly responsible
for the increase of the urea nitrogen, often consti-
tuting 70 to 90 per cent of the total. Uric acid occa-
sions the greatest difficulty in elimination; creatinine
the least; urea occupies an intermediate place. Uric
acid concentration is an early evidence of renal failure ;
creatinine concentration occurs only as a late manifes-
tation, and is an evidence of advanced disease. A
value exceeding 5 mg. per 100 c.c. of blood has usually
terminated fatally; it may reach 15 to 20 mg. A
marked increase in the total nonprotein nitrogen may
be a herald of uremia, although uremia may occur
with a low retention, indicating that some other ele-
ment is the .essential factor in its production. The
vicarious function of other organs may be a factor in
preventing nitrogen concentration with failing kid-
neys. The skin, liver, stomach, intestines and even the
bronchial tubes may excrete urea and perhaps other
nitrogenous substances as well. A patient with severe
nephritis and oliguria, expectorated a daily average
of 1500 c.c. of sputum containing over 2 per cent of
urea. With an increase in urine, the amount of sputum
and the percentage of urea rapidly diminished.
It is only comparatively recently, however, that
functional tests have been so simplified and extended
that they can be used with ease and accuracy by any
practitioner. Many important aspects of kidney func-
tion are revealed by the simplest tests, requiring only
careful observation and intelligent interpretation. The
normal kidney excretes urine that varies in concentra-
tion at different times in the twenty-four-hour period.
There is a reaction to both food and fluid stimuli, so
that the molecular concentration of the blood remains
within fixed normal limits. The kidneys show consid-
erable flexibility in their ability to meet these varied
demands, and this flexibility may be measured with
some degree of accuracy in various ways. A careful
determination of the specific gravity and quantity of
both day and night urine yields important data. A
knowledge of these two factors makes possible an
estimate of the total amount of solids excreted. The
amount of urea excreted can easily be determined by
the use of the ureometer. Another simple test of
renal excretion is afforded by the administration of a
measyred amount of water and the determination of
the amount eliminated in a given length of time. If
less than the normal amotmt is excreted, renal disease
and diminished function are indicated.
Two other simple tests may be used to reveal func-
tional impairment occasioned by contracted kidneys.
The first stage is shown by a loss of power to con-
centrate the urine. A healthy individual placed on a
very dry diet for twenty-four hours will show a rise
of urinary specific gravity to 1,030 or i,a4a In con-
tracted kidney, a patient placed on a dry diet may
excrete a urine having a specific gravity not exceeding
1,011 to 1,013. The second stage consists of a loss of
power to dilute the urine. Normally the ingestion of
a large amount of water will result in a reduction in
the specific gravity of the urine to 1,003 to 1,005. If
this power to dilute the urine is lost, it constitutes
evidence of a more advanced stage of disease.
Impairment of the kidney function is indicated by
the following findings: Nocturnal polyuria (over 750
c.c). A tendency to polyuria throughout the entire
period, the volume of urine equalling or surpassing
the amount of liquids ingested. Fixation of the spe-
cific gravity within narrow limits; in advanced stages
the maximum variation may not exceed i or 2 de-
grees. Fixation in the two-hourly quantity of urine
eliminated; absence of the diuretic influence of food
ingestion. If the night urine diminishes to within nor-
mal amounts, it will show a low nitrogen content and
low specific gravity. There may be a marked reten-
tion of both salt and nitrogen.
The phenolsulphonephthalein test is one of the sim-
plest, probably the best and withal the most reliable
test for kidney excretion. It can be made by any prac-
titioner. Convenient ampules containing slightly more
than the required amount of the solution of 6 mg. of
the dye to each i c.c. of fluid may be kept at hand.
The bladder should be emptied, at least 500 c.c of
water taken, and exactly i c.c. of the solution admin-
istered hypodermatically. At the end of one hour and
ten minutes and again at the end of two hours and
ten minutes the urine is voided and separately saved.
The amount of dye in each portion of urine is easily
estimated by means of a colorimeter or by comparison
with standard solutions of known strength.
Clinical Reports on 25 Selected Cases of Renal Dis-
orders Illustrating Varied Fimctional Tests.— The re-
port by Dr. H. W. Jones, of Philadelphia, was a pres-
entation of a series of illustrative and typical cases of
various forms of nephritis, grouped according to their
prominent clinical features, in which careful studies
of the blood chemistry, specific gravity fixation deter-
mination, urea test, and phenolsulphonepthalein tests
had been made, with a view to determining their value,
relative and absolute, and the correlation which they
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COUNTY MEDICAL SOCIETIES
681
might show with clinical findings and ordinary urine
examinations. An attempt was made to determine their
relative value under different circumstances and to
correlate them with the clinical findings. Certain con-
clusions were drawn in these and other similar cases
and certain facts regarded as of practical importance
bearing upon the etiology, diagnosis and future course
of renal disease were indicated in the course of the
case reports.
The cases were presented in groups, according to
the following plan of classification: Group I. Bi-
chlorid of mercury poisoning, with acute nephritis.
Group II. Primary acute nephritis. Group III. Acute
intercurrent nephritis, an important clinical group,
many individual cases of which are often thought to
be primary. Group IV. Chronic nephritis with cardio-
vascular disease, the largest and most important clin-
ical group which we encounter in medical practice,
showing many variations and combinations of different
degrees and manifestations. Group V. Chronic ne-
phritis with uremia, illustrating both acute and chronic
forms of the latter.
The following conclusions were submitted: The
ordinary examination of the urine does not give de-
pendable evidence of renal disease. In many cases
the urine examination yields almost negative results, in
the presence of marked functional impairment. In
other cases, the urinary findings indicate marked dis-
ease, which conclusion is not supported by functional
tests. Renal lesion of a focal or patchy character, or
an extraneous influence, due to cardiac failure, may
be the explanation. A few cases were discharged
much improved, both clinically and functionally, in
whom there were marked and persistent urinary find-
ings. The symptoms of renal disease, while of very
definite diagnostic value, are not an absolute indication
of the degree of functional impairment. This state-
ment is especially applicable to the cases of moderate
severity. Twenty-two of the cases were symptom-
atically much improved, while only eight were im-
proved both functionally and symptomatically. The
functional tests are a more exact means of estimat-
ing the prognosis than either the clinical symptoms or
the examination of the urine. The functional tests are
the best guide as to the subsequent management of the
case. The estimation of the blood nitrogen is of value
only in cases of advanced nephritis. In all of the cases,
except two, the blood nitrogen was increased only
with a reduction of the phthalein output to 40% or less.
Some investigations place the normal creatinine as
high as 2.5 mg. per 100 c.c. In the three fatal cases,
only one gave a value above 2.5 mg. Several of the
particularly severe cases showed creatinine at about
2 mg. and on discharge, the amount was unaltered, or
even slightly increased. This finding occurred in
cases improved clinically, and in the presence of a re-
duction in the other nitrogen elements of the blood.
Most of the cases had a creatinine content of i mg.
to 1.2 iflg. The amount present has some prognostic
value. Those cases in which high values occur should
receive a more guarded prognosis.
Uremia, and uremic symptoms are not dependent
upon nitrogen retention. In a case of acute nephritis
with severe uremic symptoms, the blood nitrogen ele-
ments were only slightly increased. In case 19, with
well developed uremia, the blood nitrogen was nor-
mal. In two fatal cases of uremia, there was only a
moderate increase in the blood nitrogen. In the fatal
case of mercury poisoning the blood nitrogen was
greatly increased but uremic symptoms were absent
Nocturnal polyuria was an important early symptom
of nephritis. A disturbance of the normal ratio be-
tween the amounts of the night and day urine occurred
relatively early. With improvement there was a ten-
dency to resume the normal ratio. The urea concen-
tration test is probably of value in hospital work, but
the test is comparatively recent, and additional data
must be accumulated before its general acceptance will
be justified.
It is evident from a study of the results of func-
tional tests in various cases that in some instances
they do not satisfactorily determine the renal status.
Occasionally unmistakable clinical evidence was not in
accord with the functional tests. On the other hand,
the functional tests evidenced much greater impair-
ment than was shown clinically. In many cases it
was found that the different fimctional tests did not
yield uniform indications of impairment, or that the
results were disproportionate. It would appear, there-
fore, that the best results were to be accomplished by
the use of more than one test instituted at various
periods, the results of each to be considered in a final
analysis. From the point of view of both availability
and reliability the best test was the phenolsulphoneph-
thalein. It had proved accurate and reliable and was
easily carried out in both hospital and private practice.
The two-hour fixation test had seemed to him the
test of second choice, although in some cases, indeed,
the first choice. It also had the merit of availability,
as well as dependability. It was most useful in de-
tecting chronic contracted kidney, the most frequent
form of renal disease.
In the ordinary examination of urine, slight find-
ings with a low specific gravity were of more signifi-
cance than more marked changes with a high specific
gravity. Many cases of acute nephritis which were
apparently primary were, in fact, intercurrent, the
chronic disease being unsuspected and resulting in
lowered resistance and susceptibility to infection. The
importance of a knowledge of these facts bore upon
the future management. Cardiac failure or weakness
developing in the presence of only moderately ad-
vanced renal disease might result in marked renal dis-
turbance without obtrusive evidences of cardiac fail-
ure. Clinical observations would seem to indicate
that blood pressure varied with the renal function,
tending to rise with retention, and fall with improve-
ment, provided the cardiac factor remained constant.
Dr. A. I. Rubenstone, of Philadelphia, said that the
essayists seemed to take the stand that the phenol-
suphonephthalein test was nearly as good as an esti-
mation of blood nitrogen with reference to kidney
function. As a matter of fact his own experience had
proved that this was not so. He felt that protein esti-
mation was far more important so far as kidney func-
tion was concerned than the phthalein. Phthalein
gives an estimation of kidney function for the time
being and did not tell what was retained in the blood.
Furthermore, it was a foreign substance which the
kidney was not used to excreting. He believed that
before surgical operations were permitted to be per-
formed the estimation of nitrogen was a very impor-
tant factor.
Dr. A. E. Roussel, of Philadelphia, said that the diag-
nosis of kidney lesions in many instances could not be
made by urinary examinations alone. Not only the
function tests were of importance, but the blood chem-
istry was of great importance as regarded both diag-
nosis and prognosis. Indeed one could well under-
stand that even cases of high blood pressure may be
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essential hypertonia not associated with a sclerotic
kidney. The condition could only be told by blood
chemistry and ophthalmological examination. Dr.
Roussel said that he disagreed decidedly with the
reader of the second paper. He expressed his aston-
ishment that he had found relatively low counts in his
creatinine counts, especially in the fatal cases. The
urine might be markedly improved in the percentage
of albumen and diminution of casts and yet 2 to 4
mgms. of creatinine still remained persistently present
and it was a fact in a fairly large number of cases that
he had never known a patient to live more than one
year after continued presence of 4 mgms. of creati-
nine. Both the phthalein and the fixation test were of
use. The fixation test with the total quantity of night
and day urine was more useful than the phthalein
which was more influenced by extraneous circum-
stances. Nobody had a right to diagnose a case of
kidney disease without blood chemistry and functional
tests and, in some instances, without the assistance of
.an oculist He considered the creatinine test of
greater prognostic value than any of the others yet
mentioned.
Dr. Leon Herman said that he regretted that neither
of the readers of papers went into the subject of kid-
ney functional test from the surgical point of view.
The urologists and surgeons had contributed consid-
erable from the standpoint of clinical observation of
the behavior of kidneys when traumatized by anes-
thesia and operations on the urinary tract. There was
a great deal to be learned about kidney function from
the surgical standpoint. We did not know much about
the inherent capacity of the kidney to withstand
trauma. From the surgical standpoint, while all of
these tests were of value, he agreed with Dr. Roussel
that the tests of excretion are of less importance than
the tests of retention. John J. Repp, Reporter.
SOMERST— MAY
The Somerset County Medical Society met in regu-
lar bimonthly session at the courthouse at Somerset,
May 17th, with the largest attendance in two years,
more than half the members being present. The morn-
ing session was devoted to business, correspondence,
etc. Dr. Bruce L4chty, of Meyersdale, was elected to
represent the society in the House of Delegates at the
State Society meeting to be held in Philadelphia, Octo-
ber next. Dr. M. U. Mclntyre, of Boswell, and Dr.
C. P. Large, of Meyersdale, are his alternates.
The secretary was instructed to reply to the several
pieces of correspondence. He read some requests for
information as to locations and said that he had re-
quested of the applicants that at least a little informa-
tion be given or reference to some one as to character,
qualifications, etc., before he could recommend a loca-
tion. This may have been asking too much but, not
knowing whether or not application would be made for
membership in the society, he made the request and in
no instance did he receive a reply. There are two
waiting locations in the county for good men.
A delegation of the managers, or directors, or trus-
tees of the Somerset Community Hospital was present
and heard in the interest of that institution. It was
desired that the Somerset County Medical Society
take an interest in the hospital to the extent of ap-
pointing the yearly hospital staff, that staff to appoint
a rotary or serving staff every three months. A com-
mittee was appointed to meet the trustees and see what
might be the best procedure.
The morning session was mostly devoted to the hos-
pital matter. The afternoon session was given over
to Dr. E. S. Everhart, of Harrisburg, who took the
place of Dr. Gans, who was prevented from attending
on account of sickness. Dr. Everhart's subject was
"Venereal Diseases." He outlined to us the state law,
and State Department of Health campaign against this
great moral and insidious physical evil. The doctor
told in an earnest manner what can, what may and
what must be done if this evil is to be checked and
cured. He said that as the physician is the real cus-
todian of public health it is up to him to join heart
and hand with the Department of Health to wipe out
the evil,, if possible. A vote of thanks was tendered
to Dr. Everhart for his address.
Dr. Harry J. Cartin, of Johnstown, was present and
commented on Dr. Everhart's address and then spoke
of testing, immunization and treatment for diphtheria
by the Shick method and the use of toxin-antitoxin.
We regretted that the time of trains prevented dis-
cussion of that subject. H. C. McKinley, Reporter.
WARREN— APRIL
The April meeting of the Warren County Society
was held at the Elks' Parlors, on the i8th, and was
addressed by Dr. C- W. Dodge, of Jamestown, N. Y.,
who is in charge of the x-ray department of the War-
ren Hospital.
Dr. Dodge stated that the modem x-ray machine
with the improved Coolidge tube very seldom causes
any burning and is comparatively safe for the opera-
tor. The voltage is extremely high and an exposure
of a few seconds is sufficient for most pictures. He
showed a number of pictures to illustrate the points
brought out in his talk.
After the general discussion a dinner was served.
Dr. Ralph Knapp, of Youngsville, acting as host
Dr. W. S. Peirce, a former member of the societ>'
and a practitioner in Warren County for thirty-six
years, died from cerebral hemorrhage at the age of
sixty-two. He was of sterling character and during
his many years of practice lived on the best of terms
with his colleagues.
Dr. J. C. Russell, an honored member of our so-
ciety, has been in very poor health and was taken to
Buffalo, N. v., for consultation and observation. It
is not known whether or not an operation will be
necessary. M. V. Ball, Reporter.
STATE NEWS ITEMS
engagements
The Engagement of Miss Charlotte Wehrum,
daughter of Mrs. Henry Wehrum, of Elmhurst, to Dr.
Arthur P. Gardner, of Scranton, Pa., has been an-
nounced.
Mr. and Mrs. William Aubrev, of San Antonio,
Tex., have announced the engagement of their daugh-
ter. Miss Mary Gayle Aiken Aubrey, and Dr. Peter
McCall Keating, of Wawa, son of the late Dr. and
Mrs. John M. Keating, of Philadelphia.
Dr. and Mrs. W. S. Ambler, of Aliens Lane and
McCallum Street, Chestnut Hill, Philadelphia, have
announced the engagement of their daughter, Miss
Elizabeth Wentz Ambler, to Earle Boak, U. S. N.,
who is stationed at San Diego, Cal. No date has been
set for the wedding.
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STATE NEWS ITEMS
683
MAKRIAGES
Ankouncement has b^n made of the marriage of
Miss A. Marguerite Netscher, daughter of Dr. and
Mrs. C. E. Netscher, of Lancaster, Pa., and Stanley A.
Watson, of Newton, Wednesday, April 20th.
St. John's Catholic Church, Pittston, Pa., was the
scene of a very pretty nuptial event at 9 o'clock, on the
morning of April 20th, when Miss Mary Loftus,
daughter of Alderman and Mrs. Thomas S. Loftus,
and Dr. Charles A. McGuire, of Pittsburgh, a former
resident of Pittston, were united in the holy bonds of
matrimony by Rev. Charles A. Murray. Miss Helen
Loftus, a sister of the bride, and Dr. John A. Sharkey,
of Philadelphia, were the attendants.
Following the ceremony a reception and breakfast
was held at the home of the bride's parents, after
which Dr. and Mrs. McGuire left on a wedding trip.
They will reside in Pittsburgh.
Mrs. McGuire has been organist at St. John's
church for the past several years. She is a graduate
of the Pittston High School and Scranton Conserva-
tory of Music. Dr. McGuire is a graduate of the Pitts-
ton High School and University of Pittsburgh.
DEATHS
Mary A., infant daughter of Dr. and Mrs. Joseph
A. Wagner, of Throop, Lackawanna, County, died
May 3d, following an illness of several weeks.
Mrs. Henry FotLMER, of Bloomsburg, mother of
Dr. George E. Follmer, a member of Columbia County
Society, was buried from her late home on April 23.
Interment was made at McHenry's Church cemetery.
Dr. Oliver T. Evekhart, for sixty-five years a prac-
ticing physician, died April 28, at his home in Hanover,
from infirmities of age. He was 90 years old. He
was in the Union army, acting as first assistant sur-
geon at the battle of Antietam. Later he was cap-
tured. He was the last surviving member of the class
of 1854 of Franklin and Marshall College.
Dr. Jesse M. Hughes, who was bom at Orange-
ville, April, 1865, died at Nanticoke, March 5, from
pneumonia. He was chief surgeon of the Wyoming
Division for the Susquehanna Colliers Co.; he was a
graduate of the University of New York, 1892. He is
survived by his widow and a daughter, and two broth-
ers, Dr. W. E. Hughes, of Ashley, and Edward
Hughes, of Hazleton.
Dr. George H. Halberstadt, of Pottsville, Surgeon
in Chief of the Philadelphia and Reading Coal and
Iron Company, was buried April 26, with honors from
the First Aid Corps which he established at the an-
thracite mines, and which plan has since been followed
all over the country. Dr. Halberstadt was one of the
leading surgeons of Schuylkill County and an active
member of the Coimty Medical Society.
Dr. William Marshall Barron, age 59 years, of
Latrobe, died Thursday evening, April 14th, after an
illness of eleven weeks from typhoid fever. Dr. Bar-
ron was born at Stahlstown, July 18, 1862, and gradu-
ated at the West Penn Medical College in 1892. He
was a member of the Westmoreland County Medical
Society since 1916. He is survived by his wife, one
son, Captain Marshall Barron, who was wounded in
France; one daughter. Miss Marjorie Barron.
Dr. G. M. Stites, aged 60, a practicing physician at
Williamstown for many years, died Friday, April 29,
following a three months' illness from complications.
He was one of the most widely known residents of
Upper Dauphin, and had been compensation surgeon
for the Susquehanna Colliers Company.
_ Dr. Stites had been a deputy coroner, and at one
time was chairman of Soldiers' Pension Board, which
functioned some years ago. He is survived by his
widow, two sons, Joseph, of Bethlehem, and Harry, of
Philadelphia, and one daughter, Mrs. Herbert Quinn,
of Pottsville.
Dr. Charles W. Duixes, U. of Penna., '75, retired
physician, died recently, following an attack of heart
disease, at his home, 4101 Walnut Street, Philadelphia.
Dr. Dulles was bom in Madras, India, seventy years
ago. He had been connected with many hospitals, for
a time being manager of the University Hospital. He
was also a lecturer on the history of medicine at the
University. For many years he was connected with the
Pennsylvania Society for the Protection of Children
from Cruelty, the Vivisection Reform Society and the
Western Home for Poor Children. Dr. Dulles was a
member of the College of Physicians, the Philadelphia
Academy of Surgeons and many other medical asso-
ciations. His widow, formerly Miss Mary Bateman,
and four children, survive him.
The Recent Death op Dr. Robert H. Chase oc-
curred at his home, "Crest View," near Wyncote, Pa.
Dr. Chase was bom at Salem, Mass., and received his
education at Harvard and the Medical School of the
University of Pennsylvania. From 1872 to 1880 Dr.
Chase was assistant physician at the Government Hos-
pital for the Insane, at Washington, D. C. From 1880
until 1893 he was medical superintendent of the male
department of the State Hospital for Insane, at Nor-
ristown. Pa. Later he was appointed medical super-
intendent of the Friends' Hospital, in Frankford, and
three years ago he opened his sanitarium. Dr. Chase
was the author of three books on insanity. He was
a member of the American Medico-Psychological
Medical Association, Pennsylvania State Medical So-
ciety, Philadelphia College of Physicians, Philadelphia
County Medical Society, Philadelphia Neurological
Society, Philadelphia Medico-Legal Society and the
Philadelphia* Medical Club. He was seventy-five years
old.
Ds. Frederick Marshall Davenport died May 15th,
at the Hahnemann Hospital, Scranton, after a short
illness.
Dr. Davenport was born in Plymouth, Luzeme
County, on the Sth day of January, 1871. He reecived
his early education in the public schools of his native
town, Wyoming Seminary and Bloomsburg State Nor-
mal School, after which he devoted a number of years
to teaching, being the principal of the high school in
Luzerne. He received his professional education at
Jefferson Medical College, from which he graduated in
the class of 1905, after which he served a term as
resident physician at the Pottsville City Hospital.
Later he located in 1907 in Green Ridge, Scranton,
where he has continually 'practiced. In 1908 he mar-
ried Miss Laura Church, of Luzeme, who with three
children, Harriet, Elizabeth and Frederick M. Daven-
port, Jr., survive him. He is also survived by his
mother, Mrs. Harriet Davenport, widow of Samuel
Davenport, and the following brothers and sisters:
Stanley Davenport of Wilkes-Ba^re ; Thomas Daven-
port, of Plymouth; Arthur Davenport, Esq., of
Wilkes-Barre ; Miss Blanche Davenport, a teacher in
the Plymouth School, and Mrs. Edgar Stem, of Har-
vey's Lake.
He was a member of Pylmouth Lodge, No. 323, Free
and Accepted Masons; Valley Chapter, Royal Arch
Masons; Melita Commandery, No. 68, Knights of
Templar, Scranton. He was also a member of the
Lackawanna County Medical Society, in which he took
an active part. He was a member of the Christian
church of Dunmore.
items
Born to Dr. and Mrs. Nelson J. Bailey, of James-
town, Pa., a son. May 8th.
Dr. E. C. McComb, Lawrence County, has returned
from Florida and opened offices at New Castle.
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684
THE PENNSYLVANIA MEDICAL JOURNAL
June, 1921
Dr. Lenore Gageby, member of Lawrence County
Society, is practicing at Long Beach, California.
Dr. T. M. Shafer, Lawrence County, is erecting an
apartment house at New Castle.
Dr. B. M. Bedger, Lawrence County, has opened of-
fices in the Hiland Building, Pittsburgh.
Dr. LSwartz Plymire, Doylestown, has resigned
the position of County Medical Director.
Born to Dr. and Mrs. I. C. Miller, of Berlin, a
daughter, Mary Louise, April 25th, weight Bl4 pounds.
Dr. W. S. Ramsey and Wife, Pearson House, New
Castle, have returned from Boston, Mass., where Mrs.
Ramsey recently underwent an operation.
Dr. p. p. Fisher, of Sharon, Medical Inspector of
Mercer County, spent the month of April doing post-
graduate work at White Haven Sanitorium.
Drs. James E. Groff, Doylestown, and John A.
Crewitt, Newtown, have been confined to their rooms
for several weeks by sickness.
Dr. and Mrs. W. Reynolds Wilson and their fam-
ily, Philadelphia, are occupying Westwoode, their place
at Villanova.
Dr. and Mrs. Henry P. Brown, Jr., and their fam-
ily, of Philadelphia, have opened their home at St.
Martins. ,
Dr.'. and Mrs. O. H. Perry Pepper, of St. Davids,
will go to Northeast Harbor in August, where they
will spend six weeks.
Dr. Josephine Funderburgh, assistant physician at
the Mercer Sanitarium, has resigned, and Dr. Fred-
erick C. Potter now occupies the position.*
At Tug April Meeting of the Franklin County
Medical Society a resolution was passed making the
annual dues ten dollars.
Dr. and Mrs. John J. Coffman, of Scotland, Pa.,
have returned to their home after spending the win-
ter with their son in Reading, Pa.
Dr. and Mrs. Allan P. Hyde, Dr. and' Mrs. John
F. Spearman, of Sharon, spent the first week of May
at Washington, D. C. They motored to Washington
in Dr. Hyde's car.
Miss Moore, from the State Department of Health,
Harrisburg, recently spent a week in Mercer County
assisting in organizing the work for a Baby Health
Week, beginning May i6th.
Dr. Richard H. Harte and his son-in-law and
daughter, Mr. and Mrs. Rodman Ellison Thompson,
of Philadelphia, are occupying Derry Brush, their
country home at Abington.
In Celebration of the twenty-fifth anniversary of
the founding of the Nason Hospital at Roaring Spring,
Dr. W. A. Nason, superintendent of the hospital, en-
tertained the directors and officers at dinner, recently.
The Class of 1899 of the University of Pennsylva-
nia gave a dinner in honor of Dr. Josiah C. Mc-
Cracken, '99 C, on Monday evening, April 4, at the
University Club, Philadelphia.
Dr. and Mrs. Willis F. Manges, of Philadelphia,
will move in a short time to their new home on Glen-
wood Avenue, which they recently purchased from
Mr. and Mrs. Edwin Hoopes.
The Organization Meeting of the Pennsylvania
State Medical, Dental and Pharmaceutical Association
was held in Philadelphia. June ist and 2d. In connec-
tion with the program clinics were held in the leading
hospitals of the city.
Dr. L. R. Chamberlain. Union, N. Y., who was a
member of the medical staflf of the State Hospital for
the Insane, Danville, for some time prior to two years
ago, has again returned to the institution and become
a member of its medical staff.
The Appointments of Dr. Samuel S. Woody as
Professor, and Dr. Theodore LeBoutillier as Assistant
Professor of Epidemic Contagious Diseases in the
Graduate School of Medicine of the University of
Pennsylvania, have been made for the ensuing year.
Dr. R. J. Perkins, who has been connected with the
medical staff of the State Hospital for the Insane at
Danville for some months, will leave about May 15th
for Hamilton, Canada, where he will become attached
to the medical staff of the General Hospital of that
city.
Dr. Edward B. Krumbhaar has resigned the post
of Assistant Professor of Research Medicine, Univer-
sity of Pennsylvania, to become Director of the Patho-
logical Laboratory of the Philadelphia Hospital. Dr.
Krumbhaar is also Associate Professor of Pathology
in the Graduate School of Medicine of the University.
Dr. M. W. Rosenberg, for the past year chief resi-
dent physician at the State Hospital, Scranton, has
tendered his resignation and will engage in private
practice, with offices at 616 North Washington Ave-
nue. A successor to Dr. Rosenberg has not been se-
lected as yet.
Dr. William C Miller. Chief of the Division of
Public Health Education, State Department of Health,
has inaugurated a correspondence course of instruc-
tion for health officials in every county throughout the
state. The course which is required of all health of-
ficials is open to nurses, welfare workers and workers
in allied fields.
Miss Elizabeth L. Boyd, daughter of Dr. and Mrs.
George M. Boyd ; Miss Elsie Du Puy Hirst, daughter
of Dr. and Mrs. Barton Cooke Hirst, and Miss Hen-
rietta MacDonald Wilson, daughter of Dr. and Mrs.
W. Reynolds Wilson, all of Philadelphia, recently spent
a week at Sweetbriar College, Sweetbriar, Va., where
they attended the May Day fete.
Dr. and Mrs. Henry Tucker and their daughter.
Miss E. Russell Evans Tucker, Philadelphia, returned
April 26th from Tranquility Farm, their estate on the
eastern shore of Maryland, where they passed several
days. Mr. and Mrs. Tucker and their family will oc-
cupy their farm after the middle of June for the re-
mainder of the summer.
We Quote the Following from The Call of the
Somerset County Society: "A letter from Dr. W. T.
McMillan, still a member of this society, 1742 N. Nor-
mandie Avenue, Los Angeles, California, says that he
is improving in health, is considerably stronger, and
that he feels that with care and 'patients' he will get
well."
Sellersville, Pa., May 7. — This section of the
Upper North Penn and all of Bucks and part of the
Montgomery County sections are taking an active part
in the drive for $75,000 for the Grand View Hospital
at Sellersville. Present plans are that the new hos-
pital addition will mean that 200 beds will be available
at the hospital. During 1920, 501 patients were treated,
compared with 118 in 1914.
At the Annual Meeting of the Medical Alumni
Society of the University of Pennsylvania, held Febru-
ary 19, the following officers were elected : President,
John H. Jopson ; Honorary President, Acting Provost
J. H. Penniman; First Vice-President, William Zent-
myer; Second Vice-President, Thomas S. Westcott;
Third Vice-President, Samuel Brown; Corresponding
Secretary, Stephen E. Tracy; Recording Secretary,
William K. Neely, Jr.; Treasurer, W. E. Watson;
Executive Committee : Norris McDowell, C. P. Frank-
lin, H. B. Carpenter, B. F. Stahl, J. Norman Henry,
Harvey E. Schock and Collin F. Martin.
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GENERAL NEWS ITEMS
685
The Dedication of the new building of the Babies'
Hospital of Philadelphia, was held May 9th and loth.
An elaborate program was presented. We quote the
following from the Weekly Roster of the Philadelphia
County Society: "The new building of the Babies'
Hospital of Philadelphia is not a hospital, nor a clinic,
nor a community center, nor a convalescent home, but
it is the center of a system embracing all these im-
portant phases for the conservation of child life. With
its city clinics and follow-up work, its country hos-
pital for sick babies, and seaside home for convales-
cent babies and their mothers, it offers a unique con-
tribution to the health-building machinery of Phila-
delphia— a center from which health education radi-
ates."
The many friends of Mrs. D. J. Jenkins, of West
Scranton, will be grieved to learn of her death at that
place. May 19th. She had been ill for some time. She
was formerly Miss Annie Probert, and had made her
home in Scranton for many years. She is survived
by her husband, Dr. D. J. Jenkins, and four children;
one brother, John F. Probert, of this place ; and three
sisters, Mrs. Gwilym Edwards, Mrs. John R. Jones,
and Mrs. Anthony Edwards, all of Edwardsville.
Dr. Harou) L. Foss, surgeon in chief of the Geis-
inger Memorial Hospital, Danville, is spending a few
weeks with the Drs. Wm. and Chas. Mayo, at the Mayo
Clinic, Rochester, Minn.
Dr. H. Albert Smith, of Mechanicsburg, Pa., is to
have charge of the largest dispensary in the United
States for the treatment of disabled soldiers and sail-
ors. The new dispensary will be situated in Balti-
more and will occupy two floors of the Merchants' and
Manufacturers' Association building in Light Street.
A lease for 10,000 square feet of floor space was
signed Saturday by the United States Public Health
Service, through Dr. Smith, who has charge of the
city office of the service at Saratoga and Calvert
Streets.
The dispensary will be cpnducted under the United
States War Risk Bureau, which has taken over much
work of the Public Health Service. A staff of from
fifteen to eighteen physicians will be employed.
In establishing the dispensary the War Risk Bureau
desires to keep soldiers and sailors out of the hospital
unless they absolutely need hospital treatment.
The dispensary also will look after the medical
work of the Federal Board of Vocational Training.
It will be equipped with modern apparatus, including
equipment for electric treatment.
_Dr. Smith was one of the first to go as a surgeon
with the army to France during the war, having
served both in France and Germany for a time with
the Army of Occupation. Later he has been serving
the War Department in various medical capacities at
Washington.
TheW. B. Saunders Company, of Philadelphia, the
largest exclusively medical publishing house in the
United States, recently tendered their 150 employees a
luncheon and dance in celebration of the opening of
three handsomely furnished recreation and smoking
rooms. These rooms, located on the first and second
floors of recently acquired adjacent properties, are
provided with every comfort and emergency necessity.
The girls' rooms, one for relaxation and lunchings,
and the other for the rest and care of the ill, are fin-
ished in buff and white, maintaining the colonial at-
mosphere of the buildings themselves. The furniture
is silver-gray wicker upholstered in flowered cretonne,
with draperies of the same material. A Seth Thomas
mahogany clock, of colonial design, on the mantle
piece, bears this inscription : "A gift from the girls in
acknowledgment of the thoughtful kindness of the
company in providing these rooms for their comfort
and recreation." A victrola, a library of fiction and
of heavier reading, facilities for electric cooking, and
flowering baskets complete the restful and inviting
picture.
The men's room, on the first floor, is also finished in
buff and white. It is furnished to the masculine taste
— substantial mission, leather upholstered, with ample
provision for the solace of the pipe or other forms of
tobacco. The yards of the two properties are being
converted into another of those flowering oases of the
congested business centers, such as those of the Mor-
ris homestead on Eighth Street and the Philadelphia
Savings Fund Society.
But the party itself 1 After a group picture of the
"Saunders Family" was taken outside the main build-
ing on West Washington Square, a jazz band soon set
all toes toddling. It was truly a family party, the
executives and the employees meeting on the common
ground of good fellowship. Another proof of the
soundness of the Saunders policy in which "work
with" rather than "work for" is the phrase. A buffet
luncheon was served throughout the afternoon, so that
the affair assumed all the social delight fulness of a the
dansant.
The Following is Quoted from "The Medical Pro-
gram" of Washington County:
"For over fifty years Dr. Joseph A. McElroy, of
Hickory, Pa., has been in the practice of medicine and
for fifty years he has been a member of the Wash-
ington County Medical Society.
"Dr. McElroy was born in Mt. Pleasant Township,
November 14, 1836. He attended the public and select
schools, after which he taught in the township for
about ten years. Early in his life as a teacher he
graduated in the normal school taught by County Su-
perintendent I. H. Longdon, at West Middletown, in
1858. He studied medicine under the late Dr. D. M.
McCarrell, of Hickory. He attended medical college
and graduated in what is now known as the Western
Reserve Medical College of Cleveland, in 1869. May
I, 1873, he was married to Miss Margaret Brown, of
Mt. Pleasant Township. The family consists of two
daughters, Mrs. Leila B. Kithcart, widow of Attorney
Joseph Kithcart, of Steubenville, Ohio, and Mrs. Junie
A. Moore, wife of W. C. Moore, of Hickory.
"After graduation he began the practice of medi-
cine, forming a partnership with his preceptor. Dr.
McCarrell. During the first years his traveling was
done on horseback, using saddlebags in which to carry
his medicine. In those days there were no tablets and
the custom was to carry a lump of blue mass in the
pocket. Pills, such as compound cathartics, were
made by the doctor himself, as were syrups, tinctures,
etc. It was not unusual for him when the roads were
bad, to walk from one to five miles to see a patient.
During the early days of his practice the common
house fly was considered almost a sanitary necessity,
carrying away decomposed matter from the premises,
not even knowing of the microbes which they are capa-
ble of transferring. It was a general belief that all
vegetation had some medical virtue but it was not
known how it should be applied. Along with medi-
cines were used external applications such as blisters
and poultices ; not even black cats were excluded by
the laity. A night call of the physician was not by the
tinkling of a bell, but the silence was broken by the
exclamation, Hello, Doc !
"Dr. McElroy strongly urges all legal practitioners
of medicine to become identified with the county so-
ciety. While not in very active practice he still does
office work and occasionally makes a professional
call." R. E. C.
GENERAL NEWS ITEMS
The Lancet, founded 1823, issued weekly, will
hereafter be published by the Oxford University Press.
Subscriptions to be mailed to American addresses
should be sent to the Oxford University Press, 35
West 32d Street, New York. Editorial communica-
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THE PENNSYLVANIA MEDICAL JOURNAL
June. 1921
tions should be sent to Oxford University Press, Amen
Corner, London, E. C, England.
We CONGRATUIATB THE InTBRNATIONAI, JoUKNAL OF
Gastro-enterology on the attractive appearance of
their first issue. The editorial policy of the Journal
involves the criticism and commentaries of four emi-
nent authorities on each article published, and the ad-
vertising policy requires that every advertisement con-
form to the standard set by the American Medical As-
sociation. This Journal should be a valuable addition
to the medical literature of the country.
WiscoNSiK HoME-CoMiNC— The State Medical So-
ciety of Wisconsin will celebrate its seventy-fifth birth-
day by holding a "Home-Coming" meeting in Mil-
waukee, September 7, 8 and 9, 1921. All former
Wisconsin men, whether they have practiced there or
left Wisconsin to study medicine, practicing elsewhere
after graduating, are invited to this home-coming.
The officers of the society are anxious to secure at
this time for mailing purposes the names of all former
Wisconsin men. They will confer a favor by sending
their names and addresses to Dr. Rock Sleyster, Sec-
retary, Wauwatosa, Wisconsin.
The Success of the Institute on Venereal Dis-
ease Control and Social Hygiene recently conducted
by the Public Health Service at Washington, D. C,
suggests that public health officers, practicing physi-
cians, nurses, social workers and clinicians are eager
for more training and that they will come long dis-
tances to get that training (650 attended the Venereal
Disease Institute) when the best kind of instruction is
offered to them. The service, therefore, proposes to
conduct a general public health institute to take place
during the fall of 1921, and to offer 25 to 30 courses,
including the following: Diagnosis and treatment of
tuberculosis. Nutrition in health and disease. Sanitary
engineering, CUnic nursing and social work. Clinic
management. Courses in syphilis and gonorrhea. Men-
tal hygiene. Industrial hygiene. Child hygiene. Vital
statistics. Laboratory diagnosis. Health centers. Vari-
ous courses in psychology and sociology. The insti-
tute faculty will be composed of 75 to 100 leading au-
thorities, including William H. Welch, William H.
Park, John A. Fordyce, Valeria H. Parker, John H.
Stokes, Michael M. Davis, Jr., William A. White,
Anna Garlin Spencer, Irving Fisher, C. V. Chapin, M.
H. Rosenau.
Correlation Between Mortality Rates from
Pneumonia in 1917 and Mortality Rates from In-
fluenza AND Pneumonia in the 1918-1919 Pandemic.
—Now that the population figures for 1920 for large
cities are known, it becomes possible to make more
accurate estimates of population for 1918 and 1919, the
years of the recent influenza pandemic, and to compute
more accurately the death rates from this scourge.
During the ten months, September, 1918, to June,
1910, deaths from influenza and pneumonia (all forms)
numbered 281 per 100,000 population in Grand Rapids
against 1,269 per 100,000 population in Pittsburgh.
These are the lowest and the highest rates shown for
any of the cities included in the Weekly Health Index.
In 1917 Grand Rapids had a mortality rate of 88 per
100.000 population from pneumonia (all forms) and
Pittsburgh a corresponding rate of 364.
Correlating the pneumonia and influenza rates of 48
cities and the boroughs of New York City for the ten-
month period with rates from pneumonia (alj forms)
for 1917, Gallon's coefficient of correlation _ is found
to be .67 -|- .05, while the coefficient of variation of the
epidemic rate is .25 and of the 1917 pneumonia rate is
.32. In other words, a city which ordinarily has a high
pneumonia rate may be expected to have a high mor-
tality in an influenza epidemic, and a city which ordi-
narily has. a low pneumonia rate may be expected to
have a low mortality in an influenza epidemic.
How Dusty Is Your Plant? — All industrial plants
are dusty. But how dusty is the air in any particular
plant? Knowledge as to the degree and composition
of such dust is important, for certain amounts and
sorts of air dust seriously affect the lungs and predis-
pose those who breathe them to tuberculosis and other
diiieases.
Dr. O. M. Spencer, of the U. S. Public Health Serv-
ice, discusses the matter in a recent report of the Serv-
ice. He shows that neither the fact that the exhaust
pipes, etc., required by law appear to be properly func-
tioning nor the use of wet instead of dry processes in
grinding, polishing and the like made it at all certain
that the dustiness in a given plant is what it should
theoretically be. He finds that many exhaust pipes do
not in fact exhaust as they are supposed to do ; and
that under certain conditions some wet processes
create much more dust than dry ones. Only actual
"dust counts" at the plant of the work show the real
dustiness of the air that the workman must breathe;
and such counts should be made periodically to check
the theoretical conditions.
To determine how unhealthful the dustiness of any
particular plant process may be, the composition of its
dust should be ascertained and its effects interpreted
by standard tables, which Dr. Spencer urges should be
worked out for the various industries. Different in-
dustrial processes produce dusts which differ greatly
in injurious properties.
The National Medical Association.— Organized
tv/enty-five years ago in the city of Atlanta, Ga. Mem-
bership comprises the Negro physicians, surgeons, den-
tists, pharmacists from every state in the Union.
Meetings held annually. Last session held at At-
lanta, Ga., August, 1921. Next session August 23, 24,
25 and 26, 1921, at Louisville, Kentucky. There will
be one thousand delegates at Louisville. A feature of
the annual meetings are the clinics — surgical, medical,
dental and pharmaceutical.
For the past thirteen years has published the Journal
of the National Medical Association. It is a quarterly
publication, edited by EH-. John A. Kenney at Tuskegee
Institute, Alabama.
The following commissions are permanent organiza-
tions of the National Medical Association: Commis-
sion on Medical Education and Hospitals, Commission
on Pellagra, Commission on Tuberculosis and (k>m-
mission on Public Health.
The National Medical Association is using every ef-
fort to have more Ne|:ro hospitals standardized.
Numbered among its membership are some very
eminent specialists who have done excellent work in
this country and abroad.
The officers of the National Medical Association
are : President, Dr. John P. Turner, Philadelphia, Pa. ;
vice-president, Dr. H. M. Green, Knoxville, Tenn. :
General secretary. Dr. Walter G. Alexander, Orange,
N. J. ; treasurer. Dr. J. R. Levy. Florence, S. C. ; edi-
tor and manager of Journal, Dr. John A. Kenney,
Tuskegee. Ala.; chairman executive board. Dr. G. E.
Cannon, Jersey City, N. J. ; secretary executive board.
Dr. E. T. Belsaw, Mobile, Ala.
Chairmen of Sections : Medical Section, Dr. C. C
Cater, Atlanta, Ga. ; Surgical Section, Dr. A. L.
Turner, Detroit, Mich.; Pharmaceutical Section, Dr.
T. D. Richardson, Salisbury, N. C. ; Dental Section,
Dr. W. B. Reed, Nashville, Tenn., and a state vice-
president for each state.
BOOKS RECEIVED
Rational Treatment o" Pulmonary Tuberculosis.
By Charles Sabourin, M.D., Medical Director of the
Durtol Sanatorium, Puy-de-Dome, France. Author-
ised English translation from the sixth, revised and
enlarged French edition. Cloth, 440 pages. Philadel-
phia: F. A. Davis Company, 1921. Price $3-50 net
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Issued monthly under the supervision of the Publication Committee
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original articles
END RESULTS OF SANATORIUM
TREATMENT FOR TUBERCU-
LOSIS*
H. R. M. LANDIS, M.D.
PHILADELPHIA
The value of sanatorium treatment of tuber-
culosis and, more particularly, the ultimate re-
sults of this method of treatment have been the
subjects of adverse criticism. The charge is
made from time to time that the sanatorium has
failed to accomplish what was originally, and
what is still claimed for it. It may not be amiss,
therefore, to examine into the facts of the case.
Although it is true that here and there there
were men who appreciated the basic principles
upon which the treatment of tuberculosis de-
pended, it was not until Biermer established his
sanatorium at Gorbersdorf in 1858 that the
treatment became crystallized into the form that
now exists. There have been certain changes in
the details of the treatment but the underlying
principles have undergone but little change.
The extension of the sanatorium was a gradual
process. In this country it was not until 1884
that the first one was put into operation and for
some years it was the only institution of the
kind in the United States. With the launching
of the modem crusade about fifteen years ago
the number of sanatoria, both public and pri-
vate, increased rapidly.
Much of the criticism of the sanatoria to-day
is based on the failure of these institutions to
fulfil what was unwarrantedly claimed for them
in the beginning. These institutions were to
care only for the early and supposedly curable
cases of tuberculosis. By so doing the number
of individuals who gradually progressed into
the advanced and open stages of the disease
would be rapidly diminished and in this way the
infection of others would be correspondingly
reduced. From the very beginning, however,
this hope failed to materialize. There was
hardly an institution that did not receive a fairly
large ([uota of moderately advanced and even
•Read before ifie Section on Medicine of the Medical Society
of the State of Pennsylvania, Pittsburgh Session, October o,
1920.
far advanced cases. In some instances this was
due to a misconception of the physician refer-
ring the ca.ses as to what a favorable case was ;
in others the desire to keep the beds of the sana-
torium filled led to a more liberal interpretation
of the type of case to be admitted. The result
has been that, with a few exceptions, tubercu-
losis sanatoria throughout the country contain a
relatively small number of true incipient cases.
One of the effects of this is that the number of
patients who relapse after leaving the sana-
torium increases in direct proportion to the
number of cases beyond the incipient stage.
This, of course, leads many (both physicians
and laymen) to conclude that sanatorium treat-
ment is not very effective.
Furthermore while the mortality rate from
pulmonary tuberculosis is gradually falling, it
has failed to decline at the rate that many once
confidently predicted; and for this the sana-
torium comes in for its share of the blame. In
my judgment this is a wrong conception of the
case. In our zeal to promote the prevention of
tuberculosis, we are apt to lose sight of the fact
that we, as physicians, are under the serious ob-
ligation of trying to bring about a cure or to
prolong life or to alleviate the sufferings of
those who have developed the disease. Our
duty toward these individuals is quite as urgent
as that of trying to prevent the occurrence of
the disease in others. For this reason, if for no
other, the sanatorium is an essential cog in the
machinery for dealing with the tuberculosis
problem. It does play a part in prevention and
it is one of the effective methods, and in .some
instances the only available means we have, of
restoring the tuberculous patient to health.
Almost from the onset I have been a strong
advocate of home treatment but I realize fully
that there are many, many individuals who are
unable to satisfactorily carry this out. The .sin-
gle man or woman living in a boarding house,
for example, cannot be treated in his or her
lodgings; or the home conditions may be such
that it is impossible to obtain even the simple
requirements essential for the treatment; or
well-to-do patients cannot always be divorced
from .social distractions or bu.siness worries
unless they are removed from their home sur-
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THE PENNSYLVANIA MEDICAL JOURNAL
JUI.Y, 1921
foundings. Finally there are many who will
carry out the details of treatment in the home
if they have had a preliminary course of treat-
ment in a sanatorium. I am speaking now of
sanatoria in which there is an intelligent effort
toward individualization in treatment and in
which the essential features of the treatment
are adhered to. There are, unfortunately, some
sanatoria in this country in which there is little
or no effort made to treat the patients indi-
vidually. Some of them cannot be considered
as other than isolation institutions in which the
patient does pretty much as he pleases and, if
recovery does take place, it can be ascribed to
accident and not to any special help from the in-
stitution. If I were to single out the one great
advantage which the sanatorium offers I should
unhesitatingly say "rest." Under no other cir-
cumstances can one be as certain that the pre-
liminary rest treatment and the subsequent ex-
ercise tests will be as well looked after as in a
well conducted sanatorium.
I think that the greatest disappointment from
sanatorium treatment, aside from the part it
plays in prevention, has been the frequency of
relapses among those who have undergone such
a course of treatment. For the most part criti-
cisms of this sort are not warranted by the
facts. The question of relapse must be consid-
ered from several viewpoints. In the first place
one of the characteristics of pulmonary tuber-
culosis is the tendency to relapse. This has led
to the abolition of the term "cure" and the sub-
stitution of "arrest of the disease," the latter in-
dicating that it may be temporary or permanent
but that there is no assurance that the disease
will not recur, especially if the patient fails
throughout the rest of his life to adhere to cer-
tain simple rules of living. It is this tendency
to relapse and a failure to appreciate the factors
that bring about a recurrence of the symptoms
that have led to confusion as to sanatorium re-
sults.
In the first place it must be clearly understood
that the sanatorium itself has relatively little to
do with the occurrence of relapses unless it re-
.•itricts its admissions to the type of case in
which the preliminary damage to the lungs is of
the slightest. Such an institution will naturally
be able to point to a far larger percentage of
permanently arrested cases than the one which
admits a number of moderately advanced cases.
Again the institution that receives a large pro-
portion of well-to-do patients, whether of the
incipient or moderately advanced type, will have
fewer relapses than that dealing with those who
must return to work. The well-to-do can al-
ways regulate their lives and restrict their ac-
tivities in accordance with their physical disabil-
ity, while those dependent on their labor for
support must inevitably take their chance of
breaking down. The condition of each group
on discharge from the sanatorium may be iden-
tical ; it is their manner of living after leaving
the sanatorium that determines, largely, whether
they remain well or relapse.
There are a number of causes which bring
about a relapse. Some of these are beyond the
control of the patient while others may be di-
rectly cliarged to his fault. One of the most
frequent causes of a relapse is insufficient time
given to the treatment. In some instances this
is the patient's fault ; in others it is beyond his
control. It not infrequently happens that, as
the result of rest and regular living habits, the
patient is quickly relieved of his symptoms and
rapidly gains weight. His fears are, therefore,
allayed ; he becomes unduly optimistic and it is
difficult to convince him that the pulmonary-
lesion, in spite of the disappearance of the
-symptoms, has not had sufficient time to become
fibrosed. Such a case may relapse very quickly
unless the initial lesion is of very slight extent.
Again the symptoms clear up very slowly and
the patient lacks the perseverance to prolong the
treatment. Finally, there is a large group which
cannot stand the financial drain or if in a free
institution, feel, that at all hazards, they must
take up the burden of providing for their fami-
lies.
Of those causes for which the patient himself
is responsible, it is not necessary to go into de-
tails. We are all familiar with the individual
who within twenty-four hours of his leaving a
.sanatorium has made the tentative beginnings
of returning to his former methods of living.
Dissipation is not by any means the chief of
these. More often it consists in a failure to se-
cure sufficient rest ; to become careless as to his
dietary requirements; or to be tempted by
higher wages to attempt work which is beyond
his strength.
The educational advantage of the sanatorium
has been said to be over-rated and to substan-
tiate this, examples are cited of what many pa-
tients do or fail to do on leaving such an insti-
tution. All I can say in answer to this is that,
if any intelligent individual by reason of his
surroundings, the routine imposed upon him by
a well conducted sanatorium and the verbal
teaching given, fails to have learned what is es-
sential for him to remain well, I know of no
other method that can be expected to accom-
plish this.
In addition to the hazards which the patient
can avoid if he so desires, many people have
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PSYCHOTHERAPY OF TUBERCULOSIS— NE ALE
689
their chances endangered through causes which
they cannot altogether control. Thus some
acute intercurrent illness or, as in several cases
I have had, a violent nervous shock may bring
about a recurrence of the symptoms and a
spread of the pulmonary lesion. Relapses oc-
curring under these conditions are, of course,
unavoidable and constitute one of the risks to
which every tuberculous individual is liable.
Aside from the causes controllable by the pa-
tient the most potent source of a relapse is the
effort of the handicapped wage-earner to pro-
vide for himself and his family. This difficulty
could be minimized considerably if more time
were given to obtaining a better pathological
arrest of the disease. By this I mean the time
needed to secure sufficient fibrosis to wall oflf the
pulmonary lesions.
As to the character of the work a tuberculous
individual shall do there is still a good deal of
misapprehension. Outdoor jobs are still advo-
cated. Those of us who have had. much to do
with the post-sanatorium treatment of tubercu-
losis patients have long since realized that out-
door employment is a snare and a delusion.
Work of this kind, when at all suitable, is lim-
ited; it almost invariably entails considerable
physical exertion, and this, as a rule, is to be
avoided for some time and in many instances is
never advisable. The best rule to follow is that
the patient, if he be a clerk, a tailor, etc., shall
return to that work.
Within the past six months I have been con-
sulted by two service men. One was a graduate
pharmacist, the other a licensed marine engi-
neer. Both were advised by the Vocational
Training Department to take a course in sales-
manship. It was represented to them that em-
ployment of this nature would enable, them to
spend the greater amount of their time out of
doors. That neither of them had any desire to
change their employment, in which both had ex-
cellent opportunities, or that keeping out of
doors meant being on their feet constantly did
not seem to enter into the question at all. I ad-
vised both of them to stick to what they could
do best and, while I cannot say whether or not
they will relapse, I am quite certain that their
chances of so doing have not been increased.
Given the type of case which offers a chance
of being improved, I think it can be said safely
that the well conducted sanatorium does all that
has been claimed for it. Can the ultimate re-
sults be improved? This can be accomplished
only by a well organized follow-up system.
There is no doubt that patients,' whether from a
private or a free institution, are prone to neglect
consulting anyone once they have been dis-
charged. Those of the working classes, espe-
cially, should be urged to report to a dispensary
or their physician at once on their return home,
in order that their present condition may be
noted. They should be visited by a nurse and
they should report at the dispensary at certain
stated intervals. For the great majority con-
stant supervision and the constant reiteration of
the rules of right living are essential. I am
quite aware that follow-up work is done but, in
too many instances, it is perfunctory and con-
sists of little more than a report of conditions
with little or nothing done to remove unfavora-
ble conditions or to maintain the discipline
needed to keep the patient well. Furthermore
there is often a considerable amount of social
service work necessary. All this means that
there must be an efficient corps of nurses main-
tained. For the most part this is not possible
for the sanatorium but must be carried out by
the particular community to which the patient
belongs.
PSYCHOTHERAPY OF TUBERCULOSIS*
HENRY M. NEALE, M.D.
UPPER WHICH
Notwithstanding all efforts that have been put
forth in late years to lessen its virulence, pul-
monary tuberculosis is still with us, claiming an-
nually its hundreds of thousands of victims.
Nearly all known therapeutic remedies have
been used with very little success, and all kinds
of hygienic influences have been brought into
use, some of them quite original and fantastic,
and still our sanitoria are full, often with long
waiting lists, and every active practitioner has
many private cases. As the population in-
creases, so does tuberculosis and, in spite of the
fact that statistics pretend to show that this dis-
ease is decreasing, the decrease is so slight as
not to be noticed very much.
It is not without considerable interest and
profit to carefully review some of the different
methods of treatment that have been in vogue
at various times during the past one hundred
years, each method often quite antagonistic to
the other, both therapeutically and hygienically.
At one time it was considered best by some to
send their cases to a hot climate, the hotter the
better, with a low altitude, such as Florida, and
the Bahama Islands. Later that idea was su-
perseded by advising a cold climate and high al-
titude. At one time, not so many years ago, it
was considered the last word in hygienic condi-
•Read before the Section on Medicine of the Medical Society
of the State of Pennsylvania, Pittsburgh Session, October 6,
1920.
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690
THE PENNSYLVANIA MEDICAL JOURNAL
July. 1921
tions to keep the patient in a closed room, not
allowing any more outside air to enter the room
than was absolutely necessary ; later it was very
wisely considered the proper thing to keep our
patients in the open air as much as possible.
About fifty years ago, or more, a prominent
physician in the state of Connecticut who had
quite a wide reputation in the treatment of pul-
monary diseases, came to the conclusion that
consumptive patients were using by far too
much air, and instructed his patients to spend
hours daily breathing through a small tube,
usually the stem of a clap pipe. "Use as little
air as possible" was his motto, and strange to
say, he had many cures to his credit. One in
particular that 1 knew personally, had an ar-
rested case, and lived until less than one year
ago. At another time quite a popular method
was in use, which seemed to suit a large number
of patients, and that was to drink as much
whiskey as "one could stand up under." That
was the order, and needless to say it was fol-
lowed out to the letter by many. One of these
cases I knew about, and know that his disease
was arrested and that he died only a few years
ago, over eighty years of age. It was the late
Dr. Austin Flint, St., of New York, that gave
this advice.
Notwithstanding the fact that to-day we treat
our cases along strictly prohibition lines and
have many cures, still those who followed the
opposite plan also met with success in many
instances, but probably to a much lesser degree
than our present methods can show. We no
longer allow our patients to do their breathing
through a pipe stem or drink whiskey ad libitum,
still we must admit that those methods some-
times met with success, even in apparently ad-
vanced cases, and yet many die under the most
approved modern methods of treatment. Is this
apparent contradiction due to the individual
case, or is there a strong mental factor to be
considered ?
I am strongly of the opinion that psycholc^-
cal influences play a most important role in all
these cases — considerably more than any other
factor. We know it is the "quitter" that dies
every time, and the mentally determined and
optomistic who often recovers, regardless of
what his condition may have been.
The patient must be personally satisfied that
he is in the right place and under proper en-
vironment, and following the instructions most
beneficial to his particular case in order to ob-
tain the most satisfactory results. Regarding
the methods best calculated to create in the
mind of a patient just that sense of satisfaction
and security, this is more difiicult to explain, as
one cannot make clear what one only dimly per-
ceives. In the first place, one must carefully
study the mentality of every patient, as we sel-
dom find two alike. One case will be eager to
give a full and detailed account of his condition
and will talk voluably for an hour or more,
while another will be more reticent and taciturn
and will often give no information of value.
Such patients are apt to take the stand that it is
the doctor's business to find all this out for him-
self without any assistance. Hence 1 say, when
seeing a patient for the first time it is wisest and
best to feel him out, get a Une upon his mental
attitude and win his confidence, infuse hope and
cheerfulness into his mind, which we too often
find reduced to gloomy forebodings and abject
misery.
I was taught in my student days to believe that
patients suffering with pulmonary tuberculosis
were usually optomistic and cheerful and always
fully confident that they would eventually re-
cover. Experience has shown me that this is
not true, or if so, only to a limited degree, and
is the exception and not the rule. Therefore, to
produce in the man optomistic attitude of mind
should be our first consideration. There seems
to be a strongly grounded opinion in the minds
of the laity, and also among many well in-
formed physicians, that psychotherapy has no
field of usefulness except in ailments that are
purely imaginary and that any attempt to apply
these principles is akin to quackery or one of
the various irregular cults like Christian Science
or the methods of the mystic. There is nothing
irregular, occult, or mysterious in infusing hope
into the hearts of these poor people, even if the
outlook is not bright. Every physician has seen
at times the apparently hopeless case recover.
He haS also seen many that he had no doubt
would recover but instead of doing so, con-
tinued to go rapidly down and down until the
"last scene of all" ; but he seldom sees one who
is supremely confident of recovery and earnestly
and eagerly follows all instructions that take
that road. The imaginary effects of a placebo
are too well known to mention here and, in fact,
all delusions of this kind have no standing in the
proper application of psychotherapeutic princi-
ples; but to truthfully explain the possibilities,
or even the probabilities of recovery is not only
advisable, but our imperative duty.
It is quite difficult sometimes to find a start-
ing point to apply psychotherapeutic measures
on well defined principles. But, generally
speaking, I should say first win the utmost con-
fidence of the patient — allow him to tell his
story in his own way, listen carefully to his com-
plaints, explain to him the cause of his peculiar
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TUBERCULOSIS— DISCUSSION
691
feelings that seem so important to him assuring
him of the prospect of speedy relief, admonish-
ing him to be patient and that pulmonary tuber-
culosis is not a disease to be arrested speedily,
but that months, and often years, are necessary
for recovery. Of all the medicinal agents put
forward by able physicians at various times,
only to be thrown aside at last as useless, and
only eflfective at any time in consequence of the
suggestion of therapeutic efficacy that was given
with the remedy, none remain that can be relied
upon. In fact, the majority of .these remedial
agents are more harmful than otherwise. Open
air and the giving of proper food to induce
weight gain have proved their worth, but with-
out creating the will, the determination, the
persistence in following out this plan, they too
will often fail. Most important of all is to im-
l)ress upon the minds of our patients that there
are no absolutely incurable cases ; keep the pa-
tient free from all contact with pessimistic
croakers. If- our patients are in a sanitorium
and we find that we have among the patients
one of those gloomy ones who delight in mak-
ing others as unhappy and miserable as them-
selves, put him elsewhere. Isolate such cases if
necessary. But to such cases to whom one can
apply psychological suggestion, keep everlast-
ingly at it.
Do not be discouraged if the patient loses
heart, but start again on new lines ; keep always
before the patient the probability of recovery.
Do not entirely disregard the opinion of the pa-
tient but listen to him and gradually, if possible,
create new ideas if the ones he has seem per-
nicious. Study his character and his way of
reasoning. If he is taciturn and gloomy, give
him something to think about that will lead his
thoughts into some other field of speculation,
and if he has a fixed idea as to the eflicacy of
some plan of treatment, allow him to believe
that it will be put into effect when the proper
time comes.
In conclusion, I will say that of late years it
seems to me we have been growing altogether
too scientific (or think we are), too much given
to the belief that medicine is a positive science
and that all diseases can be reduced to an abso-
lute scientific certainty, in diagnosis, prognosis
and treatment, if we are only sufficiently scien-
tific to carry out these deductions in a strictly
up-to-date manner. We are practically told all
this by the so-called leaders in modern medicine,
but I am sufficiently old fashioned to be not
quite certain of that fact, and like the man from
Missouri, "I want to be shown." There can be
no mathematical calculation in this question;
too much depends upon factors not seen or thor-
oughly understood. Too much science and too
little common sense often lead us far afield, and
as not one of the many books upon psycho-
therapy makes clear the method of application
of these principles, it is hardly to be expected
that I can point out any positive course to fol-
low that will suit every individual. It seems to
me a question for anyone who recognizes the
value of psychotherapy to apply in his own way.
We all use it, more often unconsciously than
otherwise ; but if I have awakened sufficient in-
terest in your minds to lead you to attempt to
follow out treatment along these lines, remem-
ber that considerable study and work is neces-
sary to formulate a line of action best adapted
to your own personality. Once understood and
put into practice, often the most surprising and
gratifying results will be observed.
DISCUSSION
ON PAPERS OF DRS. HENRY R. M. LANDIS AND HENRY M.
NEALE
Dr. John A. Lichty (Pittsburgh) : I should like to
emphasize a point which Dr. Landis has brought out,
and that is the advice with reference to work or oc-
cupation. I believe that he has given us a very good
and definite presentation of that problem which comes
up so very frequently in these cases. How can thoy
continue their occupation, and how can they get along
after they leave the sanitarium or leave your treat-
ment? There is a great deal of harm done by mis-
directing patients into channels which are not liked by
them and which are unsuitable.
I wish to say further that I don't believe any,
apology is necessary on the part of the sanitarium
physician for his results, even though the results ap-
parently are' not as good as we expect them, or as we
have been led to believe sanitarium treatment is. The
reason I say this is that there are other results beside
the end results that you get in sanitarium treatment,
that is, the regimen, following a definite treatment, and
carrying that home to the family. You will sometimes
see these patients in families where the surroundings
are hopeless; you can't do anything, and yet if you
get that patient out of his surroundings and get him
into a sanitarium where he will be well instructed, if
only for six weeks, that patient will go back and will
carry out those principles and probably save his life
and the lives of those about him. There will be a
change in the family which will frequently do a great
deal more good than will be represented in ordinary
statistics. For that reason alone sanitarium treatment
is justified.
TIME TO AWAKE
The doctor is a quiet bird,
In politics he's seldom heard;
Perhaps he wouldn't be the goat
With more attention to his vote.
— {Ed. Medical Program.)
If you cannot win, make the one ahead break the
recor<l. — -• ( n on \m ous.
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THE EARLY APPEARANCE OF THE
SYMPTOMS OF COMBINED SCLE-
ROSIS OF THE SPINAL CORD
AND THE SUBSEQUENT
DEVELOPMENT OF SE-
VERE ANEMIA*
WILLIAMS B. CADWALADER, M.D.
PHILADEI.PHIA
In the majority of cases of pernicious anemia
the spinal cord is affected. The evidences of
such involvement are, however, so often entirely
overshadowed by the severity of the symptoms
of anemia as to be overlooked. Nevertheless a
considerable number of cases occur in which
the spinal cord involvement is so pronounced as
. to give rise to more marked discomfort than is
produced by the anemia alone. Moreover, the
cord may be severely aflFected long before the
characteristic alterations in the blood can be
demonstrated. It is to this latter type of case
that I wish particularly to call attention.
Owing to the striking regularity and con-
stancy in the development of the symptoms of
spinal cord involvement the clinical diagnosis
can be made with great accuracy, for in the
combined sclerosis of the spinal cord associated
with anemia the degeneration affects particu-
larly the posterior columns. It is peculiar in
that it begins in the more medianly situated
fibers ; that is to say, it appears first in the long
fibers of the posterior, or Goll's, columns and
in the parts adjacent to Burdach's columns. In
consequence, in the earliest stages of the disease
deep sensation alone — more particularly bone
sensation and the sense of muscular position —
is disturbed. Because of the involvement of the
lateral columns the tendon reflexes may be ex-
aggerated.
In an article published in the Journal of
Nervous and Mental Disease of November,
1916, I discussed the diagnosis of this condition
in detail ; hence it will be unnecessary to dwell
on it here. I wish to point out, however, that
this type of combined sclerosis occurs and can
be recognized long before the anemia develops.
In such cases severe anemia invariably develops
later, although it may not at first conform to
any particular type. Sooner or later the condi-
tion progresses and takes on all the characteris-
tics of pernicious anemia. As a rule, in spite of
treatment, it terminates fatally. By the early
recognition of the cord involvement a subse-
quent fatal anemia can be anticipated.
So far as is now known, this classic type of
combined sclerosis does not occur in association
•Read before the Section on Medicine of the Medical Society
of the State of Pennsylvania, PittsburRh Session, October 7,
1920.
with any form of anemia other than that of the
pernicious type, although it has been described
as occurring in rare cases with gastric carcinoma
and in Addison's disease. The following case,
reported by Bramwell, is instructive :
This writer refers to a case in which the symptoms
suggested disseminated sclerosis. The blood count,
made two weeks before death, showed no features
characteristic of pernicious anemia. At that time the
blood showed: erythrocytes, 4,200,000; hemoglobin,
70 per cent. ; color index, a8. During the following
fortnight, without any obvious cause, a very rapid
deterioration of the blood took place, and the stage of
rigidity passed into the stage of flaccidity. The blood
count now showed : 600,000 erythrocytes ; hemoglobin,
28 per cent. ; color index, 2.3. The patient died two
days later. In this case there had been no marked
anemia for three years, although nervous symptoms
due to combined sclerosis of the spinal cord had been
present. The diagnosis was confirmed at autopsy.
1 have observed similar cases, such as the fol-
lowing :
Case I. Mr. H. presented in November, 1919, mod-
erate ataxia, impairment of bone sensation, impairment
of the sense of muscular position, moderately in-
creased reflexes, and preservation of all other fonn>
of sensation. The blood count showed : erythrocytes,
4,200,000; leukocytes, 6,600; hemoglobin, 70 per cent
The differential count was normal. In April, 1920, the
ataxia and the loss of bone sensation and of muscular
position had increased and were so marked as to
make standing and walking impossible. His hands
were so severely affected that he could use them only
with difficulty. In spite of this increase in the severit)-
of the symptoms the anemia was not so marked:
Hemoglobin, 59 per cent.; erythrocytes, 3,224,000:
leukocytes, 6,000; differential count, normal. Later
the anemia became so intense as to render his condi-
tion critical.
Case 2. Mr. C, seen in the wards of the Presby-
terian Hospital, presented the usual evidences of com-
bined sclerosis. The symptoms developed most sud-
denly, for the patient stated that he was unable to
walk without a cane in about one week's time. At
first the blood showed no evidence of anemia : hemo-
globin, 72 per cent.; erythrocytes, 4,340,000; leuko-
cytes, 6,800. Six months later, however, the blood
showed: hemoglobin, 28 per cent.; erythrocytes,
1,220,000; leukocytes, 3,200.
In still another case the patient complained of severe
paresthesia of the hands and of very slight incoordina-
tion of the lower limbs. In spite of this he continued
in active business for three years, and then developed
a severe anemia that rapidly proved fatal.
Many examples similar to those just described
might be collected.
The actual exciting cause of pernicious ane-
mia has not as yet been discovered, but the oc-
currence of spinal cord disease without the con-
comitant anemia would seem to indicate that,
when it does develop, the anemia is merely the
most conspicuous feature of a disease that af-
fects the spinal cord as well as the blood-form-
ing tissues. It is certainly incorrect to attribute
the spinal changes to the anemia alone, i.e.,
using the term anemia to indicate quantitative
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ANTENATAL HYGIENE— SCHUMANN
693
alterations in the blood elements. There can be
no doubt, however, that the constant localization
of the lesions to certain areas of the spinal ccrrd
is not brought about in a haphazard fashion
during the course of a general disease.
In an interesting article by Orr and Rows
(Brain, Vol. XVI, Part I, 1918) an attempt is
made to show that so definite a localization as
is seen in these cases can be connected with the
spinal distribution of the thoracic and lumbar
sympathetic systems which exert an influence
upon the blood-vessels that supply the lateral
and posterior columns of the cord.
In conclusion, let me emphasize again the im-
portance of recognizing a group of cases in
which the classic picture of combined sclerosis
of the cord usually associated with severe ane-
mia is presented, but in which the anemia is ab-
sent. In all these cases, however, a severe or"
fatal anemia will probably develop during the
later course of the disease.
SOME PRACTICAL ASPECTS OF
ANTENATAL HYGIENE*
EDWARD A. SCHUMANN, M.D.
PHILADELPHIA
The conservation of infant life, not only in
the post natal period, but also during the intra-
uterine existence of the fetus is a matter abso-
lutely vital to the continuance of society as a
whole. Given a decrease of the birth rate, such
as we of the civilized world have been facing
during the past half century; plus a disregard
for the lives of such babies as are conceived and
bom ; and the ultimate fate of the race becomes
alarmingly obvious.
The decrease in the birth rate is a matter of
general concern and requires no discussion here.
The question to be developed by the writer is
that of the care of the fetus in utero from the
standpoint of the physician, such care including
]>reventive medicine, general hygiene, and thera-
peusis. It has been a mistaken custom of the
past to consider an infant's life as beginning
with its birth and to approach the problems of
child conservation with this as a starting point.
Such is by no means the case, since the life of
the child begins with conception and from the
.sixth week, post conceptional, on during the re-
maining thirty-six weeks of intrauterine life its
potentialities for pathological change, for infec-
tion via the maternal blood stream, and for
morphological disarrangement due to maternal
toxemias and the like, are well developed. Our
•Rfad before the Section on Surjcery of the Medical Society
of the State of Pennsylvania, Pittsburgh Session, October 7,
1920.
problem then, is how to prevent fetal disease,
how to recognize and cure it if present, and how
to avoid undue birth traumatisms which might
endanger the life of the infant.
It is apparent that no hygienic or therapeutic
measure can be taken to safeguard the life of
the unborn child except through the agency of
the mother, and it follows that all means
adopted to the end must relate first to the
mother and only secondarily through her vital
fluids to the contents of her womb.
Antenatal hygiene naturally is divisible into
several distinct groups: i. The sociological fac-
tors, housing, sanitation, food and occupation as
applied to the pregnant woman, or better, to the
woman in whom pregnancy is a possibility. 2.
Eugenics and the care of the woman and her
fetus from the standpoint of prevention of in-
fection, recognition and treatment of disease if
present, and those prophylactic measures against
toxemia, which are so generally understood. 3.
The prevention of birth traumatisms by careful
estimation of the capacity of the maternal pas-
sages, the relative size of pelvis and fetus, etc.,
and the conduct of labor in such fashion as to
secure the best possible result for mother and
child.
The first division of the subject is of pro-
found importance, involving a consideration of
these fundamental necessities of environment
which, if good, make for a virile race and, if
defective, react upon the species in the causa-
tion of these degenerate and enervated peoples
.so familiar to the student of history.
Important as are these factors of housing,
food, and the habit of life in general of the in-
dividual, they are too broad to be managed by
the physician alone, but of necessity are the con-
cern of the state, whose perpetuation depends
upon the quality and number of its citizens. In
these matters the duty of the physician is to
guide, counsel and aid in awakening public sen-
timent. Further than this his activities are
closed by the limitations and demands of his
profession.
The question of occupation among women is
one which requires more discussion than has
been accorded in this country. Obviously no
pregfnant woman should be permitted to engage
in hazardous or exhausting labor. It is need-
less to suggest that lion-taming, aviation and
ward politics would be better left in the hands
of the non-fecund woman than in those of her
more fertile sister. There is, however, a series
of occupations open to women and freely en-
gaged in by them which, by reason of their
being sources of chronic poisoning, seriously
endanger the life of the child in utero, and in
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THE PENNSYLVANIA MEDICAL JOURNAL
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certain instances make for sterility. I refer to
working in or with the metallic poisons — lead,
mercury, and phosphorous. In the case of lead,
for example, the classical observations of Con-
stantin Paul, made in i860 have been repeatedly
substantiated by later observors. Paul con-
cluded that in case of lead poisoning in the par-
ents the oflfspring might either be expected to
perish in utero or to suffer after the birth from
disease the result of the parental saturnism. He
studied eight-one cases from workers in type
foundries, and found that, out of a total of one
hundred and twenty-three pregnancies, in sev-
enty-three the product was dead before expul-
sion from the uterus, while thirty-five infants
born alive died in the first three years of life.
From these observations, Paul concludes that
while plubism does not prevent fecundation,
it very greatly interferes with antenatal life.
(Ballantyne.) The effects of chronic mercurial
and phosphoric poisoning have been less accu-
rately studied, but in general the observations
point to a decidedly higher antenatal mortality
among the offspring of women so afflicted than
in other groups of individuals in the same com-
munity. The pregnant woman, therefore,
should not be permitted to work among metallic
poisons.
The second division of our subject includes
eugenics, and the care of the woman and her
child from the medical viewpoint. In the mat-
ter of eugenics, there is little which comes with-
in the scope of this article. The writer is con-
vinced that positive eugenics is a biological error
as well as a social impossibility, but he does
hold that the state has the right, or better, that
it is the duty of the state to see to it that no
marriage be consummated while either party to
the transaction is suffering from transmissable
disease.
In this connection let it be .said that it is the
firm conviction of the writer that tuberculosis
should not be classed among these diseases, the
sufferer from which is denied the privilege of
matrimony. Tuberculosis is .so generalized an
infection that it seems as though the gradual at-
tenuation of the virulence of the disease by
'•breeding it out" as it were, is the logical solu-
tion of this phase of the problem. Syphilis, ac-
tive gonorrhea and like diseases should be an
absolute bar to legal marriage until cured.
The safeguarding of the prospective mother
and her child from infectious di.sease is a most
important part of our subject and one which,
regrettably offers but little hope for successful
management. Vaccination against smallpox, ty-
phoid and paratyphoid fever in communities
where the latter conditions are endemic is, of
course, generally practiced, although the typhoid
vaccination has not yet attained the position of
being routine, but is rapidly reaching this point.
With regard to such conditions as pneumonia,
influenza, scarlatina, etc., there is as yet no hope
of prevention. The dreadful visitation of in-
fluenza in 1918, with its ravages among preg-
nant women, is too fresh in our minds to re-
quire any comment as to the hopelessness of
combatting such epidemics. Careful isolation
of the pregnant woman, indeed virtual impris-
onment in her home during the prevalence of an
outbreak, suggests itself as the only possible
solution, and it is a very poor solution indeed.
When we consider the treatment of infectious
disease in the pregnant woman from the stand-
point of the conservation of the fetal life, we
meet a chain of problems some of which (albeit
a very few) offer some hopes of successful han-
dling. No matter what the disease is, during its
course some toxic effect is exerted upon the
fetus which either destroys it or impairs its vi-
tality. In either case, the secondary fetal toxins
which are evolved react unfavorably upon the
maternal organisms, with the establishemnt of a
vicious circle. Inasmuch as the premature
termination of pregnancy in the presence of
acute disease is highly apt to have a most dele-
terious effect upon the lives of both mother and
child, it is imperative that the life and health of
the fetus be conserved to the last degree. To
this end, not only must the maternal disea.<;e be
painstakingly treated, but certain factors must
be managed with especial reference to the well
being of the fetus. This is peculiarly true of
hyperpyrexia, since the fetus in utero is easily
destroyed by high temperatures. It is known
that maternal fever above 104 degrees F. is
highly dangerous to fetal life, and it follows
that in the treatment of maternal infection spe-
cial care should be taken to keep the tempera-
ture reasonably low by means of hydrotherapy
or other appropriate measures.
The specific fetal treatment of transmitted
disease is as yet exceedingly limited, syphilis and
malaria being the only fetal infections amenable
to therapy in utero. A positive diagnosis of
syphilis in the mother should invariably be fol-
lowed by inten.sive treatment directed both to
the cure of the woman herself and to the at-
tenuation of the syphilitic virus to such an ex-
tent that the product of conception will be as
little affected as pos.sible. In the case of ma-
laria, it is known that the fetus becomes readily
infected, some observers reporting fetal chill as
evidenced by regularly repeated spasmodic
movements of the fetus, whose blood has later
been shown to contain plasmodia. Here, of
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ANTENATAL HYGIENE— SCHUMANN
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course, active cinchonization is a measure
whereby the fetus is specially treated for dis-
ease via the maternal blood streams.
Students of antenatal pathology hope for dis-
tinct advances along these lines of specific fetal
therapy, advances due to a more wide knowl-
edge to antenatal morbid processes and to care-
ful study of the fetus in utero with a view to
diagnosis of disease.
Having now reviewed the matter of antenatal
hygiene upon a general and theoretical basis, it
remains for us to apply to the individual case
the principles enunciated and at once certain
practical questions arise.
1. What shall be the routine of the examina-
tion of a pregnant woman ?
2. How often shall she be seen?
3. What measures are to be taken in the pres-
ence of disease ? ?
First, it is imperative that a pregnant woman
be seen by the physician early in her pregnancy
and at this time a complete and painstaking
physical examination should be made. In the
larger cities, where prenatal clinics have edu-
cated the public, it is the general practice of
women to consult their physicians during the
first three months of their pregnancy. It is to
be noted that at this time a careful physical ex-
amination is to be made. Often, when a patient
reports early in her pregnancy, she is disap-
pointed to have the physician register her name
and the expected date of her confinement, and
dismiss her with the remark that he will ex-
amine her some time later and that there is no
hurry. A woman so treated can hardly be per-
suaded that early medical attention is of any
significance and in future pregnancies, she and
such acquaintances as may come within the
.scope of her influence will most probably en-
gage a doctor only when in active labor.
The examination made at this time should in-
clude a brief history (the salient points being
recorded), a general physical examination, spe-
cial attention being paid to the condition of the
thyroid, the lungs and the possibihty of certain
cardiac lesions, notably mitral stenosis. The
pelvis should be carefully measured, a vaginal
examination made to exclude any obstructive or
inflammatory disease, and the blood pressure
and urinalysis recorded. In cases where a vagi-
nal discharge is present, a smear to determine
the nature of the causative organisms will well
repay the trouble. In doubtful cases a Wasser-
mann test should be insisted upon. The best in-
terests of forthcoming generations requires that
this test .should be routine, but as yet this is im-
practicable for social reasons.
The examination being completed and the re-
sults properly recorded, the physician is in a
position to be reasonably certain as to the out-
come of the case. If the pelvis be of full size
and the general health of the patient good, the
case remains in his mind as one in which normal
delivery is to be expected. His only concern is
to guard against toxemia and to note the possi-
bility of some abnormal presentation of fetus or
placenta late in the pregnancy. If there be evi-
dence of cardiac or other systemic disease, the
physician is well warned and may direct treat-
ment against the increase of the pathological
condition according to his judgment. Should
the pelvis be undersized or should there be some
obstructive tumor in it, the case is to be noted
as one in which difficult delivery is to be ex-
pected, possibly some operative interference
being indicated. Such cases are, of course, to
be closely studied and the- best means of de-
livery selected and mapped out before the termi-
nation of pregnancy.
How often should the patient be seen during
pregnancy ? In the normal, healthy woman one
visit to the physician's office each month should
be sufficient during the first seven months and
two visits monthly during the later period of
pregnancy. At each visit a specimen of urine
should be examined, the blood pressure re-
corded and the general health of the patient
noted. It is not necessary to make abdominal
or pelvic examinations at these visits unless
some symptom or evidence of abnormalities
makes further study necessary. At the sixth
month, the fetal heart sounds should be counted
and the position of the child determined. At
the seventh month, the fetal head should be
gently pushed through the pelvic brim to deter-
mine the relative size of passage and passenger.
From this time on the fetal heart tones should
be investigated at least twice monthly, and any
notable variations in rate or rhythm regarded as
significant of some fetal disorder, and an at-
tempt to reach a diagno.sis as to the nature of
the patholc^ical process should be made.
With the conduct of pregnancy carried on in
this manner, the obstetrician should be fully in-
formed as to the condition of his patient, and
aware as to what complications to fear, if any.
Probably the most important single duty of the
attendant upon an obstetric case is the safe-
guarding of the patient against toxemia. It is a
noteworthy fact that eclampsia is exceedingly
rare in the private practice of any specialist in
obstetrics, while among the neglected clinic
class, the disease is fairly common. The reason
for this wide variation in frequency lies in the
simple fact that the private patient is subjected
to regular examinations of the urine and blood
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THE PENNSYLVANIA MEDICAL JOURNAL
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pressure readings — the only indications of tox-
emia available to us. The presence of albumen
and casts in the urine of a pregnant woman,
who previously showed no sign of kidney fail-
ure, is a danger signal of importance and should
predicate prompt and vigorous treatment. A
milk diet, rest in bed, moderate purgation and
preventing body chilling will usually arrest the
progress of the degenerative process.
Frequently the first sign of developing tox-
emia is a rise in the blood pressure, without
urinary change. A rise of lo m. m. or more in
systolic blood pressure in a pregnant woman
should arouse suspicion as to the retention of
toxins and should be treated along the same
lines as the kidney insufficiency. During the
progress of such mild toxemia, the heart tones
of the infant are to be carefully studied and any
marked variations regarded as significant of
peril to the fetus. In such case the question as
to the premature termination of the pregnancy
is to be considered in the interests of the child.
If prophylactic treatment fails to arrest the
progress of the toxemia, then more active meas-
ures for increasing elimination are to be em-
ployed and the question of immediate delivery
by cesarean section or otherwise, to save the in-
fant's life is to be considered.
The toxemia of early pregnancy has not been
touched upon in this paper, because it plays but
a small role in the question of infant conserva-
tion. Rarely does it result in abortion and only
occasionally is a surgical termination of the
pregnancy made necessary by the severity of the
toxemia.
As to the general conduct of the pregnancy
from the standpoint of the child, a normal, care-
free life is the ideal for the expectant mother.
No curtailment of her usual activities is neces-
.«ary, and her regular routine of life is by far
the best preparation for labor and the care of a
child that a woman can have. I do not believe
that specific diet alters the growth rate or the
metabolism of the child, though there should be
a reduction in the proteids and fats ingested
during the last months, in order to avoid excess
strain upon the organs of elimination.
The traumatisms of birth are the cause of the
greatest infant mortality. Ballantyne has well
defined birth as "the traumatic transition from
an intra- to an extra-uterine existence." He
also points out that most of us were in greater
peril of our lives during the ten hours or so that
we spent in the maternal birth canal, than we
ever have been or will be during the whole of
our terrestrial lives. If then, we are to con-
serve infant life, it behooves us to reduce these
traumatisms to the minimum To this end a
detailed knowledge of four factors is absolutely
necessary: the relative size of the birth canal
and the fetus ; the presentation of the fetus and
whether the placenta is before or behind the
presented part; the capacity of the mother for
resistance to exhaustion and strain; the train-
ing and skill on the part of the physician and
the apparatus to successfully conduct any neces-
sary obstetrical maneuver. The last of these
fundamentals is presumed to be possessed by
all of us, and the first three are easily to be
ascertained by careful examination. The key-
note to successful obstetrics is a knowledge of
the details of each individual case, particularly
the mechanical conditions which may be present.
Description of obstetrical technique plays no
part in this brief resume and will not therefore
be attempted. Suffice it to say that if the posi-
tion of the fetus in utero and the size and ca-
pacity of the maternal pelvis were thoroughly
understood, in every obstetrical case, before the
onset of labor the infant mortality would be re-
duced to a remarkable extent.
In conclusion let it be said that there has been
a deal of nonsense spoken and written regard-
ing antenatal hygiene. One group of enthusi-
asts would have us believe that the bulk of re-
jections from the army during the past three
years, were the direct result of insufficient study
of these individuals in utero. Other writers
insist that stillbirths and the death of infants
during the first year of life are all brought about
by deficiency in registering and examining preg-
nant women. On the other hand too many
medical men are prone to dismiss the whole
matter with a shrug and a recourse to that
damnable doctrine, that one cannot afford to do
antenatal work for the paltry fee to be obtained
from the poorer class of obstetric patients, or to
hold that careful and detailed study of the pr^-
nant is a fantastic and unnecessary refinement,
interesting for the specialist but of no impor-
tance in the outcome of the case.
The truth, as usual, lies between these ex-
tremes. It is the fact that many, many infant
lives are sacrificed annually by reason of the de-
velopment of maternal toxemia to a point fatal
for the fetus, before recognition of the trouble
by the physician and as many more by careless,
unstudied obstetrical methods. It is also true,
however, that our knowledge of antenatal diag-
nosis is so obscure, and our therapeusis as di-
rected to the fetus so limited that fetal disease
offers problems as yet beyond our ability to
solve. In the future, however, there lies the
hope of greater knowledge and greater power.
124 South Eighteenth Street.
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July, 1921 CARE OF PARTURIENT WOMAN AND CHILD— PIPER
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SOME PRACTICAL ASPECTS OF THE
CARE OF A PARTURIENT WOMAN
AND HER CHILD*
EDMUND B. PIPER, M.D.
PHILADELPHIA
Dr. Schumann, in his paper on prenatal care,
has touched upon one of the most important
features of the care of mother and child in the
puerperium, or perhaps I should say his entire
paper has a very important relationship to the
successful care of a parturient woman and her
newborn infant. A woman, that has received
careful and proper prenatal care will, of neces-
sity, recover from the strain and stress of her
confinement much better than the one that has
gone through her pregnancy in a haphazard,
careless manner in which her habits, diet, etc.,
have had no careful regulation or proper over-
sight. The general principles of the treatment
of both mother and baby should be based upon
ordinary sound common sense, but the psy-
chological feature of the ordeal through which
the woman has just passed must not be lost
sight of in outlining the treatment. We must
remember that normal parturition is a physio-
logical act and that where any pathological con-
ditions occur, it is either due to faulty prenatal
care, to some abnormality in the act of parturi-
tion, to the failure of the mother throi^h some
inherent weakness to react properly following
parturition, or to acts of omission or commis-
sion on the part of the attending obstetrican.
I must be pardoned beforehand for going into
details which are very elementary in character
but I believe that it is the small things which,
sometimes left undone, cause us and the patient
most of our discomfort and worriment. As I
have stated, it must be remembered that a young
mother has just passed through an ordeal that
is not confined to the labor itself but extends
over a period of nine months, in which her
whole life has been changed, and, if this be her
first child, she has been through a series of
events of which she never had any conception.
Therefore the thing of great importance is that
she must be made physically and mentally as
comfortable and content as it is possible to
make her. All extraneous influences should be
avoided; quiet, fresh air in moderation, abso-
lute rest, no visitors. These regulations should
be strictly adhered to. The great trial through
which she has passed should not be spoken of,
nor on the other hand should it be minimized
if .she speaks of it. I have found that there is
nothing that annoys a new mother more than to
•Read befor<» *b*" SecHon nti S'*rar<*ry of the Medical Society
of the State of Pennsylvania, Pittsburgh Session, October 7,
1920.
be told by her husband, her nurse or her doctor
that she has had an easy time. If she has been
so fortunate as to have had a moderately easy
labor (there is no such thing as an easy labor —
at least there wouldn't be if men ever became
mothers) she will find it out soon enough for
herself by comparing notes with her friends
after she is up and around.
Every large maternity hospital must, of ne-
cessity have some fixed technique. This should
always be merely a guide, as in many conditions
that may arise each case is a law unto itself. As
we all know, it is much simpler and easier for
the obstetrican to care for the woman in a hos-
pital than in the private home but it is perfectly
possible, with a good trained nurse, to give the
mother and child just as good care in the home
as in a good maternity. The brief outline of the
routine care of the mother and child which I
am about to present to you is that which we use
at the University Maternity and naturally, as I
have said before, is open to change for each in-
dividual case.
As soon as the baby is born and found to be
in good condition, it should be removed to the
nursery. If the mother is partially under anes-
thetic at the time of the delivery I believe it to
be a wise procedure to let the baby remain in
the delivery room long enough to allow the
mother to hear it cry, as in that way she has the
proof in her own mind of the successful termi-
nation of her labor, which puts her in an excel-
lent mental attitude for the next few hours.
The child having been removed to the nursery,
the nurse should see that the ligature to the
cord is tight enough or, if the clamp flush with
the skin has been used, it should be allowed to
remain for lo to 15 minutes. The cord should
be dressed daily after the bath and sterile dress-
ing applied. Whether one uses a dusting
powder or some liquid a.ntiseptic I do not be-
lieve is of material importance but the asepsis
practiced in applying this dressing is of exactly
the same importance as that used in any other
surgical dressing. The infant is cleansed thor-
oughly with olive oil after arriving in the nurs-
ery and carefully wrapped. For the first
twenty-four hours, in particular, its color, res-
piration and signs of hemorrhage from the cord,
should be closely watched.
At the end of from four to six hours the baby
should be put to the mother's breast and there-
after every six hours for the first two days,
each nursing lasting from five to ten minutes.
When the milk begins to appear the nursing
should occur every three hours by day and less
frequently by night. Daily the baby should re-
ceive a bath, preferably with a sprinkler, and
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should be dried and powdered, with particular
attention being paid to neck, arm pits, buttocks
and genitalia. Diapers should be changed on
an average of every two hours but, of course,
this depends upon the child itself.
As stated in the preceding paragraph, the
nursing of the baby after the milk comes in
should occur every three hours during the day
time. There are some who believe that the
nursing should occur every two or two and a
half hours. Of course this is a matter of indi-
vidual opinion. The life history of the baby in
its first year is unquestionably dependent upon
habits acquired in its first four weeks. If ir-
regular methods of feeding are used the mother
and the father also, will without a doubt spend
an unrestful and unhappy subsequent year. If,
on the other hand, the baby is trained during its
first four weeks of existence in regularity as to
the duration and interval of feeding, the subse-
quent troubles of the mother, father and baby
itself will be largely decreased.
For instance, in the matter of intervals of
feeding alone, let us suppose we take the three
hour interval. The baby is nursed at 6 a. m.,
9 a. m., aijd I2 noon, 3 p. m., 6 p. m. and 9 p. m.
For approximately the first six weeks of its life
it may be nursed at sometime during the night,
let us say 12 midnight and, possibly for the first
two weeks, one other time; At six to eight
weeks of age, if the 9 o'clock feeding is put off
until 10 or 11 p.m., it is possible, in fact it
usually occurs with a well trained child, that the
night nursing may be abandoned. As the
mother gets up and around, if this is her first
baby, she usually becomes somewhat upset by
the fact that the baby is inclined to spit up a lit-
tle after the feeding and to have a considerable
amount of gas. If the child is laid over the
mother's shoulder after each feeding before
being put back to its crib this may be, to some
extent, avoided.
After each feeding the nipples of the ma-
ternal breast should be washed gently with boric
acid on sterile cotton and dried. Between nurs-
ings the nipples should be protected with a
leaden nipple shield and a binder. In case there
is a tendency for the nipples to become dry and
crack sterile olive oil may be applied twice
daily.
The early care of the mother following de-
livery has been touched on. As I have already
stated, one of the most important features is the
avoidance of worries of all kinds and our effort
in her behalf is to see that she is as near normal
as possible, both phy.sically and psychically with- .
in a reasonable length of time. In a normal
case her temperature and pulse should be taken
at least three times every twenty-four hours. A
little rise in temperature may be looked for, but
is not always present, the third day when the
milk comes in. At that time if the breasts are
engorged and sore they should be treated by the
breast pump, massage and tight mammary
binder. In hospital practice other babies may be
nursed. The diet for the first forty-eight hours
should be soft or liquid. After that, if there
are no complications, she may receive full diet
and in addition a glass of* milk or a cup of choc-
olate three times a day.
The gastro-intestinal tract of the mother is
of marked importance. If, in the prenatal care,
regularity of the bowels has been established it
will be found that this difficulty will be much
lessened in the puerperium. Routinely at the
end of forty-eight hours some saline cathartic
should be given and if this is ineffectual an
enema may be used the next day. During the
entire puerperium, unless contra-indicated by a
complete tear or some other obstetric complica-
tion, the bowels should be kept freely open. .At
least definite constipation should not be allowed
to occur.
At the end of twelve hours after delivery
spontaneous urination should be encouraged by
the usual methods. If this is unsuccessful
catheterization may be put off for a few hours
more, but it is hardly desirable to wait more
than sixteen hours and the patient should be
catheterized sooner if she complains of the sen-
sation of a full bladder. Of course it may be
necessary to catheterize and recatheterize. but
when neces.sary it should be done as carefully
and aseptically as possible.
When should the attempt at normal breast
feeding be abandoned? The only answer to
that lies in the judgment of the attending phy-
sician. One thing is certain, it should not be
abandoned to satisfy the social convenience of
the mother. On the other hand it should be
abandoned when it is assured that the infant is
not thriving under the breast feeding or when
such feeding is so great a drain on the mother
I hat for the sake of her future health it is
deemed better to transfer the child to the bot-
tle. Personally, I do not believe the latter con-
dition occurs very frequently. When this mat-
ter comes up from the point of view of the in-
fant's well being, I usually ask for and accept
the advice of a pediatrician.
The complications of the puerperium may
be so many and so varied that it is impossible
to take them up in a paper of this kind. There
are one or two, however, which occur so fre-
quently that I must say something about them
in passing. Any time during the first two weeks
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FACTORS IN FETAL MORTALITY— GLYNN
699
of the puerperium we frequently see a siulden
rise in temperature, even up to 104 degrees at
times, accompanied by a chilly sensation or a
real chill. I know of nothing in the practice of
medicine which causes the practitioner more
worry than this one thing. Of course, our first
thought is puerperal sepsis, and it should be, but
on the other hand there are so many other con-
ditions which may cause just such a clinical pic-
ture that we must not at all times jump to the
conclusion that this is puerperal sepsis. I f early
in the puerperium, we must think first of en-
gorgement of the breast when the milk is com-
ing in; later on, we must think of a damming
back of the lochia. This latter may be verified
by the report of the nurse as to the amount,
color and odor of the lochia. W^e must think of
pyelitis, of phlebitis and, by all means, of breast
abscess. I will not go into the various methods
of treating these and numerous other conditions
which might cause a sudden rise in temperature
e.xcept to say that in a case in which there has
been a sudden stoppage or decrease in the
amount of lochia. The lochia may, in some
cases, be brought back to the normal by the
mere elevation of the head of the bed or by the
u.se of a Fowler or semi-Fowler position.
It must not be thought that, in speaking of
these other factors as being the possible cause
of this condition, we set aside the possibility of
it being a true puerperal sepsis. Of course no
obstetrican or general practitioner cares to think
that he has a case of puerperal sepsis but I, for
one, believe the propaganda for more careful
obstetrics has made many believe that all cases
of puerperal sepsis are due to errors of omis-
-sion or commission on the part of the attending
physician. This I do not believe to be true.
Our friends, the internal medical men, frequent-
ly think that when we call one of them in con-
sultation we try to avoid the responsibility of a
])uerperal .sepsis and that we think of every
other condition that might cause this clinical
picture as being the cause rather than true puer-
peral sepsis. This is not the case when a con-
sultation is requested only to eliminate the other
])ossible factors before we proceed on the treat-
ment of puerperal sepsis. It is thought by some
members of the profession who do not use the
intra-uterine douche in indeterminate cases of
this kind that it is done with the idea that by so
doing a cure of an early puerperal sepsis may be
accomplished. This is a mi.sconception, the
intra-uterine douche is used primarily to induce
drainage and wash out necrotic material. Nat-
urally it can have no bearing upon a blood
stream infection exce])t in so far as a general
."^urgeoii may wash out or irrigate an al)scess
cavity from which a septicaemia has developed.
The final step in the puerperal care should be,
in all cases, a routine examination of the
mother, six to eight weeks after her delivery.
At this examination there should be noted the
condition of the pelvic floor, the anterior wall,
the cervix, the position and involution of the
Uterus, position of the kidneys, condition of the
abdominal wall and the condition of the coccyx.
All this should be observed and advice given
according to the individual judgment of the at-
tending physician.
In a paper of this kind it is impossible to
avoid touching upon subjects most rudimen-
tary in character nor can one go into details of
diagnosis and treatment in regard to the condi-
tions that may arise. I have merely tried to
outline in a general way the routine care that
should be exercised in the normal or almost
normal case.
In conclusion, the psychical side of this treat-
ment may not be too greatly emphasized, espe-
cially in the primipara. The surroundings both
in a hospital and in a home should be made as
happy as possible. It should be our care to
make this time in a woman's life as beautiful a
period of sunshine and happiness as we can.
FACTORS IN FETAL MORTALITY*
WILLIAM H. GLYNN, M.D.
PITTSBURGH
The aim of the obstetrician is to preserve the
life of mother and child. No case is completely
successful that fails to attain this ideal. This
ambition, though not always realized, may be
more nearly reached by a careful scrutiny from
time to time of our methods, thereby tending to
standardize our procedures. We offer no new-
ness of thought, but rather a reiteration of what
is common knowledge. This with the sole idea
of impressing its importance. Also we wish to
learn from a di.scussion of a few of the accepted
methods if .some abuses are not creeping into
obstetrical practice.
In the first place, obstetric practice re(|uires
besides obstetric knowledge an obstetric judg-
ment. It is not enough for us to be familiar
with surgical asepsis and technic to successfully
perform version, induction of labor or even
cesarean section. Each one of these purely ob-
stetric methods requires a thorough obstetric
knowledge to determine the exact indication of
each procedure. The abuse of hasty hystero-
tomy from which obstetric practice so lately
"Rfa<l before the Section on SurRery of the Medical Society
of the State of }*ennsylvania, VittshiirKh Session, October 7,
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THE PENNSYLVANIA MEDICAL JOURNAL
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suffered was due to viewing obstetrical condi-
tions through surgical eyes. When one ob-
server reports two cesarean sections in "eleven
hundred and thirty-five cases we know he is
viewing his cases with obstetric knowledge and
skill. The indications and limitations of cesa-
lean section are gradually becoming more clear-
ly defined, just as are also the indications for
version and forceps. We hope the day is not
far off when the indications for cesarean sec-
tion will be stated. In all obstetric cases we
need a thorough working understanding of the
mechanics of labor as well as intimate knowl-
edge of the physical condition of the mother;
then an early and clear recognition of the exact
condition, if it be pathologic, and a prompt ap-
plication of the proper method to bring about
its relief. DeLee very clearly impresses this
point in his recent discussion of obstinate pos-
terior occiput positions.
In obsterics, as in other branches of medi-
cine, a careful examination of the patient is very
essential to enable us to make an accurate diag-
nosis. Fetal mortality in those cases of pos-
terior occiput that do not rotate anterior is still
very high. DeLee says, "In my opinion more
children are lost from this complication (pos-
terior occiput) than from the effects of a con-
tracted pelvis." If the condition is recognized
early and proper methods applied many chil-
dren as well as mothers would be saved. When
the head is high and dilatation complete, version
is to be considered in primipera as well as multi-
para. The expectant treatment is followed only
while condition of mother and child remains
good ; not one minute longer. Let us have the
situation well in hand so we may be able to in-
stantly apply any of the well recognized
methods of delivering the child.
Extreme obliquity of the uterus will fre-
quently interfere with the normal propulsive ef-
forts of the uterus. This is found especially in
multipara who have relaxed abdominal walls.
Prolonged labor, maternal exhaustion requiring
forceps, or fetal asphyxia is sometimes present.
A prompt recognition of the condition with a
properly adjusted abdominal binder will lessen
forceps application and its possible fetal injury.
The insistence of the present day parturiant
that she be relieved from pain has brought into
too frequent use dangerous drugs. Morphin is
particularly dangerous to the fetus. In cases of
rigid, hypersensitive os, wild pains of first
stage in primiparae or nagging but ineffectual
pains of first or second stages relief may be ob-
tained in most instances by chloral hydrate. In
the rectal administration of chloral hydrate
alone or combined with sodium bromide we
have a drug comparatively safe for both mother
and child.
Pituitary extract is another drug commonly
used in obstetric practice which has been re-
sponsible for fetal and maternal deaths. This
erratic and powerful agent has been too long
the object of indiscriminate use without a crit-
ical review of its possibilities. This is not the
place to give it more than passing mention as to
some of its contra-indications. Pituitary ex-
tracts has undoubtedly saved fetal life and les-
sened the use of low forceps operations in many
instances. It deserves a place in obstetric prac-
tice, but we must not lose sight of the many
dangers in its use. During the first stage of
labor it should never be used. In the latter part
of second stage where the cervix is fully di-
lated, head firmly engaged, and no obstruction
to head being born, then small doses of pituitary
extract may be exhibited. Where the pains are
feeble and lagging at this time it undoubtedly
lessens the time of the second stage. Small
doses should always be used and may be re-
peated if necessary. In our experience, if small
doses of 3 to 5 minims do not have the desired
effect, larger doses are also ineffectual. Large
doses of fifteen minims may cause such rapid
recurring and tumultous pains as to simulate
tetanus uteri. In such cases fetal death from
compression and asphxia is almost certain. If
obstruction exists or improper engagement of
head, ruture of uterus may occur. Unfortu-
nately we have seen both of these conditions.
Mundell, in the American Journal of Obstetrics,
reports twenty-one fetal deaths and seven ma-
ternal deaths out of three thousand nine hun-
dred and fifty-two cases from the use of pitui-
tary extract. Six of the maternal deaths were
due to rupture of the uterus. Personally we
have seen one maternal death due to rupture of
the uterus from pituitary extract. We believe
pituitary extract is very powerful and frequent-
ly erratic in action and its exhibition should
always be made with extreme caution.
Borderline cases of pelvic contraction must
always contribute to the fetal and maternal
death rate where they are not discovered until
sometime after labor begins. Prolonged pres-
sure on the fetal head and infection of the
mother are the most frequent sequelae of these
cases. External measurements should be made
in every primipara, where these are close to the
borderline; then the internal measurements
must be made. Naturally these should be made
early in pregnancy so that the case may be de-
livered in an institution at full term, or labor
induced at the proper time after viability of the
child. If these cases are not discovered before
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MATERNITY PAPERS— DISCUSSION
701
they are potentially infected from repeated vagi-
nal examinations, then the proper treatment
cannot be instituted. A version may have to be
attempted, with danger to the child or hyster-
ectomy performed, causing unnecessary mutila-
tion to the mother.
There is perhaps no condition in the pregnant
woman where fetal life may be more surely
concerned than in the toxic states. In those
grave toxemia of pregnancy where the child is
viable we believe labor should always be in-
duced. Peterson pertinently remarks that as
the cause is as yet unknown the treatment must
be empiric. Therefore, empty the uterus after
the first convulsion, when the child is viable,
and f etel and maternal mortality will be lessened.
Really this seems to cover the case very com-
pletely. There is nothing to be gained by tem-
porizing. We have a colloidal poison that can-
not be eliminated. In a goodly proportion of
cases the mother improves after the uterus is
emptied. In those unfortunate cases where the
toxemia persistes after the uterus is emptied
there can be* no harm done the mother in de-
livering the child.
The same plan of treatment, we feel, should
be exhibited in the preeclamptic states after via-
bility of the child. Given a case where the al-
bumen is abundant, some granular casts with a
high or increasing blood pressure, we believe
the best interests of both mother and child will
be served in emptying the uterus. However the
blood pressure is not always, in our experience,
a very reliable prognostic or diagnostic sign.
Where the pressure is high its presence is noted ;
where it is not high the pressure is disregarded.
The induction of labor is certainly a proce-
dure of considerable value in obstetric practice.
In preeclamptic states, grave toxemia of preg-
nancy, cases of postmaturity or cases of mod-
erate pelvic contraction labor induced under
proper conditions will conserve fetal and ma-
ternal life, though we do not feel that this is
always the simple procedure that Reed would
have us believe. No one method serves all
cases, each case must be considered of itself
and the condition of the cervix is one of the
most important factors in determining which
method must be used.
The obstetric forceps has proved of inestima-
ble value in conserving fetal life, yet the high
application of forceps and axis traction forceps
should always demand a careful consideration
of all things before their use. The use of high
forceps is rapidly being discarded for more con-
' servative methods. After listening to the fig-
ures of Potter we feel that, in the hands of
most men only excepting the most expert, ver-
sion offers a far better chance for fetal life than
the application of the high forceps.
1 121 Highland Bldg.
DISCUSSION
ON PAPERS OP DRS. SCHUMANN, PIPER AND GLYNN
Dr. Paul Titus (Pittsburgh) : Dr. Schumann has
spoken particularly of the education of the public in
obstetric matters. There is no question about the im-
portance of this and it is going on in constantly in-
creasing volume. The public is rapidly coming to a
thorough understanding of the fact that antenatal care,
for instance, is necessary and it is only a question of
time until pregnant women will demand that the doc-
tor give them the care that they know they deserve
whether he does it of his own volition or not
Dr. Piper gave an excellent outline of the care
which should be given the mother and baby at the
time of delivery. One point which he brought up I
should like to stress. This was in respect to cord
dressings. Too often this is done in a haphazard
fashion, without regard to the fact that the cord must
be soiled from having passed through the vaginal
canal and vulva. It has been my custom to wipe off
the cord with fifty per cent alcohol and then paint it
with half strength tincture of iodine. It is then tied
and cut, and the cut end painted with iodine.
Dr. Glynn has discussed the matter of hypnotics
during labor, and almost everyone will agree that a
parturient woman should be given the benefit of any
relief that can be derived from them. I disagree
somewhat as to the end-result of the breaking up of
chloral in the body, because I believe that this end-
result is chloroform. I think if Dr. Glynn's guinea
pig had been sectioned, that he would have found cen-
tral necrosis of the liver lobule as the result of chloro-
form poisoning. Nitrous oxid is coming into vogue
in obstetrics, and has the advantage not only of being
safe, but also that it can be used over a far greater
period of time than ether or chloroform, without in-
terfering with the progress of labor.
Dr. H. C. Winslow (Meadville) : My limited ex-
perience in maternity work does not warrant my tak-
ing part in this discussion. However I wish to take
exception to Dr. Piper on one point (I feel at liberty
to do this inasmuch as he was a classmate of mine),
that is, in the matter of the use of the breast pump.
The early congestion of the breast is due largely to
the inflow of an excess of blood and the slowness of
its venous return and if the breasts are properly
raised, supported and massaged in the direction that
will support the venous return the use of the breast
pump will, as a rule, be unnecessary. In a large per-
centage of breast abscesses I think we will find that
the breast pump has been used. The competent nurse
relieves congestion due to an excess of milk by mas-
sajr ', with less damage to the breast than by using the
br<!: st pump.
]'. t Piper (in closing) : I want to thank my good
fr't nd, Dr. Winslow, for bringing up the question of
th'- >)reast pump. The breast pump I alluded to be-
ca'i e I was noting a technic from which I said you
CO J d vary according to the individual case. The
br>: St pump has its function but it is abused without
any doubt. There are some cases in which you must
use it, particularly the woman who has lost her child,
when you must quickly stop her milk supply. At the
beginning you must use the breast pump, but if this is
continued milk will be secreted for a long time.
Dr. Titus spoke of the cord stump. My statement I_
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THE PENNSYLVANIA MEDICAL JOURNAL
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made that it was immaterial what was used so long as
asepsis was carefully employed, was due to a series of
infections in the babies at the University Maternity
about a year ago. I think Dr. Titus was there and I
went oyer it with him then. We had one child after
another who would develop septic arthritis, maybe in
a foot or in the shoulders or other joints. We went
over it in every way and distinctly traced the condi-
tion to infection of the cord stump. At that time we
were using a powder. We changed to the iodine,
much in the same manner Dr. Titus stated, but even-
tually found it was due to a careless bit of system in
the Maternity. Owing to the small number of nurses
they had to double up. There were certain infectious
nurses that had to take care of babies at the same
time. Since we straightened that out there have been
no more cases of infection. Now we use iodine.
Taking up Dr. Glynn's paper, for information I
should like to know if, as in the guinea pig given
chloral hydrate, they tried on guinea pigs the use of
morphin? I had the bugbear thrown into me as an
undergraduate that morphin was the one big thing
bad for mother, child and everybody in labor. I must
say since then in personal use I have not been able to
see it when confined to the first stage of labor. I be-
lieve, carefully used, that with ordinary common sense
it will not have the bad results that some practitioners
fear.
His remarks on pituitrin I cannot emphasize too
strongly. I believe everyone has seen bad results
from the use of pituitrin at the wrong time. In other
words, if someone takes a student's diagnosis of dila-
tation of the cervix and says go ahead and give
pituitrin he is going to be up against it. If you give
pituitrin in the first stage of labor you are taking a
chance. About pelvic contraction, it seems to me the
subject of pelvic contraction is really relative. Is it
always just as easy for the woman with a contracted
pelvis to deliver a baby weighing eight pounds as to
deliver a nine or ten pound baby? The relative size
of the head seems more important. In measurements
the personal equation is an important factor.
Dr. Glynn (in closing) : Dr. Titiis and I will take
our little argument into the back parlor. I think Dr.
Piper's remarks are very important in regard to the
relative size of the head to the pelvis, but we have not
reached the stage where we can definitely determine
the size of the head. When we have borderline cases
we must work on that assumption. (Dr. Glynn then
read the conclusions of his paper.) We have a col-
loidal poison not possible to eliminate and in view of
that fact hot baths and saline cathartics (those things
we have been accustomed to use in the past to elimi-
nate this toxemia) are practically useless and if we
get a convulsion with blood pressure going up and
albumen present, we believe the uterus should be
emptied promptly. I do not believe that castor oil and
quinin and the Voorhees bag will empty the uterus in
all these cases.
THK WORLD'S GRI'.AT NEED
Dr. Charles Eaton, in Leslie's: The end toward
which civilization moves is the making of men. And
this is one result which can be reached only by proc-
esses of life. Machine-made men are like machine-
made dolls — poor imitations of the real thing. The
great need of the world to-day is the hberation of
new, vital, man-building energies in and by a universal
spiritual awakening.
THE TREATMENT OF BICHLORIDE
POISONING
For a number of years the stock treatment of
poisoning by mercury and its compounds has limited
itself to the use of washing out of the stomach, and
administration of egg albumen as a chemical antidote.
Notwithstanding the energy with which these meas-
ures have been pushed, results have been far from
satisfactory. In theory, washing out of the stomach
is sound practice. When it comes to acttial working
it is virtually useless for it has been demonstrated
with a fair degree of certainty that by the time a
physician reaches the patient (even if it is within fif-
teen minutes) scarcely any of the poison remains
therein. Furthermore egg albumen as a chemical anti-
dote has never been satisfactory, for while given in
a proper amount it will produce the insoluble albumi-
nate of mercury, if given in excess it will render the
mercury soluble once more. Inasmuch as the physi-
cian can never know what quantity of mercury still
remains in the stomach, it would appear to be im-
possible to estimate the efficient dosage of egg albu-
men. Of late years calcium sulphide' has been recom-
mended. This agent coming in contact with the
bichloride solution produces an insoluble sulphide of
mercury and no excess of antidote is capable of re-
dissolving the precipitate, hence it should prove to be
an efficient antidote; the objection to it, however, is
that by the time it is introduced into the stomach the
latter organ is empty and any antidotal influence of
calcium sulphide depends upon its absorption into the
circulation.
About three years ago one of our younger men, J.
H. Willms, of Cincinnati, made some elaborate experi-
ments covering this subject, published in the Journal
af Clinical and Laboratory Medicine. The plan of
treatment is beautifully simple, so simple indeed that
the physician is only too likely to make efforts at im-
proving it or making it look complicated, thus defeat-
ing his purpose. Its very simplicity is a testimonial
to its efficiency. Of the last fourteen cases of poison-
ing treated at Hahnemann Hospital but one patient
died, and that one took over 140 grains. One patient
who recovered had taken 49 grains. Of those who
recovered not one had nephritis. * * •
The treatment as carried out was this: An intra-
venous administration of sulphide calcium in the pro-
portion of one grain to the ounce in sterile water was
employed promptly on the admission of the patienL
The total quantity of calcium sulphide used was one
grain for every grain of bichloride supposed to have
been taken. * » » The main care in the prepara-
tion of the sulphide solution was the avoidance of
small particles of calcium sulphide held in suspension
and not evenly enough divided. These can very readil)
be taken out by passing through some loosely packed ab-
sorbent cotton in a filter. Following the intravenous,
the patient is given one grain of calcium sulphide,
sometimes more, by the mouth every hour for several
days. Such is the treatment.
No attempt should be made to mix the sulphide with
normal saline solution, as such most unquestionably
would interfere with the chemical reaction. No time
should be lost by preliminary washing out of the
stomach. No attempt should be made to add any
details which the imagination or ingenuity of the
physician may suggest. It is simply a question of
getting suflicient calcium sulphate into the circulation as
quickly as possible. And that is all there is to it—
The Hahncmannian Monthly, April, igzi.
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ELEVENTH CONFERENCE OF INDUSTRIAL PHYSICIANS AND SURGEONS
HELD UNDER THE DIRECTION OF THE DEPARTMENT OF LABOR AND IN-
DUSTRY 6F the COMMONWEALTH OF PENNSYLVANIA
BELLEVUE-STRATFORD HOTEL, PHILADELPHIA, DECEMBER 17, 1920
(Concluded from iJic June Issue of the Pennsylvania Medical Journal.)
Dr. Patterson : I am going to call on Dr. Frederick
L. Van Sickle, Executive Secretary of the Medical
Society of the State of Pennsylvania, who will present
a paper outlining the needs of legislation, after which
we will have a symposium on the "Treatment of
Wounds."
OUR LEGISLATIVE PROGRAM
FREDERICK L. VAN SICKLE, M.D.
Execiitivf Secretary, Medical Society of the State of
Pennsylvania
BARRISBURG
I am not quite sure why your chairman in-
jected this particular subject into this meeting
of a conference devoted to industrial lines of
work. I am sure, however, that there will be a
mutual relation between the industrial physicians
and the Medical Legislative Conference of Penn-
sylvania, if the future of medicine and surgery
continues worth while. I know that many of
you are thoroughly familiar with what has been
done in the past, but I would say that some few
years ago an apparent lethargy had overcome
medical men in our state as to their personal wel-
fare and the welfare of the profession. Then
they conceived the necessity of forming an or-
ganization through which could be carried on
successfully some form of a system by which af-
fairs medical and legislative could be combined.
This organization has continued up until the
present time, and I trust that it will continue for
many years to come.
Those of you who have viewed the medical
profession only as a purely scientific business,
have failed to realize something which is going
on in this and every other state in the United
States of America, namely, a new type of legis-
lative wave which is sweeping over this country
in some states for good ; and in others, for good
and bad. Pennsylvania happens to be a state in
which this legislative wave contains both good
and bad. These legislative problems occur in
Pennsylvania every two years. As such, they
must be met in some form or other ; and I re-
spectfully ask your indulgence for a moment,
while I simply outline what has occurred in the
minds of the Medical Legislative Conference as
to the needs of the profession and, particularly.
the need of an association between your confer-
ence and the Medical Legislative Conference. I
have not attempted to individualize in picking
out bills or measures, or types of legislation only
in perspective; because, in a discussion of this
kind, you can read between the lines, if neces-
sary.
Speaking for the Medical Legislative Confer-
ence, the organization, which is the one to which
has been assigned the duty of watching and
carrying forward legislative problems, and which
will be the active factor in medical legislative af-
fairs during the session of the legislature for
192 1, I have a few thoughts and recommenda-
tions to offer to this conference.
No organization, having such a definite pur-
pose as the conference can proceed into action
without some definite program. For the infor-
mation of those who have not been informed as
to the objects of the conference, I may suggest
that it was this body who, in 1919, prepared the
campaign for legislative action during the ses-
sion of that year's legislature. During the past
months, the conference has not been idle, but
has organized the medical profession of this state
into a wide-awake, active and interested group
of men, who are now preparing to wage a de-
cisively active campaign for the interests and
welfare of the people of Pennsylvania along
medical legislative lines. We have conceived the
necessity of informing the members of the
county societies of the three groups of practi-
tioners comprising the conference regarding all
the possible measures which may be presented
during the coming session of the legislature.
We believe that the senators and representa-
tives who will make the laws during this session
are very familiar with the needs and wishes of
the people of this state regarding medical af-
fairs; and we are assured that the men who
come to Harrisburg during that session in the
official capacity of legislators will be very fa-
miliar with the desires of their constituents in
every section of the state. I desire to make this
very plain, as I believe that the profession of
I^ennsylvania have realized many of their former
shortcomings in the interests of the public, and
are now prepared, as never before, to consider
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THE PENNSYLVANIA MEDICAL JOURNAL
July, 1921
every problem that may be presented ; and all of
this work will be done through the Medical Leg-
islative Conference.
There will be, of course, much obstructive ac-
tion during the coming session on the part of the
conference, due to the effort of some misguided
people of the state to place upon the statute
books new laws and amendments to previous
acts, which, if carried into practice, would be ex-
tremely detrimental to the welfare and best in-
terests of the people; and the people have no
way of becoming informed as to the detrimental
influence which might result from such legisla-
tion, only by the careful investigation on the
part of medical men, who are informed by read-
ing and by investigation of such measures where
attempts have been made to apply them in other
states, as well as in states which have been un-
fortunate in having placed upon their statute
books such detrimental legislation. I refer par-
ticularly to acts which would restrict investiga-
tion of disease and measures for the protection
of the public in providing curative remedies
through such investigation. We also point to
some who desire to express their personal liberty
views by restricting the profession from per-
forming certain necessary preventive measures
that will protect the public against disease.
Again, there are others who would enter the field
of medical art and science through a side door,
presenting misstatements and incorrect asser-
tions which would lead the public to believe that
they possessed knowledge, information and edu-
cation; when, in fact and in truth, such is not
and cannot be possible without the necessary
course of instruction, teaching and practice,
which is required to procure such knowledge.
There may possibly be other legislative meas-
ures introduced which, in the last analysis, would
be detrimental to the people of the state; and
we believe it our duty to stand ready to obstruct
such measures, should they be presented.
Our duty, then, is one of watchful waiting,
anticipating whatever may come before the next
session, and taking such action as may be re-
quired to protect the people of this common-
wealth in legislative affairs.
Constructive legislation is, and will be, the
real duty of the conference during the coming
session, and we hope it will continue so far many
years to come. We have in mind public health
matters which can be brought to the attention
of the session, whereby laws may be amended
and new laws enacted to create a better health
condition in the state through the departments
already in existence and, possibly, to create
whatever new departments or subdivisions of
departments may be necessary to carry into ef-
fect such protective plans.
To this body of industrial physicians, particu-
larly, we wish to express the satisfaction which
has come about through the influence of this
conference in the past years, by aiding in the
improvement of the Workmen's Compensation
Act, which, at the present time, appears to be
working fairly well. It is our belief that during
the coming session no interference with this act
should be made, as it would only lead to a mis-
understanding as to the attitude of the profes-
sion regarding our position in interpreting the
various provisions of that act. We believe that,
if the English language contained in that act be
correctly interpreted, there is no need for any
amendments or adjustments.
True, the act is not entirely without fault; it
might be improved for the financial benefit of
the industrisJ surgeon; but whenever such ef-
forts are made, our motives are misconstrued,
and we are apt to have a serious obstruction
placed in our way, with a possible effort made to
curtail our usefulness, rather than to increase
the benefits in industrial practice.
The duty of the Medical Legislative Confer-
ence is to receive suggestions, recommendations
or legislative bills, with such information as this
conference might present for constructive l^s-
lation during the coming session.
May I, therefore, suggest to this conference
that if any member or group of members have
in mind recommendations which should come be-
fore the Medical' Legislative Conference, with
the thought of presenting the same for enact-
ment into law, now is the time to prepare and
present the same.
We bespeak the most active and earnest coop-
eration on the part of every surgeon in this state,
. to protect the interests of the people and the peo-
ple's welfare through industrial surgery; and
solicit their influence, both financially and mor-
ally, towards the support of the Medical L^sla-
tive Conference, so that we may obtain a more
confidential relationship between the political
powers of the state and the medical fraternity
than has existed in the past.
It cannot be said that the medical profession
look upon this form of activity as being for per-
sonal gain or private emolument. However ac-
tive medical men have been in the past, but few
instances can be pointed out wherein they have
had selfish motives in obtaining l^slative
power. This holds true as well to-day as ever
in the history of the profession in this great
state; and we trust that we shall be able to
make plain to those who seek our advice r^ard-
ing legislative affairs that we do not, nor will
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July, 1921
CONFERENCE OF INDUSTRIAL PHYSICIANS
705
not, stand for measures which are only selfish,
and in the end prove detrimental to the welfare
of the people of the state.
In conclusion, may I again urge that you offer
to the conference your carefully thought out
plans and suggestions for the legislative session
of 1921?
Dr. Patterson : I am sure that Dr. Van Sickle and
the Medical Legislative Conference can count on the
hearty support of this Association in any program that
will mean the benefit of our profession at large.
If there is any subject that is of importance, it is
the "Treatment of Wounds." There is hardly a day
that goes by in which we do not get reports of cases
of septic infection following injury; so I have pleas-
ure in introducing to you Dr. Hubley R. Owen, Chief
Surgeon, Bureaus of Police and Fire, Philadelphia.
SOME OBSERVATIONS ON THE
TREATMENT OF WOUNDS
HUBLEY R. OWEN, M.D.
Chief Surgeon, Bureaus of Police and Fire
FHILADELFHIA
After I had written this paper and read it, I
came to the conclusion that it was very elemen-
tary ; but I thought it would be a good thing to
impress on you some of those elementary things
that we often forget in the treatment of wounds.
These post helium days are crowded with war-
inspired surgical procedure, wise and otherwise.
Occasionally we find that a tomb of surgical
antiquity has been violated, and the crumbling
shroud of an ancient and rugged truth has been
disguised in the soft garments of modern
phraseology. I am not of the select few to
whom has been granted the privilege of discov-
ery of a new idea ; and if I discuss well-known,
fundamental — even elementary, principles, it is
because not a few of the abuses existing in our
industrial and hospital dispensaries result from
neglect of primary fundamental surgery.
Some of those present are in charge of the
clinics of large industrial plants; others teach
some branch of surgery.
The duties of the industrial surgeon are three,
— to relieve the injured employee, to restore him
to full wage-earning capacity at the earliest date
and to reduce time lost to employer.
To accomplish these results many important
steps have been taken; such as, the "Safety
First" movement, first-aid instructions, and the
establishment of industrial clinics and dispen-
saries.
The "Safety First" movement is still in its in-
cipiency. Its scope is growing daily, not only in
industrial plants, but also in schools and other
departments of our municipalities.
It is a strange fact that our towns and cities
are usually the last, instead of the first, to en-
dorse such a movement. When a municipality
finally does endorse such propaganda there usu-
ally follows more talk than work. The results
are often poor. A municipality seldom practices
all that it preaches. Many examples of this civic
hypocrisy could be cited.
Great care must be taken with instructions to
the layman on the subject of first-aid. The first-
aid enthusiast is far too often a tyro, who may
be dangerous. He frequently does more harm
than good. Many wounds treated by him would
heal more speedily without his first-aid treat-
ment. In an emergency, he may be a complica-
tion, instead of a blessing; and we have often
hoped that his "first-aid" may be his last.
The use of iodin as the great panacea in the
first-aid treatment of wounds is greatly over-
done. The layman has been instructed to paint
every wound with iodin, irrespective of the
strength of the iodin or character of the injury.
As a result, the tissues are often irritated, and
iodin burns are frequent.
Although it is a drastic statement to make, yet
I have seen more evil than good result .from
iodin used as a first-aid expedient. This is not
because of its use, but because of its abuse.
The difference between the use of iodin as a
disinfectant of a wound, as a disinfectant of the
skin and as a counterirritant does not seem to
be sufficiently emphasized by the surgeon. Cer-
tainly this distinction is understood imperfectly
or not at all by the first-aid worker. The same
strength is often erroneously used for every
purpose.
Another frequent dressing for a wound is the
application of iodin, followed by a hot bichlorid
of mercury compress. This always causes se-
vere irritation of the wound, with actual vesica-
tion of the surrounding skin. A basin of bi-
chlorid of mercury should not be permitted in
the same room in which iodin is being used.
It is perfectly right to teach the use of iodin
as a first-aid treatment of wounds ; but implicit
instructions should be given as to the strength
of the iodin to be used, the character of the
wound to which it is to be applied, and the
proper dressing after such application.
Any antiseptic used in sufficient strength to
irritate a wound and the surrounding skin les-
sens tissue resistance, increases wound fluid, and
makes the wound more liable to infection.
Peroxid of hydrogen is another drug which is
misused in our dispensaries by the first-aid
workers. Peroxid is far too often poured into
a woimd, regardless of whether such a wound be
cleanly incised or infected.
Peroxid is a cleansing agent. It is not a ger- j
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THE PENNSYLVANIA MEDICAL JOURNAL
July. 1921
micide. It may be used to dean a dirty wound
or to assist in the removal of small particles of
dirt or other foreign bodies. It should not be
used in a sterile wound. If used in the treat-
ment of boils and carbuncles or abscesses, the
liberation of oxygen in the presence of pus will
tear tissues, break down normal barriers and
spread infection. Yet many persist in using
peroxid in such infections.
Time does not permit us to cite the many
abuses of bichlorid of mercury. The evils re-
sulting from the use of bochlorid of mercury in
surgery seem to have outweighed any of its al-
leged virtues. Its use has been attended by
death and destruction. It has a host of incom-
patabilities. "Does bichlorid of mercury ever
do any good whatsoever in surgery?" would be
a very proper subject for debate in a medical so-
ciety. If bichlorid of mercury should pass into
a state of surgical desuetude, the sole mourners
would be undertakers ; and most of the surgeons
would agree with Shakespeare that "The tears
live in an onion that would water this sorrow."
Bichlorid of mercury, however, has been the
most abused, because it is the best known, anti-
septic, but instances of the improper use of
other antiseptics in the treatment of wounds
could be multiplied indefinitely.
In the autumn of 1917 I had the oppor-
tunity of taking the War Course of instructions
in the treatment of wounds at the Rockefeller
Institute under Dr. Carrel. It was my initiation
into the correct technic of the Dakin-Carrel
treatment. It is not my purpose to discuss the
Dakin-Carrel technic, nor the results obtained.
Those who still decry the use of the method do
not carry out the procedure in its minute details.
At that institute, we studied the action of nu-
merous antiseptics on the tissues. We noted
daily the healing of wounds, macroscopically and
by bacteriological tests, as well as with the use
of the planometer. We were taught the value of
properly cleansing a wound. By properly cleans-
ing a wound is not meant washing the wound
with peroxid or bichlorid but by removing all
foreign bodies and devitalized tissues, shaving
the hair surrounding the wound, and washing
the wound and surrounding skin with neutral
soap and water followed by ether.
Very often a wound cannot be properly
cleansed without an anesthetic. Anesthesia is
not employed frequently enough for this pur-
pose.
In France, Severiand's Mixture was used. It
is a rapid anesthetic. In my dispensary work, in
the Police and Fire Department, nitrous oxid
gas is used. Many wounds will heal readily
without any treatment other than daily cleansing
of the wound and surrounding skin in the man-
ner described. Too much stress cannot be laid
upon the necessity of the daily removal of all
crusts from the edges of the wound. Under
these crusts are harbored the bacteria which re-
tard granulations. Those who take routine cul-
tures of wounds know that very often, after the
surface of a wound is sterile, a positive culture
can still be obtained by passing the platinum
loop under these crusts.
A large infected wound should be treated with
the instillation of Dakin fluid by the Carrel
technic.
Deridement is not indicated in civil surgery
as frequently as in military surgery ; but deride-
ment is an accepted principle of surgery and
should be practiced in civil or industrial surger\-
when indicated.
An infected wound of smaller size can be
treated with chlorinated oil. The abuse of this
oil, either as a first-aid measure, or as a treat-
ment to be continued, must be prevented.
If the dichloramin-T is too strong, or decom-
posed, after standing a number of days, it will
irritate. Dakin's solution is unstable, and a fresh
solution must be made daily. Dichloramin-T
must be watched closely each day, as it becomes
rancid. This point is frequently neglected in
dispensaries. The dichloramin-T is used until
the bottle is emptied, without thought as to
whether or not the oil has become rancid. A
rancid oil will often cause irritation. As stated
in the first paragraph of this paper, these facts
are essentially elementary; but the neglect of
these first principles causes our employees to
lose unnecessary time due to the delay in healing
of wounds.
Ether has been mentioned in connection with
the cleansing of a wound. This is a most useful
agent. In my first-aid work, at the present time,
I am using more ether than iodin. The wound
and surrounding skin are washed with ether, and
a sterile dressing applied. This is more .satisfac-
tory than iodin, although the procedure is more
expensive.
When a wound is sterile, it will heal without
the further u.se of antiseptics, provided there be
no secondary contamination. Some sterile
wounds can be closed with secondary suture;
this .shortens convalescence. Secondary suture
is especially applicable to gunshot wounds, which
usually require extensive debridement. Second-
ary closure is another accepted surgical prin-
ciple which should not be neglected in civil or
industrial surgery.
Upon a sterile granulating wound, not suit-
able for secondary sutures, paraffin mesh and a
sterile gauze dressing or a salt solution should
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July, 1921
CONFERENCE OF INDUSTRIAL PHYSICIANS
707
be applied. The parffin mesh prevents the gauze
from sticking to the granulations, permits suffi-
cient drainage of secretions and, by making pres-
sure, tends to prevent flabby or exuberant granu-
lations.
Unhealthy granulations are those which are
ixile or edematous and those which grow too
slowly or too rapidly. Granulations which rise
above the cutaneous level are unhealthy; these
are called exuberant granulations. The causes
of unhealthy granulations are local and consti-
tutional. The local cause is irritation, due to in-
fection or the use of too strong an antiseptic.
If, after the technic of local treatment has been
corrected, the wound does not heal, a complete
blood count should be made, a Wassermann
taken, and the urine examined. If these tests
are made routinely, many cases of delayed heal-
ing will be found to be due to anemia, Bright's
disease, syphilis or diabetes.
Punctured wounds and poisoned wounds are
always worrisome. Until a year and a half ago,
it had always been my policy to open a punc-
tured wound by a crucial incision ; to search the
wound for foreign bodies; to disinfect the
wound with carbolic acid, washing away the ex-
cess of the acid with alcohol, and to drain the
wound. For the past eighteen months, I have
not used carbolic acid in either punctured
wounds or poisoned wounds. A punctured
wound is now opened by crucial incision;
searched with dressing forceps for foreign
bodies, such as pieces of shoe, rubber boot, dirt
or a splinter; washed with ether, and drained
with rubber tissue. Since carbolic acid has been
omitted, I have noticed that few of these wounds
suppurate.
Carbolic acid is a powerful germicide, but very
irritant. It causes necrosis of tissue, and sup-
puration. Tetanus is far more prevalent in
wounds where suppuration, sloughing and nec-
rotic tissues exist than in clean and incised
wounds.
Stick silver nitrate is in the same category as
carbolic acid. It acts as an irritant and lessens
tissue resistance. When silver nitrate is used to
cauterize a punctured wound, or a poisoned
wound caused by the bite of a human being, dog,
cat or other animal, it tends to seal the wound
and to make drainage difficult.
Tetanus antitoxin is given far too seldom.
We teach that it should be given in punctured
wounds, wounds contaminated with street dirt
or stable dirt, gunshot wounds, wounds made by
blank cartridges and wounds where there is ex-
tensive tissue destruction. It is given faithfully
in gimshot wounds and punctured wounds ; but
in other wounds of a nature calling for tetanus
antitoxin, it is frequently neglected. Tetanus is
a disease which possibly cannot be wholly eradi-
cated by civil surgery ; but, by the proper use of
antitoxin, tetanus can be reduced to a minimum.
The victory over tetanus in the late war was one
of the triumphs of surgery. Again, it should be
remembered that the experience in the late war
proved that it is often necessary to repeat the
administration of the antitoxin.
In what part of the body should the tetanus
antitoxin be given? In a case of punctured
wound of the foot reported to me for treatment
a few days ago, tetanus antitoxin had been ad-
ministered in the tissues of the calf of the leg.
The leg was badly inflamed, and the patient lost
a week's work because of cellulitis. It was for-
merly thought "that tetanus antitoxin should be
given as near the wound as possible. This be-
lief is fallacious. When antitoxin is given in the
tissues of the arm, it frequently causes inflam-
mation and cellulitis, with resulting incapacity.
The subcutaneous tissues of the loin or abdomen
are the least painful areas in which to inject the
antitoxin. In either of these areas, the antitoxin
is quickly absorbed, and there is but little sub-
sequent irritation.
Those who give antitoxin routinely often neg-
lect to tell the patient of the possible symptoms
which may follow the injection of antitoxin.
The symptoms are, occasionally, gastrointestinal
irritation, slight rise in temperature and urti-
caria.
If not warned in advance by the surgeon of
the possibility of such conditions arising after
the injections, patients often fear that such
symptoms are indicative of oncoming tetanus.
A poisoned wound should be thoroughly
washed with soap and water, and then with
ether ; and then should be drained. The wound
should never be sutured. In a previous article,
stress has been laid on the virulence of a wound
caused by a tooth cut. Policemen frequently re-
ceive such wounds. Over 50 per cent, of these
wounds have been sutured without drainage be-
fore the patient reports to me. We have a num-
ber of officers whose hands are permanently crip-
pled because of this practice.
Sufficient thought is not given to the question
of drainage of wounds. Many wounds which
should be drained are not drained. A rubber
tissue drain is more efficient than a gauze drain,
when pus is present.
Contused and lacerated wounds are sutured
too frequently without drainage, and the sutures
are often tied too tightly. This is especially true
of contused wounds of the scalp. A drain made
of rubber tissue, or of a few strands of silk-
worm gut, placed in the wound for bwentv-fourf
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708
THE PENNSYLVANIA MEDICAL JOURNAL
July, 1921
or forty-eight hours, frequently prevents subse-
quent cellulitis. A fireman recently sustained a
contused wound of the scalp. This wound was
not only sutured without drainage, but was also
sealed with collodion. Eighteen hours later,
there was severe infection of the sub-aponeurotic
area, necessitating multiple drainage. It is far
better to use the old axiom, "When in doubt,
drain."
Collodion is frequently abused by the first-aid
worker. Many contused and lacerated wounds
of the scalp and many small, but primarily in-
fected, wounds of the extremities are sealed with
it. Severe infection frequently results.
Burns and scalds should be classified under
the heading of wounds. This suggestion is made
with the idea that burns and scalds should be
treated , antiseptically, utilizing the same princi-
ples of surgery which apply to the treatment of
wounds. Bums should not be treated with
greases or pastes, or with a dirty preparation
such as carron oil. A burn should be cleansed in
the identical manner in which a wound is
cleansed. The hairy portions of the skin sur-
rounding a burn should be shaved. An anes-
thetic is often necessary to permit the proper
cleansing of a burn. In a case under my obser-
vation at the present time, ether was adminis-
tered every other day for a period of twenty-
eight days, in order that the burned area and
surrounding parts could be properly cleansed.
The administration of the anesthetic prevents
pain and subsequent shock. If the condition of
the kidneys will not permit the administration of
ether, nitrous oxid may be administered.
Dupuytren's classification of bums should be
taught. By understanding his six degrees, a
burn may be better described, and its pathology
better understood.
All burned areas of the same patient, and very
often all parts of the same burn, cannot be
dressed alike. The principles of surgery must
govern the treatment of each burn. For ex-
ample, one portion of a burn may be granulat-
ing, while another portion of the same bum is
sloughing. The same treatment will not suffice
for the two areas. Sloughs should be loosened
with an antiseptic compress, then cut away. A
healthy granulating area must be kept free from
infection, and pressure should be applied over
the granulations. At each dressing, care should
be taken not to tear off the granulations. Par-
affin gauze mesh or vaseline gauze (which is
more pliable) may be used for the purpose of
protecting granulations. This gauze should be
of wide mesh, in order not to dam secretions
and, at the same time, permit access of an anti-
septic solution, if necessary. The vaseline gauze
is sterilized before being used. An infected
bum can be treated by Dakin's solution, if the
patient does not find it too painful. At times,
this solution may be used with comfort ; at other
times, it causes severe pain. Dakin oil may be
used. This is not as painful as the solution. If
this oil is to be used daily, the strength should
be one half of one per cent, or one per cent.
Dr. Hartwell, of New York, tells me that he
is now using one half of one per cent, solution
of acetic acid in the treatment of infected bums,
and that the results have been most encouraging.
The edges of the burn should be kept scmpu-
lously free from all crusts. This important
point has been emphasized in the discussion of
the treatment of wounds. If this antiseptic
treatment of a burn be carried out faithfully, it
will be found that even after a burn of the
fourth or fifth degree, the scar will be soft and
pliable; nor will there be the usual claw-like
contractions, which so frequently follow bums.
The more virulent the infection, and the
longer its duration, the greater will be the
amount of fibrous tissue in the scar ; and, there-
fore, the greater will be the tendency to contract
and deform. Rapid sterilization of an infected
burn will be followed by a pliable scar and slight
deformity. It is the contracting fibrous tissues
which deform.
Industrial dispensaries are growing in num-
ber. Nobody doubts their usefulness. Great
care, however, must be used in order that the
non-medical individuals in charge of these dis-
pensaries may not be given too much freedom
in the treatment of injuries and the administra-
tion of drugs. Nominally, a surgeon is in
charge ; but he is not always present when cases
are treated. No cases are treated in my office at
City Hall, unless a physician is present. This
rule cannot be obeyed by all industrial surgeons,
but care should be taken in the selection of the
nurse or layman who is to act as the physician's
deputy. This individual's duties should be
clearly defined by the physician, in order that he
or she may not err in the side of over-zealous-
ness.
None but a physician should attempt to cut
away devitalized tis.sue. None but a physician
should attempt to suture a wound. A phj'sician
alone knows the proper tension for sutures or
whether or not the wound requires drainage.
Another danger of our dispensaries is the
promiscuous prescribing of drugs. Cold tar
products are frequently dispensed without any
knowledge of the patient's cardiovascular condi-
tion. Laxatives are given indiscriminately.
Last summer, three cases of appendiceal ab-
scesses came under my care. AH three of these
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July, 1921
CONFERENCE OE INDUSTRIAL PHYSICIaNS
^09
cases had been purged with castor oil. This oil
had been given in industrial dispensaries. In
each case, the history was the same: sharp ab-
dominal pain followed by nausea and vomiting.
Each had applied to his dispensary for treatment,
and had been given castor oil. The greatest care
must be used lest the dispensary practice be
abused.
CONCLUSIONS
1. Care should be taken in the selection and
administration of a lay person in charge of an
industrial clinic, lest he or she usurp the preroga-
tive of the physician, resulting in the over-zeal-
ous treatment of wounds.
2. Minute observation and detail is necessary
in the treatment of wounds, to insure rapid con-
valesence.
3. Cleanliness and sane use of antiseptics are
the essentials in the treatment of wounds. An-
tiquated applications of ointments and dusting
powders should be procedures of the past.
4. When a wound is not amenable to local
treatment, more systematic studies of the pa-
tient's general condition should be made.
5. Bums and scalds should be cicissifled under
the heading of wounds, and treated according to
the principles of surgery, as the different condi-
tions of burn or scald may indicate.
6. Industrial plants should employ experi-
enced physicians or surgeons, and should pay a
salary commensurate with the responsibilities of
the office. It is poor economy to employ a young
and inexperienced physician or surgeon.
Finally — industrial surgeons should be en-
couraged, rather than discouraged, to maintain
affiliation with a hospital, in order to keep up to
date with surgical work.
Dr. Patteksok : I am going to call on Dr. Walter
Estell Lee, of Philadelphia, to open the discussion on
this splendid paper of Dr. Owen's.
DISCUSSION
Dr. Walter Esteli, Lee, Philadelphia: If the sub-
ject of wound infection was more frequently presented
in wjiat Dr. Owen calls "an elementary way" and such
elements or etiological factors became generally ac-
cepted, we feel sure there would be more uniformity
in the surgical treatment of infected wounds than
there is at the present time.
No one can disagree with Dr. Owen's outline of the
work of the industrial surgeon, (i) To relieve the
injured employee. (2) To restore him to full effi-
ciency at the earliest possible moment. (3) To mini-
mize the loss to the employer. We particularly ap-
prove of the order in which he places these objectives.
Every one with an average hospital experience has
had opportunities of seeing some of the unfortunate
results of the "first-aid" efforts of sympathetic friends
and bystanders. It is useless to enumerate to this
audience the many types. In the instruction we have
given to laymen our text has been "when in the slight-
est doubt as to the nature of the condition you are to
treat or of the specific treatment that is indicated, do
nothing." In other words, "when in doubt, don't."
At times we have felt that it was unfair to limit this
advice to laymen.
We also agree with Dr. Owen as to the dangers in
the indiscriminate use of tincture of iodin as a first-
aid dressing. It is now generally accepted that the
infection of traumatic wounds remains a surface con-
tamination for at least three hours after the injury
and there are very few occasions in civil life where
the patient could not be brought in touch with a com-
petent surgeon within this period. The covering of
the wound with a dry sterile dressing will adequately
protect against further contamination, and if there is
to be a long delay before surgical aid can be received
a mechanical cleansing with soap and water will be
.harmless and is one of the most efficient methods of
disinfecting a wound. If we were forced to choose
between soap and water and any or all of the known
antiseptic agents we would unhesitatingly cling to soap
and water. The ideal antiseptic would be one that
was lethal to all parasitic life and yet without any ef-
fect upon the living human tissues. Such an agent
.would be perfectly safe in the hands of laymen but
we do not have such an antiseptic at the present time
and iodin, hydrogen peroxid, bichloride of mercury,
carbolic acid, nitrate of silver are not only injurious
to living human tissues but unfortunately delude the
layman and often the surgeon by a false belief in
their efficacy.
There is little to be added at the present time to the
results obtained by the studies in the surgical treat-
ment of infected tratmiatic wounds by Dakin-Dehelley-
Carrel. It will not be amiss to recall them.
1. The etiological factors in wound infection are:
(a) the presence of bacteria in the tissues and (b) in-
adequate vital resistance of the tissues to these bac-
teria so that they increase in numbers.
2. The pathology of wound infection is that of in-
flammation. Inflammatory changes result not only
from bacterial irritation but also from the associated
factors as trauma, chemicals, etc.
3. The prevention of wound infection is completely
expressed in the principles of surgical asepsis.
4. The control of wound infection should be di-
rected toward its causes — the introduction and growth
of bacteria in the tissues and vital resistance. Vital
resistance depends upon the bactericidal, antitoxic and
autolytic properties of the blood and local tissue re-
sistance which is modified by the inability of the cells.
Bacterial control may be obtained by mechanical re-
moTHtl of the organisms or their destruction by nat-
ural (the blood with its bactericidal substances or the
process of phagocytosis) or artificial agents such as
chemical antiseptics.
The practical application of these principles has re-
sulted in the following clinical procedures.
Bacteria when they are introduced into a wound are
usually applied to the most superficial surfaces only.
The exceptions of course are in penetrating or per-
forating wounds, but here also the bacteria at first are
found only upon the surfaces of the tract made by the
penetrating object. Though they may grow very rap-
idly it has been shown both clinically and experimen-
tally that they merely spread over the surface of the
wound for the first three to six hours. From then on
to the twelfth or even the twenty-fourth hour they
penetrate into the lymphatics and intracellular spaces.
After twenty-four hours the inflammatory reaction of
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710
THE PENNSYLVANIA MEDICAL JOURNAL
July, 1921
the tissues has reached the stage of exudation and pus
is formed.
Clinically we have come to speak of these stages as :
I. Contamination, during the first 3-6 hours. 2. Infec-
tion from the 3d to 12th hour. 3. Suppuration after
24 hours.
Contaminated wounds. During the period of con-
tamination the bacteria can be removed in many
wounds by a mechanical cleansing with soap and water
and the excision of the devitalized tissues. Also dur-
ing this period the normal tissue resistance can be re-
iU>ied in most instances by the excision of all devital-
ized tis.<!ue and foreign bodies. Theoretically and
actually the large majority of wotmds will heal with-
out the clinical symptoms of infection after mechan-
ical cleansing, debridement and closure of the skin. If
iney are not closed they will sooner or later become
•nfected.
Infected wounds. After the twelfth hour the or-
ganisms have developed to such numbers that they
have penetrated the tissues beneath the surface of the
wound and it is impossible to remove them by mechan-
ical cleansing and dangerous to attempt the removal
of the infected and devitalized tissues by excision. In
this type of wound the chlorin antiseptics are pecu-
liarly efficient. The aqueous hypochlorite dissolves
the devitalized tissues and thus removes the culture
material upon which the bacteria develop and also
opens the lymphatics, permitting the outpouring of the
vital serum. When surgically sterile, such wounds
must be closed promptly. Nothing can keep them
sterile for any length of time except they be covered
with skin.
Suppurating wounds. Again mechanical removal of
the bacteria or devitalized tissues is impossible. The
use of the chlorine antiseptics and practice of sec-
ondary closure is ideal.
As you know, there is one exception to all of these
general rules. If the wounds contain streptococci they
must not be closed until these little mischief makers
are eliminated.
As to drainage, we do not agree with Dr. Owen.
Surgeons are more and more accepting the principle
"when in doubt, don't drain," instead of the former
rule. We entirely agree with Dr. Owen when he in-
cludes burns and scalds under the classification of
wounds. Because an extensive wound of the surface
of the body is caused by moist or dry heat instead of
trauma makes but little difference in the pathology,
merely changes in degree. With the pathology the
same there is no question that the same principles
should govern our surgical treatment. To cover in-
fected wounds of this kind with dirty occlusive dress-
ings of the type of dispensary ointments is as unsur-
gical as if they were applied to any other type of open
wound.
Dr. Patterson : With your permission, the chair-
man is going to continue this discussion.
I want to call specifically to your attention the fact
that we have to-day in Pennsylvania a large number
of cases of infection, which are, in my judgment, the
result of nothing more nor less than the practicing of
medicine without a license. It is the law that nurses
and other first-aid people may not make a redressing
in accident cases except under the direction of a li-
censed physician, and those who take it on themselves
to do so in an illegal manner should properly be prose-
cuted. The Medical Practice Act provides what is
necessary to secure a license to practice medicine in
this commonwealth ; and we intend to make an effort.
in harmony with the Board of Medical Education and
Licensure, to carry out the purposes of this act.
Hardly a day goes by that I do not get a report of
some industrial accident or fatality, in which either the
loss of time or the death of the unfortunate person
has been caused by septic infection, the doctor having
probably been called in at the same time as the repre-
sentative of the church, to administer the last rites.
We propose to stop this. It is perfectly legal for any
one to render first-aid to an injured person, and it is
perfecty proper that this should be done; but it is
illegal for the nurse or any one else to do any dressing
or give any medicine afterwards, tmless a licensed
physician is personally present to direct what is to be
done or what medicine is to be administered. This
department is engaged in making a survey of the in-
dustrial establishments of Pennsylvania, to find out
in which ones the law is violated ; and we ask you that
the dressings in your factories or mines shall be made
tmder your supervision and when you are personally
present If nurses or other persons continue to dress
cases and otherwise practice medicine in this common-
wealth, we intend to prosecute them. An example
will have to be made of them that will be a lesson to
others in this state.
In closing my remarks; I would say that I feel that
it is due to us all to pay a silent tribute to one who did
much to further the proper surgical treatment of
wounds. To those of you who knew him, it will come
as a regret to learn that Dr. William Furness, whose
assistant Dr. Lee was in his study of dichloramin-T
and chlorcosane, is dead. His was one of the best
minds that ever graced the medical profession and our
commonwealth has suffered a great loss in his un-
timely decease.
I should like to hear from some doctor who believes
that nurses should dress cases.
Dr. Edward P. Case, Travelers Insurance Company,
Hartford, Conn.: I would like to ask two questions,
first, the opinion of Dr. Owen as to the relative value
of ether and fuming nitric acid in the treatment of
punctured wounds ; second, his reason for omitting to
mention the use of ambrine in the treatment of bums.
I have seen some wonderful results from the use of
ambrine in the treatment of extensive and serious
burns during my service abroad with the United States
Army.
Dr. Patterson : Dr. Owen, will you answer Dr.
Case's question?
Dr. Owen : Fuming nitric acid is in the same cate-
gory as silver nitrate and carbolic acid. It is too great
an irritant. You caimot convince me that applying
nitric or carbolic acid to a wound for a second or two
will kill the tetanus bacilli and the spores. X^e^
bacilli are more likely to thrive where there is necrotic
tissue. If you open the wound freely, wash it out with
ether and apply drainage I think you have done all
that you should do.
Regarding poison wounds, in the past fourteen years
I have had a number of cases of police officers and
children bitten by rabid dogs. Instead of cauterizing
such wounds with silver nitrate, I wash these wounds
out with ether and drain them, and find that the
wounds do far better than if they are cauterized. Of
course such a wound should never be sutured. AH of
these cases are given Pasteur Treatment.
On Tuesday last I had a fireman who ran a large
splinter in his foot. I remo.ved the splinter and treated
the wound as I have suggested, by crucial incision,
washing with ether and drainage, and the man re-
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CONFERENCE OE INDUSTRIAL PHYSICIANS
711
ported for duty to-day. If I had disinfected this
wound with carbolic acid or fuming nitric acid the
wound would certainly have suppurated and his con-
valescence would have been greatl)^ prolonged.
I have used ambrine in the treatment of burns, but
do not like it as well as the antiseptic treatment. I
think that ambrine tends to dam up secretions. You
cannot keep the bum as clean when using ambrine as
by using an antiseptic dressing with paraffin gauze. I
will admit an ambrine dressing is very comfortable.
I can recall two children treated with ambrine at the
Philadelphia Hospital. These children had been re-
ceiving a fraction of a grain of morphine every few
hours, but were free from pain after we started to use
the ambrine dressing. We are getting equally good
results from the parafKn gauze mesh.
Dr. Pattgsson : Is there any further discussion on
Dr. Owen's paper?
Dr. Bassin : The paper of Dr. Owen is most oppor-
tune. One matter, however, has been overlooked in
my estimation, and that is the subject of immobiliza-
tion relative to dressing the wound. Most of the cases
of contraction deformities that I have seen, especially
Dupuytren's variety, were due to lack of proper im-
mobilization. The surgeon had been so occupied with
the healing of the wound that he had forgotten the
possibility of contraction deformity.
Dr. Steim : I would take issue with this sweeping
denunciation of the use of iodin for emergency dress-
ing of wounds. Neither do I agree with the use of
soap and water in the hands of a lay emergency first-
aid worker, for washing wounds. I quite agree with
Dr. Owen that if we have a sterile basin, sterile soap,
and sterile hands, it is all right. ^
I would however, regret very much to see the adop-
tion of soap and water as a wash for wounds in in-
dustrial plants and mines. I think it would be much
safer to advise, not attempting anything at all in the
way of first-aid treatment of wounds.
Before this discussion closes I should like to have
the opinion of some of our mine and railway surgeons
who see a large number of cases after they are
dressed for the first time.
Db. Patterson : Let us hear from some of the min-
ing and railroad surgeons concerning this point.
Dr. S. p. Mengel, Lehigh Valley Coal Company,
Wilkes-Barre : I do not believe in the use of soap and
water in the cleansing of recent wounds. The parts
outside should be carefully washed and the wotmd it-
self cleansed with gauze, tincture of iodin, etc. In all
first-aid work we do not allow the use of drugs, iodin,
alcohol, etc. Iodin deteriorates rapidly and unless it
is used from a sealed container it is imreliable. Again,
a first-aider may use it carelessly about the face and
especially the eyes, where it is capable of doing con-
siderable damage. In our first-aid work we instruct
our men to depend on applying sterile gauze, bandag-
ing the part carefully and getting the patient to the
hospital, or to the surgeon, at the earliest possible mo-
ment.
We have been using antitetanic serum in all cases of
punctured wounds and in all extensive wounds in
which there is obvious dirt. Fortunately the coal dirt
that contaminates our wotmds in the mines is not so
septic as other dirt, for instance, dirt from the fields
or street, so that with ordinary care in cleansing the
wounds of this dirt with gauze, or some other good
method, these wounds can usually be kept from be-
coming infected, although, of course, all wounds con-
taining coal dirt, or any other kind of dirt, must be
regarded originally as septic wounds. About twenty-
five to thirty per cent, of the patients with a punctured
wound object to the use of serum. During the past
five years we have not had a single case of tetanus
among our injured. I think this experience is borne
out by others who are practicing traumatic surgery in
the coal regions.
In regard to the Carrel-Dakin treatment there is no
doubt that this is perhaps the best treatment for
wounds in existence, to-day. This applies to hospitals,
or institutions where they are equipped with the nec-
essary appliances and where the technic can be care-
fully followed and skillfully executed. In the ordi-
nary hospitals where these dressings are often done by
the resident physician, the treatment often fails be-
cause of the lack of care in the technic. It is neces-
sary that Dakin's solution should be titrated. It must
be exactly right. If it falls below the point 4 it is
not strong enough, to be efficient; if it is above .5 it
is too strong and is irritating. So you practically have
a margin of one-tenth of one per cent., in which lies
the efficiency of the antiseptic qualities of this solu-
tion.
I have had excellent results in the treatment of
burns with ambrine, or some of its preparations. I
do not believe it makes much difference which prepa-
ration is used. If the burn is extensive and covers a
large area the ambrine may be applied with an electric
pump, after the parts have been thoroughly dried. It
is usually a comfortable dressing to the patient. I
think the patient complains much less with pain with
this dressing and it leaves the tissues more pliable and
you have less contraction after healing. In dressing
the severe burns (the deep bums), the surgeon should
be careful to prevent contraction. This can usually be
done by placing the parts in the correct position as
healing occurs, for instance, a severe bum of the neck,
the head can be kept in an erect position and the chin
elevated by the use of a high collar or perhaps a col-
lar made of plaster of Paris. A bum of the axilla
should be dressed with the forearm above the head;
so in severe bums of the thigh, the legs should be
kept wide apart, so as to prevent contraction of the
thighs.
Dr. Pattersok: Is there any further discussion?
Dr. Halberstadt : I am talking from first-aid stand-
point. Many of the surgeons would take from Dr.
Lee's discussion of Dr. Owen's paper that soap and
water cleansing should always precede first-aid dress-
ings. It is impossible to keep sterile soap and water
for the purpose, also impossible to have reasonably
sterile hands to apply them. Our instruction has al-
' ways been to cover up all wounds with sterile dress-
ings and leave cleansing to the surgeon. For several
years, one half strength tincture of iodin in a small
container with cotton mop attached, has been issued
for instant use. As the solution is hermetically sealed
and has to be used at once it cannot gain strength by
evaporation.
Mine bums, including explosions of gas and powder,
have all been dressed with picric acid g^uze, 2 per
cent. This is fastened in place with gauze bandages,
then plenty of absorbent cotton, and this is covered
with cotton bandages. A case with this dressing prop-
erly applied can be left tintouched for 48 hours, if
necessary, the patient not being subjected to immediate
secondary shock. This method has been in use for 17
years and I see no reason to adopt any other. This is
of course the standpoint of first-aid work.
So far as ambrine dressing is concerned we have
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712
THE PENNSYLVANIA MEDICAL JOURNAL
July, 1921
never believed it practical for mine burns, ki our
experience with etxensive burns, the more frequently
they are dressed the more likely the patient is to die.
An antiseptic g^uze dressing that will permit drainage
can be allowed to remain for days. Ambrine must be
applied daily. Daily dressings of mine and railroad
burns have proved fatal.
Dr. Mengel speaks of septic earth.
In the lower anthracite region corneal wounds are
always infected unless immediately cleansed not only
of the foreign body itself but of all the tissue that
have been injured.
Dr. Pattebson: If there is no further discussion, I
will ask Dr. Owen whether he has any remarks to
make in closing.
Dr. Owen : I want to say a word about iodin. I did
not intend to convey the idea that idoin was of no
value in the first-aid treatment of wounds, but I do be-
lieve that great care should be used in regard to the
strength of the idoin used. Occasionally we find the
iodin has been standing in a bottle for a long time.
Possibly the stopper of the bottle is made of cork,
and the alcoholic contents of the iodin have evaporated
and left almost pure crystals of iodin. Strong iodin
will cause blistering of the skin surrounding the
wound and irritation of the wound.
Of course we do not carry soap and water with us
to a fire and wash out the wounds which the firemen
may receive. Our instructions are to apply the sterile
gauze compress which is carried in our emergency kits.
It is a compress similar to that carried in the first-aid
package of the army belt. The fireman is then taken
to a hospital, where the' wound is cleansed thoroughly
and an antiseptic dressing applied.
We have had but one case of tetanus in the history
of the Fire Department. This was not the result of a
puncture wound, but the result of a burn. This case
occurred many years ago. As a matter of fact I can-
not recall ever having seen a case of tetanus following
a puncture wound, probably because these wounds are
so thoroughly treated and tetanus antitoxin is always
given. The cases of tetanus which I have seen have
occurred in wounds where tissue has been devitalized,
such as, crushes by machinery. The last case I saw
was a boy who had a finger caught in the cogwheel of
a bicycle.
Regarding the Carrel-Dakin treatment my thought
is that if the resident physicians do not know how to
properly give the Carrel-Dakin treatment there is
something radically wrong with the teaching of our
medical schools. If they are not taught the procedure,
they should be taught.
Regarding the use of picric acid for bums, it is an
excellent first-aid dressing, and we still use picric acid
as a first-aid dressing in the Fire Department. Picric
acid solution is carried in our emergency kits. Care
must be used, however, with picric acid in an' exten-
sive burn. I have a case under my care at the present
time of a little girl who was burned. The burn was a
very extensive one, and picric acid was used for
twenty-four hours. Twenty-four hours later she de-
veloped picric acid poisoning.
Dr. Halberstadt : Our bum dressing is sterile
gauze impregnated with a 2 per cent, solution of picric
acid. This is dried, then resterilized, packed in waxed
paper and covered and sealed in rubber cloth. There
have never been any bad results from its use.
Our men have, from the beginning, been taught that
subsequent dressing of any injury by them, would sub-
ject them to prosecution for practicing medicine with-
out a license, which carries with it imprisonment
Dr. Patterson : It gives me pleasure to announce
that the Board of Directors of the American Associa-
tion of Industrial Physicians and Surgeons have en-
tered into an arrangement with "Modern Medictnc"
by which it becomes the journal of our Association
and will be sent to all our members without addi-
tional cost.
We will now have the motion picture reels. The
first is the one by the Women's Division of the United
States Department of Labor. After that has been
shown, we will have the New Jersey reels, and then
the others, if there is still time. If any one does not
want to wait, our feelings will not be hurt We hope
that you will take with you our wish that you may
have one of the merriest of Christmases, and that the
New Year may be one of the greatest prosperity and
happiness. If any one wants to leave, he may do so
at any time he wishes.
The motion pictures were started at 4:30 p.m. and
were finished at 5 : 30 p. m.
LIST OF PERSONS ATTENDING THE
ELEVENTH CONFERENCE OP INDUS-
TRIAL PHYSICIANS AND SURGEONS,
HELD UNDER THE DIRECTION OF THE
DEPARTMENT OF LABOR AND INDUS-
TRY. DECEMBER 17. 1930.
Dr. John W. Abbott, Baltimore, Md. ; Maryland Casu-
alty Company.
Dr. C. D. Ambrose, Ligonier; Ramsey Coal Company.
Dr. W. H. Ammarell, Birdsboro; E. and G. Brooke
Iron Company, Birdsboro Steel Foundry and Ma-
chine Company.
Dr. J. V. Austin, 5915 Greene St., Germantown ; The
American Pulley Company.
Dr. S. Josephine Baker, 33 W. 96th St., New York
City ; New York Department of Health.
Dr. C. J. Balliet, Lehighton ; Lehigh. Valley Railroad
Company.
Dr. C. A. Barron, 6327 Torresdale Ave., Philadelphia ;
Quaker City Rubber Company.
T. N. Bartlett, Baltimore, Md.; Mai-yland Casualty
Company.
Dr. John N. Bassin, 613 Bangs Ave., Asbury Park, N.
J. ; New Jersey Rehabilitation Commission, Newark,
N.J.
Dr. R. P. Batchelor, Palmerton; New Jersey Zinc
Company.
Leonard T. Beale, 705 Lafayette Building, Philadel-
phia ; John T. Lewis and Brothers Company.
Dr. C. A. Bicking, 5512 Center Ave., Pittsburgh;
American Sheet and Tin Plate Company, American
Bridge Company.
Dr. J. C. Biddle, State Hospital, Ashland.
Dr. Frank B. Block, 2035 Chestnut St., Philadelphia;
Barrett Company.
Miss Gladys Boone, Department of Industrial Super-
vision, Bryn Mawr College, Bryn Mawr.
Dr. L. H. Botkin, Duquesne ; Carnegie Steel Company.
Dr. J. L. Bower, Broad Street Station, Philadelphia;
Pennsvlvania Railroad Company.
Dr. T. John Bowes, 1000 Chestnut St., Philadelphia;
Philadelphia Electric Company.
Dr. H. Brady, Grays Landing; Consolidated Coke
Company.
Dr. L. T. Bremerman, Downingtown; Pennsylvania
Railroad Company, Downingtown Iron Works.
Mrs. H. Brewin, 519 Penn St., Chester; Penn Sea-
board Steel Corp.
Dr. Elizabeth B. Bricker, Harrisburg; Pennsylvania
Department of Labor and Industry.
Dr. F. E. Brister, Reading Terminal, Philadelphia;
Philadelphia and Reading Railway Company.
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Dr. Geo. W. Brose, Altoona; Pennsylvania Railroad
Company.
Dr. G. J. Bryen, Duquesne; Carnegie Steel Company.
Dr. Stillwell C. Bums, 1925 Spring Garden St, Phila-
delphia; The Baldwin Locomotive Works.
Dr. Chauncey R. Burr, i Madison Ave., New York
City; Metropolitan Life Insurance Company.
Dr. H. B. Buterbaugh, Indiana; Pennsylvania Rail-
road Company.
Dr. B. Franklin Buzby, 4427 Wataut St., Philadelphia ;
Keystone Leather Cotnpapy, Joseph Campbell Com-
pany, Camden, N. J.
Dr. J. B. Camett, 123 S. 20th St., Philadelphia.
Dr. J. S. Carpenter, Jr., Pottsville; Pennsylvania
Railroad Company.
Dr. Edwjard P. Case, Hartford, Conn.; Travelers In-
surance Company.
Dr. R. C. Casselberry, 700 Madison St., Chester ; The
Baldwin Locomotive Works.
Miss Elizabeth Cavanough, R N., Camden, N. J. ; Jos.
Campbell Company.
Dr. Tailferro Clark. Washington, D. C; United
States Public Health Service.
Mr. J. J. Coffey, 1115 North American Building, Phila-
delphia ; Pennsylvania Department of Labor and In-
dustry.
Dr. W. H. Clymer, Philadelphia; Franklin Sugar Re-
fining Company.
Hon. Clifford B. Connelley, Harrisburg; Commis-
sioner, Pennsylvania Department of Labor and In-
dustry.
Dr. D. B. Cragin, 179 Allyn St., Hartford, Conn.
Dr. William Curry, Holyoke, Mass. ; American Thread
Company.
Dr. Douglas T. Davidson, Overlook, Claymont, Del.;
General Chemical Company, Marcus Hook.
Dr. E. T. Davies, 822 Main St., Old Forge; Jermyn
Coal Company.
Dr. D. W. Davis, Six Mile Run; Commercial Coal
Company, Philadelphia.
Dr. George C. Davis, Milton; American Car and
Foundry Company.
Miss Virginia Detweiler, Harrisburg; Pennsylvania
Department of Labor and Industrv.
Dr. E. L. Dickey, Oil City; National Transit Com-
pany, Pennsylvania Railroad Company.
Dr. James M. Dinnen, Ft. Wayne, Ind. ; New York
Central and St. Louis Railroad Company.
Dr. Robert L. Donoghue, 1603 W. Lehigh Ave., Phila-
delphia; Ford Motor Company.
I. Donoghey, Philadelphia; Evening Bulletin.
Dr. Seneca Egbert, 4JB14 Springfield Ave., Philadel-
phia.
F. H. Elam, 332 S. Michigan Ave., Chicago, III.;
American Steel Foundries Company.
Dr. Joseph M. Ellenberger, 644 Haws Ave., Norris-
town.
Dr. W. D. Farber, Northampton ; Lawrence Portland
Cement Company.
Phil. G. Fenlon,, Duquesne; Carnegie Steel Company.
Dr. C. R. P. Fisher, Bound Brook, N. J.
Dr. Judson C. Fisher, 90s West End Ave., New York
City.
Dr. W. G. Fulton, Scranton; Hudson Coal Company.
Dr. James W. Geist, 527 S. Franklin St., Wilkes-
Barre; Lehigh and Wilkes-Barre Coal Company.
Dr. Jno. M. Gelwix, Chambersburg ; Pennsylvania
Railroad Company.
Mrs. Jno. M. Gelwix, Chambersburg.
Mrs. L. H. Gilbert, 4533 Tacony St., Philadelphia;
Miller Lock Company.
Miss Efiie D. Gilman, Harrisburg; Pennsylvania De-
partment of Labor and Industry.
Mr. Chas. F. Glueck, 809 66th Ave., Oak Lane, Phila-
delphia; John Hancock Mutual Life Insurance Com-
panv, Boston, Mass.
Dr. Martin E. Griffith, Monessen; Pittsburgh Steel
Company.
Dr. I. Haines, 120 Franklin St., Boston, Mass.; John
Hancock Life Insurance Company.
Dr. G. H. Halberstadt, 218 W. Market St., Pottsville;
Philadelphia and Reading Coal and Iron Company.
Dr. C. A. Hall, 1021 Prospect Ave., Cleveland, Ohio;
Wheeling and Lake Erie Railway Company.
Dr. C. H. Harbaugh, 1143 S. Broad St., Philadelphia.
Dr. Margaret Hassler, 417 N. 5th St, Reading.
Dr. Wm. S. Higbee, 1703 S. Broad St, Philadelphia;
Pennsylvania Salt Manufacturing Company.
Dr. J. B. Hileman, 413 Market St., Harrisburg; Penn-
sylvania Railroad Company.
Dr. Wm. H. Hinkel, Tamaqua; Atlas Powder Com-
pany.
Dr. Frederick L- Hoffman, Newark, N. J. ; Prudential
Insurance Company of America.
Dr. E. R. Hunter, Washington, D. C. ; American Red
Cross.
Dr. E. C. Jackson, Harrison, N. J.; Edison Lamp
Works, General Electric Company.
Dr. T. B. Johnson, Jr., Towanda ; Lehigh Valley Rail-
road Company, Susquehanna and New York Rail-
road Company.
Dr. D. W. Jones, loii S. Ellwood Ave., Baltimore,
Md. ; Standard Oil Company.
Dr. E. W. Kaufman, Colonial Hotel, Penns Grove, N.
J.; E. I. du Pont de Nemours and Company, Wil-
mington, Del.
Dr. Geo. B. Klump, 430 Pine St., Williamsport ; Dar-
ling Valve_ and Pump Manufacturing Company,
Pennsylvania Railroad Company.
John A. Lapp, 22 E. Ontario St., Chicago, III.; Mod-
em Medicine.
Dr. A. H. Laros, Northampton; Atlas Portland Ce-
ment Company.
Miss A. Estelle Lauder, 814 Otis Building, Philadel-
phia ; Consumers League of Eastern Pennsylvania.
Dr. Walter E. Lee, 905 Pine St., Philadelphia.
Dr. William D. Lithgow, 301 W. 7th St., Chester;
Atlantic Steel Castings Company.
Dr. T. A. Little, 259 E. 5th St., Erie; General Electric
Company.
J. P. Ulley, Harrisburg; Pennsylvania Department of
Labor and Industry.
Dr. C. W. Lueders, 2039 Chestnut St., Philadelphia.
Dr. J. P. MacFarJane, Vintondale; Vinton Colliery
Company.
Wm. F. MacKenzie, 2545 Aramingo Ave., Philadel-
phia ; John T. Lewis and Brothers Company.
Dr. William P. MacLeod, Emergency Hospital, Grand
Central Terminal, New York City; New York Cen-
tral Railroad.
Dr. John R. McDill, Washington, D. C; United States
Public Health Service.
Dr. H. E. McGuire, Pittsburgh Life Building, Pitts-
burgh ; Jones and Laughlin Steel Company.
Dr. John D. McLean, Harrisburg; Pennsylvania State
Department of Health.
Dr. C. C. Mann, Arlington, N. J.; E. L du Pont de
Nemours and Company.
Thos. P. Mark, Pennsylvania Building, Philadelphia;
Employers Mutual Insurance Company.
Col. Edward Martin, Harrisburg; Commissioner,
Pennsylvania State Department of Health.
Dr. W. Horace Means, Lebanon; Bethlehem Steel
Company.
Dr. S. P. Mengel, 181 S. Franklin St., Wilkes-Barre;
Lehigh Valley Coal Company.
Glenn W. Moffatt, Harrisburg; Pennsylvania Depart-
ment of Labor and Industry.
Dr. F. F. Moore. Homer City; Rochester and Pitts-
burgh Coal and Iron Company, Indiana.
Dr. Casper Morris, 2050 Locust St., Philadelphia;
Philadelphia and Reading Railway Company.
A. C. Newberger, Philadelphia; H. K. Mulford Com-
pany.
Dr. Mary Riggs Noble, Harrisburg; Pennsylvania
State Department of Health,
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THE PENNSYLVANIA MEDICAL JOURNAL
July, 1921
Dr. J. Henry OrflF, Wyomissing; Philadelphia and
Reading Railway Company.
Dr. H. R. Owen, 319 S. i6th St., Philadelphia; De-
partment of Public Safety.
Dr. Francis D. Patterson, Harrisburg; Pennsylvania
Department of Labor and Industry.
Dr. J. W. Phillips, Troy ; Pennsylvania Railroad Com-
pany.
H. R. Pierce, 1801 Chestnut St, Philadelphia; Harvey
R. Pierce Company.
Dr. Ellen C. Potter, 106 State St., Harrisburg; Penn-
sylvania State Department of Health.
Jos. T. Pratt, Reading; Philadelphia and Reading
Railway Company.
Dr. Otto A. Rath, 3568 Queen Lane, Philadelphia;
John and James Dobson, Incorporated.
Dr. F. L Rector, 10 E. 39th St., New York Gty; Na-
tional Industrial Conference Board.
Dr. J. J. Reilly, 24«S S. 2ist St., Philadelphia; Beth-
lehem Laboratories, Incorporated, Bethlehem.
S. S. Riddle, Harrisburg; Pennsylvania Department
of Labor and Industry.
John Roach, Trenton, N. J.; New Jersey Department
of Labor.
Dr. John B. Roberts, 313 S. 17th St., Philadelphia.
Dr. J. Pierce Roberts, Shenandoah; Locust Mountain
Coal Company.
Dr. J. S. Rodman, 13 10 Medical Arts Building, Phila-
delphia.
John C. Rose, 432 Commercial Trust Building, Phila-
delphia; Pennsylvania Railroad Company.
Dr. Frank S. Rossiter, Pittsburgh; Carnegie Steel
Company.
H. A. Rowe, 90 West St., New York City ; Delaware,
Lackawanna and Western Railroad Company.
Dr. R. R. Sayers, Washington, D. C; United States
Bureau of Mines.
Dr. Jos. Scattergood, West Chester; Pennsylvania
Railroad Company, Denny Tag Company.
Dr. L. E. Schoch, Shamokin; Susquehanna Colliers
Company, Philadelphia and Reading Coal and Iron
Company.
Dr. Harvey E. Schock, 2048 Pine St., Philadelphia;
Maryland Casualty Company.
Dr. W. Schroeder, Jr., 61 Broadway, New York City;
Employers Mutual Insurance Company.
Raymond Scott, 500 N. isth St., Philadelphia; The
Baldwin Locomotive Works.
Harry Shelley, 140 N. Broad St., Philadelphia; Atlas
Powder Company.
Dr. W. O. Sherman, Carnegie Building, Pittsburgh;
Carnegie Steel Company.
Dr. -Loyal A. Shoudy, Bethlehem; Bethlehem Steel
Company.
Dr. John J. Singer, Greensburg; Keystone Coal and
Coke Company.
Dr. Harvey F. Smith, 130 State St., Harrisburg.
Dr. Lawrence H. Smith, 189 W. Church St., Hazleton ;
Pennsylvania Power and Light Company.
Dr. Jay D. Smith, 406 Ohio Building, Akron, Ohio;
Pennsylvania Railroad Company.
Dr. Rollo L. Smith, 2987 Richmond St., Philadelphia;
Philadelphia and Reading Railway Company.
Dr. Henry Field Smyth, Philadelphia; University of
Pennsylvania.
Dr. Chas. J. Steim, 435 6th Ave., Pittsburgh; Phila-
delphia Company.
Dr. Lever F. Stewart. Clearfield ; Pennsylvania Bitu-
minous Mutual Association, American Mine Owners
Mutual Association.
Dr. Oliver Stout, 3351 N. Sth St., Philadelphia ; Han-
cock Knitting Mills.
Miss C. S. Strimple, R. N., Camden, N. J. ; New Jer-
sey Rehabilitation Commission.
Dr. C. W. Sturtevant. 4321 Frankford Ave., Phila-
dephia; Dill and Collins, Barrett Company, Miller
Lock Company.
Dr. F. A. Taylor, Bridgeport, Conn.; General Elec-
tric Company.
Dr. Louis L. Thompson, 522 Greenwich St, Reading;
Philadelphia and Reading Railway Company.
Dr. Martha Tracy, 1820 Pine St., Philadelphia.
Clare J. Trager, 1044 Henry W. Oliver Building, Pitts-
burgh; Pittsburgh Coal Company.
B. D. Troutman, Pottsville ; Philadelphia and Reading
Coal and Iron Company.
Dr. Frederick L. Van Sickle, 212 N. 3rd St. Harris-
burg; The Medical Society of the State of Penn-
sylvania.
Dr. J. M. Wainwright, Scranton; Delaware, Lacka-
wanna and Western Railroad Company.
Dr. Roland F. Wear, Berwick; Amencan Car and
Foundry Company.
H. J. Webster, Philadelphia; Public Evening Ledger.
Dr. S. L. Weintraub, 1239 S. Broad St., Philadelphia.
Dr. E. R. Whipple, Steelton; Bethlehem Steel Com-
pany.
W. F. Whittle, 324 Walnut St., Philadelphia: Mary-
land Casualty Company.
Miss M. M. Williams, Bala; Philadelphia Electric
Company.
S. G. Worton, Duquesne; Carnegie Steel Company.
Dr. G. R. Wright 140 N. Broad St, Philadelphia;
Atlas Powder Company.
Dr. J. H. Young, Lansford; Lehigh Coal and Navi-
gation Company.
PROPAGANDA FOR REFORM
MoRe MiSBRANDBD VENBitEAL NOSTRUMS. — The fol-
lowing products have been the subject of prosecution
by the federal authorities on the ground that the cura-
tive claims made for them were false and fraudulent:
Saxon Gonorrhea Injection (Saxon Co.), represented
as a treatment, remedy and cure for gonorrhea, gleet
and the prevention of stricture. Santalets (Sharp &
Dohme), represented as a treatment, remedy and cure
for gonorrhea, gleet, catarrh of the bladder — acute or
chronic — whether due to gonorrheal infection or other
causes. Specific Globules No. 37-77 (Sharp & Dohme),
claimed to be an improved combination for the treat-
ment of gonorrhea and its complications. Methylets
(Sharp & Dohme), claimed to be of great value in all
forms of urethritis, especially gonorrheal and allied
varieties. Saxon Methygon Tablets (Saxon Co.).
claimed to be a reliable remedy for treating gonorrhea
and gleet Columbia Short Stop (Coliunbus Drag
Co.), recommended for "gonorrhea, gleet, running
range, inflammation of the kidneys and bladder." Al-
lan's Compound Extract of Sarsaparilla with Iodide
(Allan-Pfeiflfer Chemical Co.), claimed to be the best
known remedy for syphilis, a powerful purifier of the
blood and to have other curative effects. Bonkocine
(J. E. Gasson), sold with the claim that "well defined
cases of gonorrhea yield to treatment in one to five
days, chronic gonorrhea and gleet in five to ten days,
provided they are not complicated with stricture or en-
larged prostate gland" (Jour. A. M. A., Jan. 8, 1921,
p. 126).
Biologic Therapy. — The various problems, the con-
tradictory opinions and the commercialization of bio-
logic therapy, induced the Council on Pharmacy and
Chemistry to appoint a committee to prepare and pub-
lish an authoritative review of this subject. The ob-
ject of the series, which has now been published, was
to present to physicians concise, authoritative state-
ments concerning indications, contraindications,
methods of administration, dosage, value and possible
danger of serums, vaccines and nonspecific proteins in
the treatment of infectious diseases (Jour. A. M. A.,
Jan. 29, 1921, p. 318).
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July, 1921 EDITORIALS 7l5
THE PENNSYLVANIA stricted, due to the pages occupied by this list of
names.
l^P»'rv I/^AI TOTTRN^AI should you notice the absence of a name,
■*■ ^*-^^*^-^*^ J W UlyiirVl^ i^^jgj^j ypj, jjQj ygg yQ„j influence to have this
~~7~~ ~ ' ;^ ~ , . „ . ,. .. member reinstated?
Published monthly under the supervision of the Publication
Committee of the Trustees of the Medical Society of the State
of Pennsylvania.
^^T THE COUNTY MEDICAL SOCIETY
FREDERICK L. VAN SICKLE, M.D Harrisburg . ., , . • •
Assistent Editor ^ wiae awake, progressive county society is
FRANK F. D. RECKORD, Harrisburg of incalculable benefit' to the members that at-
Auociate Editors tend regularly. It tends to make better physi-
&" E.'^?p*i:S«i.. *M°D.. •::::::::;:::::::::: ilhiladei^hS cians of us and presents an opportunity to be-
GSJL«"c.&?o^'M"D^.:::::::::::•:::;::::■p^!Sbuf^^ come acquainted with one another, which con-
^o„l"TMcAus?«;M'b°;\::-.:-.:-.::::-.:-.::-.:::^ ^"<^^s to a spirit of good fellowship. Regular
Bernaxd J. Myus, Esq Lancaster attendance becomes a habit just as nonattend-
PabUcation oommittm ance may become one.
Ira G. Shoeuakks, M.D., Chairman, Reading t i i- i • i i* _ ~„ U»..1,1
THinnoRK B. Arm., M.D. Lancaster Interesting and instructive programs should
Fra», c. Hammokd. M.D PhiUdeiphia ^^ presented, so that the members are led to feel
All communications relative to exchanges, books for review, that they should not misS the Opportunity of be-
3;?siTrF"r:Je';icl''T"7aS '§?ck1^,"S'S:ri<iTor.'%^, "n": . ing present. It has been quite noticeable through-
Third St.. Harrisburg, Pa. ^^^j ^j,g g^^jg jj,jjj county meetings show better
The Societjr does not hold itself responsible for opinions ex- attendance than formerly, which suggests that
pressed in original papers, discussions, communications or ad- , . . ,. * ^i * _ x
vertisements. physicians realize more and more the importance
„ . 7~. r~i I ; J of regular attendance. It is also noticeable that
Subscription Price — $3.00 per year, in advance. ,? , . , • ^ xi.
usually the same members enter into the open
July, 1921 discussions. Many members, while being good
— listeners, never take part "in the discussions. An
effort should be made to make the discussions
EDITORIALS ^^^^^^ universal, and this may be accomplished
by putting such men on the program and empha-
MFMBKRSHIP LIST OF COUNTY sizing the importance of their cooperation. We
MEDICAL SOCIETIES *^^" '^^™ much from one another, owing to the
fact that all physicians' practices are varied in
Following the custom which the Pennsylva- character. One member may have been in prac-
NIA Medical Journal has adopted for some ^■^^^ f^j. ^^ny years without having .seen a case
years past, we publish in this number the list of ^f ^ certain type, while his neighbor, in the
names of those in good standing in the com- course of a few months' practice, may have had
ponent county societies, as of March 31, 1921. ^^ opportunity to di^nose and treat just such a
In reading over the list of the county societies, case, a recital of which would be of great bene-
you may perhaps miss seeing the names of some fit. Habitually delinquent members should be
you supposed were members. It is as much our put on committees in the hope of arousing their
regret as yours that any name is missing from interest and making them feel that their presence
tliis list which appeared on lists of former years, js essential to the success and welfare of the
It is not our purpose to comment upon the value society.
of the advantages of membership in the com- Xhe social feature should not be neglected, in
ponent county societies, and upon the benefits the form of dinners, smokers and picnics, which
thereby derived through membership in the bring the men together and foster the spirit of
Medical Society of the State of Pennsylvania, good fellowship.
We cannot help but believe that lapses of mem- A permanent home for the county society is a
bership would not occur if those who are indif- splendid means of keeping up interest, and
ferent or careless about paying their dues could should be a possibility in the larger towns and
realize, as some of us do, the real need and real cities which are headquarters for the Various so-
benefit derived by keeping in good standing. cieties. Here the meetings are held and a medi-
We trust that the members will preserve this cal library maintained for the use of members,
number of the Journal, thereby retaining the The new home of the Medical Society of the
membership list for reference. The usual amount District of Columbia in Washington. D. C, is a
of reading matter has of necessity been re- revelation along this line ; a magnificent granite
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716
THE PENNSYLVANIA MEDICAL JOURNAL
July, 1921
building, containing an auditorium, a library,
committee rooms and facilities for holding social
functions. Of course, it is manifestly impos-
sible for most societies to own a home of such
pretentious proportions, but it is feasible, in
many localities, to own a comfortable home
which would meet every requirement.
A. F. H.
rOST MORTEMS
The official organ of the Chester County
Medical Society, The Medical Reporter (March,
1921), has a timely editorial in re the subject of
post mortems. There has been shown renewed
activity recently for the necessity of obtaining
post mortems. Hospital records, as a whole,
show an apathy in this matter. With the stand-
ardization of hospitals, now going on throughout
the country, hospital management is becoming
keenly alive to the necessity of obtaining autop-
sies. It seems rather strange that the hospital
staffs have not made more attempts to obtain
autopsies, in the past ; but now that the securing
of autopsies is required as part of the process of
standardization, the medical profession is being
awakened to the situation. There are many ways
by which consent may be obtained to perform an
autopsy, and the various institutions and the pro-
fession must correlate these reasons and be pre-
pared to properly place them before relatives.
Undertakers do not cooperate as they should and
frequently have the family withdraw the per-
mission. Much may be done to overcome the
antagonism of the undertaker if, when internal
organs are removed, the vessels leading to them
are ligated. This will prevent the embalming
fluid from running out into the abdominal and
thoracic cavities, which causes a loss of fluid and
interferes with the proper embalming of the
body. Opening the skull should be done only
when necessary.
As regards Philadelphia, little or no coopera-
tion can be obtained from the coroner. Dr.
Joseph C. Doane, Medical Director of the Phila-
delphia General Hospital, is to be congratulated
upon the good work that is being done in that
hospital to obtain autopsies. This hospital aver-
ages about two thousand deaths yearly, and until
eighteen months ago, only 7.37 per cent of
autopsies were obtained. In June, 1919, Dr.
Doane called a meeting of the internes, gave
them a talk upon the necessity of obtaining post
mortems and the various reasons that were to be
used, just as a business house would give its
employees a talk on .salesmanship. They were
further advised that their activities in this en-
deavor would serve to show interest in their work
and would be so taken into consideration. As
a result of this plan, a list is posted each month
on the hospital bulletin board, which gives the
names of the internes, the number of deaths on
his service and the percentage of post mortems
obtained. A friendly rivalry thus is created,
and enthusiasm stimulated. Internes showing a
low percentage are called to the office of the
medical director and are warned that they are
not manifesting the proper interest in this por-
tion of their duties, and to "get on the job."
Also, a list is posted of the hospital staff, with
the number of deaths on each service and per-
centage of autopsies. This list affords the visit-
ing chief an opportunity to see when his service
is "falling down," and to further cooperate with
his interne in the matter. In this way the matter
first is placed squarely up to the interne, because
he is invariably in the hospital at the time the
deaths occur, and comes in contact more fre-
quently than the chief with the relatives and
friends of the patients. As a result of this con-
certed action, the first month showed a jump
from P-SS*?? to 23.06% of autopsies. Since then
there has been a monthly average of 31.297^
The monthly average during 1921 has been
38.5%. The average for April, 1921, was
42.07%.
The following percentages are of interest
from the Peter Bent Brigham Hospital: 1917.
5.S% ; 1918, 42%', 1919, 43%, and 1920, 6i'"r.
The superintendent of this hospital consider*
that the percentage is very good when one takes
into consideration the fact that many of the
deaths were Jews, who almost never permit
autopsies.
In order to obtain post mortems, the follow-
ing must be borne in mind: peculiarities and
prejudices incident to race and creed ; the neces-
sity for making a diagnosis in order that a
proper death certificate may be issued ; when the
deceased is insured it is desirable, if possible, to
give the exact facts of death in answer to the
question, "Was an autopsy made?"; the value
of the findings in aclministering to other pa-
tients, etc. F. C. H.
Genuine sociability relieves f.-itigue. delights
the soul, strengthens the will, induces longevity,
stimulates the powers of love and is an ingredi-
ent of the elixir of immortality. — Myers
Cheer reaches the goal while gloom is putting
on his shoes.
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The Medical Society of the State of Pennsylvania
OFFICERS' DEPARTMENT
WALTER F. DONALDSON. M.D.
Secretary
8014 Jenkins Arcade Building
Pittsburgh, Pa.
THE BOSTON A. M. A. SESSION
The Medical Society of the State of Pennsyl-
vania, entitled to nine delegates in the House of
Delegates, was represented daily by the follow-
ing nine good men and true : William F. Bacon,
York; George R. S. Corson, Pottsville; Her-
bert B. Gibby, Wilkes-Barre ; George G. Har-
man, Huntingdon; Wilmer Krusen, Philadel-
phia; George A. Knowles, Philadelphia; John
D. McLean, Philadelphia ; Jefferson H. Wilson,
Beaver; and Victor P. Chaapel, Williamsport.
The latter two were alternates designated for
Drs. C. A. E. Codman and John B. McAlister,
who were unable to serve. The duties of the
conscientious members of the House of Dele-
gates were arduous, and our society is indebted
to its representatives, who neglected both scien-
tific and social features to attend to floor and
committee work.
The proper interpretation and application of
State Medicine elicited a rather prolonged and
spirited discussion, resulting in the recorded con-
clusion, however, that the function of the state
in the control of public health was limited to
the prevention of sickness through the control of
communicable diseases, the control of water and
focxl supplies and sewage disposal, leaving the
treatment of sickness to the individual physician.
The registered attendance totaled about 5,500,
approximately one-twelfth of those registered be-
ing members of the Medical Society of the State
of Pennsylvania. The various departments of
the A. M. A. occupied an unusually large amount
of space in the exhibit hall this year, and we
were impressed with the efforts of the Associa-
tion in educating the public and the medical pro-
fession to distinguish between truth and deceit
in the fundamental qualifications for preventing
and recognizing and treating disease and injury.
In the moving picture theater seating about
four hundred, lantern slides and films were
shown every day from 9 a. m to 5 : 30 p. m.,
demonstrating the latest methods of diagnosis
and treatment under such titles as "Etiology of
Epidemic Hiccough, Encephalitis and Poliomye-
litis," by Dr. E. C. Rosenow, of the Mayo
Clinic ; and "Ununited Fractures ; Use of Frac-
ture Table and Electric Tool for Bone Cutting,"
by Dr. Fred H. Albee. In most instances the pic-
tures were presented and commented upon by
the author.
The president-elect, Dr. George E. deSchwei-
nitz, of Philadelphia, will require no introduc-
tion to the majority of the members of the
American Medical Association.
Those of us who took advantage of the oppor-
tunity to visit the historic shrines of American-
ism at Bunker Hill, Lexington, Concord or
Plymouth, should be inspired with a new deter-
mination to educate our people to the menace of
Paternalism and Bureaucracy, as expressed by
unabsorbed Europeans in their propaganda for
Health Insurance, Old Age Insurance, Unem-
ployment Insurance, etc.
A great many physicians were much dissatis-
fied with the living quarters to which they were
assigned and quite a few who went without hav-
ing made reservation were more than disap-
pointed. We trust that none of our members
will have this experience at Philadelphia, Octo-
ber 3-6, 1 92 1. Make your hotel reservations for
this year's session of the Medical Society of the
State of Pennsylvania now. A list of hotels
with rates was printed on page 671 of the June
Journal.
OK GUARD
The Compulsory Health Insurance bill intro-
duced into the 1921 New York State Legislature
included unemployment insurance and old age
pensions. The legislation was introduced by
Representative Orr, a member of the Socialist
party.
The administration of the objectionable Har-
rison law adds insult to injury this year by
threatening a 25% penalty to those who do not
reregister, remitting $3.00 on or before July i.
All our protests against this very unjust piece of
Federal legislation will continue to be unavailing
until we retain the unflagging interest of some
energetic member of Congress.
POSTGRADUATE WORK
One component society with more than one
hundred members boa,sts that twenty-three of its j
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THE PENNSYLVANIA MEDICAL JOURNAL
July, 1921
members are engaging in graduate study at dis-
tant points during the current year. Such a rec-
ord manifests the spirit that properly answers
the demand for more good physicians, and we
congratulate the people of Cambria County on
their selection of medical men.
The first so-called Postgraduate Program by
our State Society will be presented in the town
of Somerset, Somerset County, on Tuesday,
July 19, beginning at 11 a. m. Dinner will be
served at 12: 30 p. m., and the scientific program
will be continued from i : 30 to 4 : 30 p. m. The
meeting is being arranged by a subcommittee of
the Scientific Work Committee and by local
members of the_ Somerset County Medical So-
ciety. A return post card announcing the pro-
gram and inviting every physician in Somerset,
Indiana, Fayette, Westmoreland and Bedford
Counties will be mailed two weeks in advance of
the meeting. Through these columns the com-
mittee urges all physicians within forty miles of
Somerset to attend. The program will be varied
and practical. Somerset may be reached by the
Baltimore & Ohio Railroad and by motor.
CHANGES IN MEMBERSHIP OF COUNTY
SOCIETIES
The following changes have been received to June
15th:
Adams: Nnv Member — Alfred C. Rice, McSherry-
town.
AuKCHENV : New Af embers — Edith A. C. Robinson,
7105 Monticello St.; .Tames O. Donaldson, 5229 Butler
St.; William J. Fetter, Mercy Hospital; John G.
Lloyd, 959 Greenfield Ave. ; Frank D. Johnston, 412
Columbus Ave., Pittsburgh ; Frank L. Conwell, 104
Brackenridge St., Tarentum ; Ann ■ Gray Taylor, 501
Lincoln Ave., Bellevue; Joseph T. Belgrade, 506 Lo-
cust St., McKeesport; Uriah F. Rohm, 217 E. Main
St., Carnegie. Reinstated Member— Louis M. Kridel,
373 Semple St., Pittsburgh. Transfers — Benjamin M.
Berger, Hiland Bldg., Pittsburgh, from Lawrence
County; Joseph M. Lukehart, 7002 Jenkins Arcade
Bldg., Pittsburgh, from Jefferson County.
Berks: Harry A. Britton, 351 N. Fifth St., Read-
ing, from Philadelphia County.
Carbon : New Member — Edward G. Bray, East
Mauch Chunk.
Erie: New Members — Francis S. Bodine, 1019 East
Ave. ; Lewellyn O. Howe, 606 Victory Road ; Samuel
L. Scibetta, 306 W. i8th St., Erie.
Huntingdon : Removal — Raymond R. Decker, from
Orbisonia to Lewistown (Mifflin Co.).
Lancaster : Removal — Thaddeus S. Irwin, from
Atglen to Christiana..
Lackawanna : New Members — Harry M. Mittel-
man, 504 Main St., Duryea; Herbert E. Simrell,
Clark's Summit ; Louis A. Milkman, 1917 N. Main
Ave. ; Zygmunt Nowicki, i loi Pittston Ave. ; Fred-
erick G. Robinson, Scranton Life Bldg.; Byron Jack-
son, County Bank Bldg.; James R. Newton, 311 Spruce
St., Scranton. Reinstated Members — Leo A. Nealon,
425 Prospect Ave. ; Nathan Silverstein, 540 Wyoming
Ave. ; Scranton. Death — Fred M. Davenport (Jeff.
Med. Coll., '05), of Scranton, May 15, aged 50.
Luzerne: New Members— Stephen W. Gryczka,
Kingston ; James A. Mulligan. Plains. Transfer —
Augustine J. Mulligan, Ernest, to Indiana County.
Bucks: Death— Jitnes E. Groff (Jeff. Med. Coll.,
'80). of Doylestown, June 10, aged 65.
Montgomery : New Member — George E. McGimiis,
Norristown.
Montour: New Members— Frank D. Glenn, Stitt
Hospital ; Leslie R. Chamberlain, State Hospital, Dan-
ville.
Philadelphja : New Members — Henry Wildenimi
1318 S. Fifth St.; E. Stanley Abbot, The Lenox, i.w
Spruce St.; Irene P. Chandler, 741 N. Forty-first St.-
Walter R. Krauss, 1614 N. Sixteenth St.: C. CaKnii
P'ox, 350 S. Sixteenth St.; Richard T. Ellison, in
Rex Ave., Chestnut Hill; David Farley, 1906 i>ine
St.; Francis V. Gowen, 904 E. Chelten Ave., Gntn,
Philadelphia. Deaths— Oscat H. Atlis (Teff. Mfd
Coll., '66). of Philadelphia, May 16; Charles W.
Dulles (Univ. of Penna., '75), of Philadelphia, Mav 6,
aged 71 ; Pierre N. Bergeron (Jeff. Med. Coll., '02).
of Philadelphia, May 11, aged 53; Job Robert Mans-
field (Hahnemann Med. Coll., '79), of Philadelphia.
May 21, aged 66; Jesse A. Bolin (Jeff. Med. Coll,
'81), of Philadelphia, May 27, aged 66.
Schuylkill: Death — George H. Halberstadt (Univ.
of Penna., '78), of Pottsville, April 26, aged 66.
Snyder : Removal — Percival Herman, from Kratier-
ville to Selinsgrove.
Warren : Transfer — Alan D. Finlayson, Cleveland.
O., to Cleveland Academy of Medicine.
Westmoreland: Transfer — Homer R. Mather,
from Philadelphia County.
Wyoming: Removal — Clarence L. Boston, from
Center Moreland to Noxen.
York : Removal — J. Nelson Dunnick, from Stew-
artstown to 200 E. Cottage Place, York.
PAYMENT OF PER CAPITA ASSESSMENT
The following payment of per capita assessment has
been received since April i6th. Figures in first column
indicate county society numbers ; second column, statt
society numbers:
For 1921
May 16 Adams 25 7028 $5.00
Luzerne 222-223 702^7030 laoo
Lackawanna 170-178,
180-187 7031-7047 85.00
Philadelphia 2017-2021 7048-7052 25.00
18 Schuylkill 100-103 7053-7056 20.00
Susquehanna 20 7057 5.00
Somerset 43 7058 5.00
19 Franklin 51 7059 S*"
20 Fayette 116 7060 5.00
Washington 125 7061 5.00
Lawrence 56,59 7062-7063 10.00
Philadelphia 2022-2027 7064-7069 30«i
21 Lebanon 22-23 7070-7071 laoo
Allegheny 63^, 1135-1145 7072-7(^2 55-00
Somerset 44 7083 5.00
Montour 20-21 7084-7085 laco
Juniata 12 7086 S-OO
Northumberland 60 7087 500
23 Wayne 26-27 7088-7089 10.00
24 Dauphin 151 7090 500
25 Erie 118-122 7091-7095 25.00
25 Blair 85-86 7096-7097 10.00
Jefferson 46-47 709&-7099 1000
I.ackawanna 188-192,1797100-7105 3aoo
Cambria 114-120 7106-71 12 35-0O
27 Montgomery 147 7 113 500
31 Luzerne 224-225 7114-7115 laoo
Northampton 129 7116 5-oo
June 1 Monroe 12 7117 5-00
2 Lackawanna 193-194 71 18-71 19 10.00
3 Carbon 29 7120 SSX>
6 Allegheny 1146-1 147 7121-7122 10.00
Cumberland ■ 41 7123 500
Snyder 13 7124 5-00
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OFFICIAL TRANSACTIONS
The Medical Society of the State of Pennsylvania
Organized 1848 Incorporated, December 20, 1890
Officers and Members of the Sixty-three Component County Societies
June 30, 1921
ADAMS COUNTY SOCIETY
(Organized Aug. 25, 1904.)
President.. .George H. Seaks, New Oxford.
1st V. Pres..J. McCrae Dickson, Middle and Waslin
Sts., Gettysburg.
2d V. Pres... Harry E. Gettier, Littlestown.
Sec.-Treas... Henry Stewart, 230 Baltimore St., Gettys-
burg.
Censors Edgar A. Miller, East Berlin.
John C. Felty, 238 Baltimore St., Gettys-
burg.
James P. Dalbey, Gettysburg.
Committee on Public Policy and Legislation:
Eugene Elgin, East Berlin.
J. McCrae Dickson, Gettysburg.
William E. Wolff, Arendtsville.
Stated meetings the second Friday in each month at
2 p. m. in Gettysburg or other place as may be deter-
mined by vote of the society. Election of officers in
January.
MEMBERS (25)
Cashman, Elmer W., York Springs.
Crist, Chester G., Gettysburg.
Crouse, Harry S., Littlestown.
Dalbey, James P., High and Baltimore Sts., Gettys-
burg.
Dickson, J. McCrae, Middle and Waslin Sts., Gettys-
burg.
Elderdice, Robert B., McKnightstown.
Elgin, Eugene, East Berlin.
Felty, John C, 238 Baltimore St., Gettysburg.
Gettier, Harry E., Littlestown.
Hartman, Harry M., 26 Baltimore St., Gettysburc;.
Henderson, Ira M., Fairfield.
Hildebrand, J. Hamilton, Biglerville.
Hollinger, Wilson F., Abbottstown.
Lindaman, Rice H., Littlestown.
Miller, Edgar A., East Berlin.
Miller, Tempest C., Abbottstown.
O'Neal, Walter H., 106 Baltimore St., Gettysburg.
Rice, Alfred C, McSherrystown.
Seaks, George H., New Oxford.
Sheetz, J. Lawrence, New Oxford.
Stewart, Henry, 230 Baltimore St., (^ttysburg.
Stock, George A., U. S. P. H. S., Saranac Lake, N. Y.
Stover, James G., Bendersville.
Wolff, William E., Arendtsville.
Woomer, Albert, Cashtown.
ALLEGHENY COUNTY SOCIETY
(Organized April 20, 1865. Incorporated Jan. 30,
1892.)
(Pittsburgh is the post office when street address only
is given.)
President... Carey J. Vaux, 526 Larimer Avenue.
1st V. Pres. .Louis C. Botkin, 11 Prospect Ave., Ingram.
V.Presidents.Goldson T. Lamon, New Kensington.
John S. Kelso, 740 California Ave., .\va-
lon.
William C. Wallace, Ingram.
Alfred Sigman, 404 Bessemer Bld^.
Frank S. Pershing, 786 Pcnn .\ve., Wil-
kinsburg.
Gilbert C. McMaster, 319 Washington Rd.
Secretary... William H. Mayer, Jenkins Arcade Hldg.
Treasurer... Elmer E. Wible, Diamond Bank Bldg.
Censors Louis F Ankrim, 5014 Penn Ave.
Hugh E. McGuire, Pittsburgh Life Bldg.
William T. Burleigh, 825 N. Negley Ave.
John W. Boyce, Jenkins Arcade Lldg.
John G. Burke, Jenkins Arcade, Secretarj'.
Reporter.. .Lester Hollander, Jenkins Arcade.
Sanitation Committee:
Samuel R. Haythorn, Singer Memori.il
Laboratory.
Public Health Legislation Committee:
Thomas G. Greig, 1501 Carson St., S.S.
M. E. Stover, 519 Allegheny Ave.
J. G. Steedle, 1037 Chartiers Ave., Mc-
Kees Rocks.
W. F. Donaldson, 8103 Jenkins Arcade.
R. G. Bums, Dept. P. H.
Milk Com...Alvin S. Daggette, 400 S. Craig St.
Branch Or... Alfred Sigmann, Bessemer Bldg.
Sci. Prog... Harold A. Miller, Pittsburgh Life Bldg.
Med. Relief. William S. Foster, 252 Shady Ave.
Membership. Nicholas Shillito, May Building.
Finance George W. McNeil, 6001 Penn Ave.
Directors. . .Carey J. VauXj 526 Larimer Avenue.
Louis C. Botkin, 27 Prospect .\v'e., In-
gram.
William H. Mayer, Jenkins Arcade.
Elmer E. Wible, Diamond Bank Bldjj.
Isaac L. Ohlman, Jenkins Arcade.
Edward B. Heckel, Jenkins Bldg.
Raleigh R. Huggins, Westinghouse Bldg.
Harold A. Miller, Pittsburgh Life Bldg.
John A. Hawkins, Jenkins Arcade.
John M. Thorne, 7036 Jenkins Arcade.
George W. McNeil, 6001 Penn Ave.
James P. McKelvy, 519 N. Highland Ave.
John J. Buchanan, 1409 N. Highlatul Ave.
Walter F. Donaldson, 8103 Jenkins Arcade.
Official Publication: Pittsburgh Medical Bulletin.
Issued Weekly.
Editor : Isaac L. Ohlman, 8122 Jenkins Arcade.
Meetings held at Pittsburgh Free Dispensary Build-
ing, 43 Fernando Street (Third Floor), Pittsburgh.
Scientific Meetings, third Tuesday of October, Novem-
ber, December, January, February, March, April, May
and June, 8 p. m. Business meetings, second Tuesday
of January (the annual meeting), the second Tuesday
of April and October, 8 p. m.
ALLEGHENY VALLEY BRANCH
Chairman . . . Charles S. Orris, Brackenridge.
Secretary. . .Warren T. O'Hara, New Kensington.
OHIO VALLEY BRANCH
Chairman... John S. Kelso, 740 California Ave., Ava-
lon.
Secretary... G. Clyde Kneedler, Jenkins Bldg.
WILKINSBURG BRANCH
Chairman... Frank S. Pershing, 786 Penn Ave., Wil-
kinsburg.
Secretary. . .Elton S. Warner, Wilkinsburg Bank
Bldg., Wilkinsburg.
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THE PENNSYLVANIA MEDICAL JOURNAL
July, 1921
NORTH SIDE BRANCH
Chairman. . .Anthony J. Boucek, 624 Chestnut St., N. S.
SecreUry... George Leibold, 616 Chestnut St., N. S.
CHARTIERS VALLBY BRANCH
Chairman... J. Donald lams, 2863 Chartiers Ave.
Secretary.. .Louis C. Botkin, 27 Prospect Ave., In-
gram.
SOUTH HILLS BRANCH
Ciiairman...Chauncey L. Palmer, Diamond Bank Bldg.
Secretary... John L. Steffy, 111 Brookline Blvd.
MEMBERS (1,159)
Aaron, Charles J., 2847 Wylie Ave.
Aber, A. Howard, Maple Ave., Dravosburg.
Abrams, Wilmer D., c/o Mayo Clinic, Rochester, Minn.
Adams, Charles M., 2302 California Ave., N. S.
Adams, Samuel H., 7138 Hamilton Ave.
Ahlstrom, David N., Valencia (Butler Co).
Aiello, Alfonso, 909 Wylie Ave.
Albrecht, Nicholas, 82 S. Twelfth St.
Alexander, 1. Hope, Jenkins Bldg.
Alexander, John H., Westinghouse Bldg.
Allen, Charles W., 310 Fifth Ave., Tarentura.
Allen, James F., 1320 Boyle St., N. S.
Allison, Robert W., 808 Wood St., Wilkinsburg.
Allison, Thomas B., Tarentum.
Allison, Viola Z., 7225 Race St.
Allison, Wesley L., 8133 Jenkins Arcade.
Almquest, Benjamin R., Jenkins Arcade.
Alter, Joseph G., New Kensington (Westmoreland
Co.).
Alvino, Guirino, 541 Paulson Ave.
Anderson, Clyde O., 6830 Thomas Blvd.
Anderson, George C, 1504 Lincoln Ave.
Anderson, J. C, 14 Oakland Sq.
Anderson, James M., 1304 Wood St., Wilkin'sburg.
Anderson, Robert L., Jenkins Arcade.
Anderson, Thomas S., Jenkins Arcade.
Anderson, William, 1338 Middle St., Sharpsburg.
Andrews, Vernon L., West Penn Hospital.
Ankrim, Louis F., 5014 Penn Ave.
Apgar, Charles S., 7508 Hamilton Ave.
Arbuthnot, Thomas S., 6425 Fifth Ave.
Armstrong, Thomas S., 919 S. Evans Ave., McKees-
port.
Am, Gottfried, 531 E. North Ave.
Arnold, Charles A., 156 McClure Ave.
Arnold, William A., 207 Jenkins Arcade.
Arthur, Herbert S., 627 Walnut St., McKeesport.
Arthurs, Howard, 612 Grant St.
Ashe, Henry P., 1304 Colwell St.
Askin, Ralph J., 1926 Brownsville Road, Carrick.
Atkii>son, Daniel A., 132 Oakwood Ave., Westview.
Aufhammer, Charles H., 5004 Jenkins Arcade.
Aughenbaugh, Walter G., 1405 Columbus Ave.
Aye, Walter, Penna. R. R., Conway.
Ayres, Samuel, Jenkins Arcade.
Bachman, Milton H., 202 Masonic Temple, McKees-
port.
Baer, Harry Leonard, 2326 Eidridge St.
Bailey, Frank R., King Edward Apt.
Bair, Charles Homer, 419 Station St., Wilmerding.
Bair, Clarence E., 437 Library St., Braddock.
Bair, George E., 643 Braddock Ave., Braddock.
Bair, John W., 802 Amity St., Homestead.
Baird, Joseph A., 924 Highland Bldg.
Baker, Moses W., Diamond Bank Bldg.
Baker, Theodore, 6079 Jenkins Arcade.
Baldwin, Marcus E., Bessemer Bldg.
Ballagi, John, 438 Fifth Ave., Homestead.
Ballantyne, James V. H., 820 Wood St., Wilkinsburg.
Ballard, Howard S., 504 People's Bank Bldg., McKees-
port.
Baltrusaitus, Johanna T. Z., 205 Seneca St.
Barach, Joseph H., Jenkins Bldg.
Barbrow, Abraham L., 705 Sandusky St., N. S.
Barchfield, Andrew J., 2937 Brownsville Rd.
Barkley, A. Wray, 2217 Perrysvillc Ave.
Barndollar, William P., Westinghouse Bldg.
Bamette, William M., 413 Market St., Harrl»burg
(Dauphin Co.).
Banihardt, Harry A., 410 Brushton Ave.
Bamhart, Henry B., 704 Broadway, McKees Rocks.
Barone, Charles J., Elizabeth Steele Magee HospiUl.
Barr, Andrew M., 5149 Butler St.
Barr, James M., Valencia (Butler Co.).
Barrett, Thomas McS., Dixmont
Baumann, Harry F., 603 E. E. Trust Bldg.
Bazell, David Louis, 2818 Penn Ave.
Beach, William M., Bessemer Bldg.
Beals, C. Weame, Seneca (Venango (3o.).
Bearer, Albert J., New Kensington (Westm. Co.).
Beggs, David B., 792 Penn Ave., Wilkinsburg.
Behan, Richard J., 6079 Jenkins Arcade.
Belgrade, Joseph T., 506 Locust St., McKeespon.
Bennett, Newman H., 736 Brownsville Road.
Bennett, Oliver J,. 680 Preble Ave., N. S.
Benz, Henry J., 809 Grandview Ave.
Berg, Gustav F., 858 Lockhart St., N. S.
Berger, Benjamin M., Highland Bldg.
Bernatz, Clarence F., 1105 Park Bldg.
Bernstein, Hyman, 1227 Wvlie Ave.
Beswick, George L., 200 Caldwell Ave., Wilmerding.
Bianco, Antonio, 4518 Liberty Ave.
Bicking, C. Austin, 5512 Center Ave.
Bietsch, Charles Frederick, 714 Jenkins Bldg.
Billings, Frederic T., 626 Union Arcade.
Bixler, Lewis C, Highland Bldg.
Black, D. Grant, State Sanatorium, Mont Alto (Frank-
lin (3o.).
Blackburn, James P., 508 People's Bank Bldg., Mc-
Keesport.
Blair, Alexander C, Jenkins Bldg.
Blair, Esther L., King Edward Apts.
Blair, William W., Diamond Bank Bldg.
Blessing, Frank C, 5208 Second Ave.
Blick, William, Zl Station St., Crafton.
Bloomberg, Senior, 1608 Center Ave.
Blumberg, Solomon, 1712 Carson St., S. S.
Blumer, Max A., 1631 Denniston Ave.
Bode, Frederick W., 403 Empire Bldg.
Boggs, David Alexander, 920 (ierritt St.
Boggs, George G., 920 (Serritt St.
Boggs, Joseph C, 1311 Allegheny Ave., N. S.
Boggs, Russell Herbert, 215 Empire Bldg.
Boice, James M., Washington Bank Bldg., Burgetts-
town (Washington Co.).
Boiling, George H., 3042 Penn Ave.
Booher, Wayne E., 803 E. E. Trust Bldg.
Bornscheuer, Albert Adam, 8036 Jenkins Arcade.
Botkin, Lester H., 120 Kennedy St., Duquesne.
Botkin, Louis C, 27 Prospect Ave., Ingram.
Botkin, Robert L., Library Apt., Duquesne.
Boucek, Anthony J., 624 Chestnut St., N. S.
Boucek, CHiarles F., 812 Lockhart St., N. S.
Boucek, Fi-ancis C, 1442 Pennsylvania Ave., N. S.
Bo wen, Charles J., 4526 Penn Ave.
Bowers, Francis M. S., 814 Braddock Ave., BraddocL
Bowman, Charles L., 205 Brownsville Rd.
Boyce, John W., Jenkins Arcade.
Boyd, D. Hartin, 3654 Perrysville Ave.
Boyd, John A., 25 Wabash Ave.
Braden, Frank R., 1616 State St., Coraopolis.
Bradford, Claude L., 12th floor, May Bldg.
Bradford, Mark A., 12 Wabash Ave., W. E.
Bradshaw, William A., 4634 Fifth Ave.
Brant, Ross D., 11 N. Emily St., Crafton.
Bremer, Fred W., 1104 East Ave., N. S.
Brenneman, Richard E., Jenkins Arcade Bldg.
Broadhurst, William S., Tyre.
Brown, Harrison M., 1303 Wylie Ave.
Brown, James E., 6319 Broad St.
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MEMBERSHIP LIST
721
Brown, Jolin M. Evans, Creighton.
Brown, John R., 1005 Wylie Ave.
Brown, Louis M., AUe. Co. Home, Wo«dville.
Brown, Lu Van Leer, Castle Shannon.
Brown, Prentiss A., 859 Fourth Ave., New Kensington
(Westmoreland Co.).
Brown, Silas S., 2533 PerryswUe Ave., N. S.
Brown, Walter E., Eighth Ave. and Amity St., Home-
stead.
Bruce, Paul C, 1001 Western Ave.
Bruecken, Albert J., 1201 Troy Hill Rd., N. S.
Bryant, William C., Jenkins Arcade.
Bryson, William J., Hays.
Bubb, George S., 146 Greydon Ave., McKees Rocks.
Buchanan, Edwin P., Mercy Hospital.
Buchanan, John J., 1409 N. Highland Ave.
Buka, Alfred J., 516 Federal St., N. S.
Bulford, Daniel N., 100 E. North Ave.
Bulger, Alvin Edmonds, 836 Braddock Ave., Braddock.
Bumgarner, Frank O., 615 Highland Bldg.
Burke, John G., Jenkins Arcade. —
Burkett, John Wesley, Moon Run.
Burleigh, William T., 825 N. Negley Ave.
Bums, Harry B., Fulton Bldg.
Burns, Richard G., 3930 Perrysville Ave.
Burt, James C, Westinghouse Bldg.
Bushong, Park W., 1824 Webster Ave.
Buvinger, Charles L, 702 Bessemer Bldg.
Cadwalader, John S., R. D. 6, Meadville (Crawford
Co.).
Caldwell, Charles S., 2003 Monongahela Ave., Swiss-
vale Branch.
Caldwell, Francis M., 130 Kirk Ave., Mt. Oliver.
Caldwell, J. Clarence, 135 W. Jefferson St., Butler
(Butler Co.).
Calhoun, Bruce L., 474 Front St., Verona.
Calhoun, George A., Gairton.
Callomon, Vemer B., 353 Melwood St.
Calvert, Joseph F., 3047 Chartiers Ave.
Cameron, Donald W., 510 Highland Bldg.
Cameron, Markley C, 510 Highland Bldg.
Cameron, William H., Iroquois Apts.
Camp, George H., 5605 Penn Ave.
Campbell, Charles L., 2867 Chartiers Ave., Sheridan.
Campbell, Robert A., 810 Ann St., Homestead.
Campbell, Robert John, Jenkins Arcade.
Campbell, William McF., Jenkins Arcade.
Cancelliere, Andrew R., 6226 St. Marie St.
Carrier, Sydney S., 825 Highland Bldg.
Carroll, Charles H., 1109 Federal St., N. S.
Carroll, Thomas B., Jenkins Arcade Bldg.
Carson, John S., Jackson St., Bellevue.
Carson, Waid E., 7095 Jenkins Arcade.
Case, Ralph E., 1122 S. Evans Ave., McKeesiwrt.
Cashman, Bender Z., Westinghouse Bldg.
Cathcart, Wilson B., 203 Frankstown Ave.
Cavanaugh, William J., 4047 Perrysville Ave.
Cave, William Arthur, 414 Forest Ave., Bellevue.
Caven, William A., 2126 Fifth Ave.
Chalfant, Sidney A., 7048 Jenkins Arcade.
Chambers, William H., 133 Fifth Ave., McKeesport.
Chapman, Ira W., 1004 Chislett St.
Charles, William S., 2110 Carson St.
Chatham, Edgar T., 25 Broadway, N. S.
Cheesman, Leroy H., Fulton Bldg.'
Christian, William H., 7348 Monticello St.
Clark, Harry E., 2919 Chartiers Ave., Sheridan.
Clark, Harry G., R. F. D. No. 3, Bridgeville.
Clark, Henry H., 6821 Thomas Blvd.
Clark, J. Julius, E. E. Trust Bldg.
Clark, James W., 5173 Penn Ave.
Clark, Nelson H., Highland Bldg.
Clark, Robert W., 655 Maryland Ave.
Clark, Walden A., 1034 Jancey St.
Qarke, Robert C, Wallace Bldg.
Qifford, Charles H., 316 Eighth St., Braddock.
Cochran, T. Preston, 2301 Salisbury St.
Cohen, Morris, 819 Wylie St.
Cohen, Samuel R., 1915 Beaver Ave., N. S.
Cohn, Charles W., 108 S. First St., Duquesne.
Cohoe, Benson A., Highland Bldg.
Colcord, Amos W., Clairton.
Coleman, Ihomas, 2137 Center Ave.
Colwell, Alexander H., Highland Bldg.
Connelly, William J., Ill E. Main St., Carnegie.
Conti, Gaetano, 29 (Chatham St.
Conti, Giacomo, 66 Washington PI.
Conway, John M., 620 Warrington Ave.
Conwell, Frank L., 104 Brackenridge St., Tarentum.
Cook, Orlando L., 1300 Monterey St., N. S.
Cort, Austin L., Wilson.
Cossitt, Henry De La, 818 Ann St., Homestead.
Cotton, Robert W., 600 Chartiers Ave., McKees kocks.
Cowan, Victor W., 823 Fifth Ave., McKeesport.
Craig, Ford B., Box 56, Pitcairn.
Craighead, Nancy B., 7002 Jenkins Arcade.
Cramer, George E., 1305 Middle St., Sharpsburg.
Cratty, Alfred R., 813 Wylie Ave.
Cratty, LeRoy D., 914 South Ave., Wilkinsburg.
Crawford, Herbert P., Ridge Ave., Crafton.
Crawford, J. Slater, 17 Center Ave., Ingram.
Crawford, Stanley, 1202 Westinghouse Bldg.
Creaven, Mathew F., 823 Carson St.
Creighton, Lawrence C, Unity.
Cristler, John W., Midland (Beaver Co.).
Croll, Walter Lewis, 400 W. North Ave., N. S.
Crookston, William J., State Dept. of Health, Harris-
burg (Dauphin Co.).
Cross, Albion A., 725 Jenkins Arcade.
Crozier, Alfred W., 5000 Penn Ave.
Cruikshank, Omar T., 8148 Jenkins Arcade.
Cubbison, Carl J., 1304 Wood St. (Wilkinsburg).
Cunningham, Daken W., Fairchance (Fayette Co.).
Cunningham, William N., 1911 Braddock Ave., Swiss-
vale.
Curll, Qyde L., 99 Hazelwood Ave.
Curry, Glendon E., Westinghouse Bldg.
Cutts, Wen Galaway, 2834 Wylie Ave.
Daggette, Alvin S., 400 S. Craig St.
Davis, Adam C, Creighton.
Davis, David Moore, Broughton.
Davis, Fannie, 511 Diamond Bank Bldg.
Davis, Fred A.. Highland Bldg.
Davis, Isaac, 2035 Center Ave.
Davis, James A., 4704 Penn Ave.
Davis, James R., 1000 Chartiers Ave., McKees Rocks
Davis, Nelson P., 1405 Fifth Ave.
Davison, Glenn H., Westinghouse Bldg.
Davison, Robert E., 6076 Jenkins Arcade.
Dawson, Stephen A., 5119 Jenkins Arcade.
Day, Ewing W., Westinghouse Bldg.
Dean, Howard E., 428 Library St., Braddock.
Dearth, Walter A., Jenkins Arcade.
Decker, Harry R., 1126 Highland Bldg.
Deemar, William Rogers, Tarentum.
DeMuth, Jesse S., 5136 Jenkins Arcade.
Denny, Clark B., Oakdale.
Denslow, Walter B., 3652 California Ave., N. S.
Depta, Michael J., St. Francis Hospital.
Devlin, Charles J., 7416 Washington Ave., Swissvale.
Dickinson, Breese M., Union Arcade.
Dickinson, James J., 637 Union Arcade.
Dickson, Joseph Z., Renshaw Bldg.
Dickson, Robert W., Sewickley.
Diller, Isaac S., 4630 Fifth Ave.
Diller, Theodore, Westinghouse Bldg.
Dillinger, G. Arthur, 1005 E. E. Trust Bldg.
Disque, Thomas L., Jenkins Bldg.
Dixon, John W., 820 Wood St., Wilkinsburg.
Dodds, Wallace T., 702 E. E. Trust Bldg.
■ Donaldson, Holland H., Union Arcade.
Donaldson, James O., 5229 Butler St.
Donaldson, John S., 600 Lincoln Ave., Bellevue.
Donaldson, Walter F., 8103 Jenkins Arcade.
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722
THE PENNSYLVANIA MEDICAL JOURNAL
July, 1921
Donovan, John D., 817 Greenfield Ave.
Donibush, Bertha E., 228 Amber St.
Douthett, Joseph M., E. E. Trust BIdg.
Doyle, Paul B., 2006 Beaver St., N. S.
Dranga, Amelia A., 706 Lyceum Bldg.
Duff, A. William, Fulton Bldg.
Duffy, Charles A., 310 McKee Place.
Duggan, John P., 817 Wylie Ave.
Duncan, Joseph L., Jenkins Bldg.
D'zmura, Andrew, 608 Diamond Bank Bldg.
Eakins, Olin Martin, Farmers Bank Bldg.
Katon, Percival J., Highland Bldg.
Ebc, R. W., 135 W. Swissvale Ave., Swissvale P. O ,
Edgewood.
Eber, Samuel I., Jenkins Arcade.
Ecker, Charles .S., Oakmont.
Edgar, Joseph C, 354 Washington Ave., Oakmont.
Edwards, Ogden M., Jr., 5607 Fifth Ave.
Eggers, August H., 5815 Rural Ave.
Eicher, Charles G., 604 Chartiers Ave., McKees Rocks.
Eisaman, Ottice N., 7137 Idlewild St.
Eisenhart, James E., 1323 Federal St., N. S.
Elkin, Cortlandt W. W., 519 N. Highland Ave.
Ellenberger, Jacob W. E., 813 Wood St., Wilkinsburg.
Elliott, Andrew H., 625 California Ave., Avalon.
Elliott, George B. C, 409 North Ave., Millvale.
Elliott, Herbert T., 889 Fifth Ave., New Kensington.
(Westmoreland Co.).
Ellis, Charles J.. 902 E. E. Trust Bldg.
Elpinstone, J. Wade, 3544 California Ave.
Elterich, Theodore J., 724 Highland Bldg.
Ely, George W., 7105 Frankstown Ave.
Emmerling, Karl A., 1018 Highland Bldg.
Engle, Guy D., 221 Penn Ave., Wilkinsburg.
Entwisle, Robert Morgan, 5004 Jenkins Arcade.
Epperson, Adah, 147 Oakview Ave., Edgewood.
Erhard, Ernest L., Glassport.
Ertzman, Richard L., 710 Greenfield Ave.
Evans, David R., 2006 Carson St.
Evans, Edward E., 2700 Fifth Ave., McKeesport.
Evans, Thomas, Jr., Highland Bldg.
Everhart, James K., Highland Bldg.
Ewing, William H., 590 Herron Ave.
Eyman, William G., 976 Greenfield Ave.
Farquhar, Howard L., 1136 Brownsville Rd.
Fausold, Lucian C, Glenshaw.
Fawcett, Charles E., 1535 Hillsdale Ave., N. S.
Feeley, Joseph B., Seventh St. and Vermont Ave.,
Glassport.
Feldstein, George J., Highland Bldg.
Felker, Wilbert, 373 Graham St.
Feltwell, Myrtle R., SS3 Centennial Ave., Sewicklcy.
FenoUosa, Sydney K.. 4715 Fifth Ave.
Ferguson, Agnes B., 325 Highland Bldg.
Ferner, Joseph J., 5541 Ellsworth Ave.
Ferrari, Pasquale, 807 Wylie Ave.
Fetter, William J., Mercy Hospital.
Fetterman, James M., 919 Fulton St.
Fife, S. John S., Bridgeville.
Findley, William McCrae, 1101 Franklin St., Wilkins-
burg.
Fink, Harry M., Bessemer Bldg.
Finkelpearl, Abraham, 1906 Fifth Ave.
Finkelpearl, Henry, 1906 Fifth Ave.
Fischer, Henry F., Springdale.
Fischer, N. Arthur, 623 Union Arcade.
Fisher, Abraham, 817 Fifth Ave., McKeesport.
Fisher, Joseph W., 3517 East St.. N. S.
Fiske, Ebcn W., 1208 Westinghouse Bldg.
Fleming, James C, 654 Herron Ave.
Flood, Henry C, 805 Highland Bldg.
Flude, John M., 529 Hill St.. Wilkinsburg.
Fogelman, Adam P., Munhall.
Forster, William A., 922 Chartiers Ave.
Foster. Curtis S.. 308 Diamond Bank Bldg.
Foster, Eli N., 115 Climax St.. Mt. Oliver.
Foster, James LeRoy, Freeport Rd.. Holwken.
Foster, William S., 252 Shady Ave.
Fouse, Orlando, Craig and Forbes Sts.
Frank, Austin C, 138 Brownsville Rd., Mt. Oliver.
Franklin, Paul H., 417 Jenkins Bldg.
Frederick, Frank H., Chateau and Penna. Ave , N. S.
Frederick, William, 1001 Chartiers Ave.
Fredette, John W., Mercy Hospital.
Freed, Raymond S., 2010 Fifth Ave.
Frey, John W., 523 Shady Ave.
Frishman, Morris, 519 Jenkms Bldg.
Frodey. Raymond J., 714 Jenkins Bldg.
Frost, Ellis M., 311 Neville St.
Frye, Daniel W., Jenkins Arcade.
Fulton, Brown, 610 Highland Bldg.
Fulton, Louis C, E. E. Trust Bldg.
Funk, John W., 1 Roose Bldg., East Pittsburgh.
Gamble, John Clarke, 633 California Ave., Avalon.
Gantt, Allen G., 6287 Frankstown Ave.
Gardner, Christopher C, 832 Braddock Ave., Braddock.
Gardner, E. Roy, May Bldg.
Gardner, Harold B., Highland Bldg.
Gardner, William E., 714 Cedar Ave., N. S.
Gardner, William H., 714 Cedar Ave., N. .S.
Gaub, Otto C, Westinghouse Bldg.
George, Shaul, 926 Highland Bldg.
Gillis, George H., 3725 Brighton Rd., N. S.
Gilmore, James L., 500 Pittsburgh Life Bldg.
Glass, Samuel J., Jr., 3447 California Ave.
Glynn, William H., 273 N. Craig St.
Godlewski, Stanislaus A., 1907 Carson St.
Goehring, Walter G., 1301 Denniston Ave.
Goehring, William N., 568 Homewood Ave.
Gold, Joseph B., 1947 Perrysville Ave.
Goldberg, Samuel, 611 Fifth Ave., McKeesport.
Golden, John F., W. Liberty Ave., Dormont.
Goldsmith, Luba Robin, 5802 Beacon St.
Goldsmith, Maurice F., Jenkins Arcade.
Goldsmith, Milton, Jenkins Arcade.
Goldstein, Harry R., 4210 Butler St.
Goldstein, Julius H., 2219 Murray Ave.
Goodpaster, William H., Moore Road, Carrick.
Goodsell, John W., Springdale.
Goodstone, Morris A., 302 Washington Bank Bldg.
Goodwin, Ralph D., Box 564, East Pittsburgh.
Gorfinkell. Julius, 5548 Avondale PI.
Gould, Margaret A., 606 Sherman Ave., N. S.
Graham, Norman R., 1304 N. Canal St., Sharpsburg.
Graham, Walter G., 7423 Race St., E. E.
Grahek, Joseph V., 843 East Ohio Street.
Graver, Edward, 401 N. St. Qair St.
Gray, Earl P., 510 Hay St., Wilkinsburg.
Grayson, Jhomas Wray, 8037 Jenkins Arcade.
Greenberger, Bessie, 2016 Center Ave.
Greenfield, John C, Clairton.
Greer, Martin N., 1534 Lowrie Ave., N. S.
Greer, Robert J., New Kensington.
Greig, Thomas G., 1501 Carson St., S. S.
Grekin, Jacob, 1801 Center Ave.
Grier, George W., Jenkins Arcade.
Griffith, Jesse B., 618 McKce Ave., Monessen (West-
moreland (3o.).
Griffith, John P., 4715 Fifth Ave.
Grogin, Paul B., 2031 Center Ave.
Gross, Arthur H., 688 Forest Ave., Bellevue.
Gross, Julius Edward, 8030 Jenkins Arcade.
Groth, Herman. 216 Greentree Ave., N. S.
Grove, Robert E., 1600 Maplewood Ave., Wilkinsburg.
Guerinot, Albert J., 7090 Jenkins Arcade.
Guffey, Albert A., 310 Shaw Ave., McKeesport.
Guy, William H., 500 Pittsburgh Life Bldg.
Haljen, John F., 218 Sixth Ave., McKeesport.
Hagemann. John A., Highland Bldg.
Hager, Christian, 917 Braddock Ave., Braddock.
Haines, Arthur S., 22 Wilkinsburg Bank Bldg., Wil-
kinsburg.
Halferty, Homer E., 707 East End Trust Bldg.
Hall, Henry M.. Jr., Adah (Fayette Co.).
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July, 1921
MEMBERSHIP LIST
723
Hall, Johii P., 6554 Frankstown Ave.
Hall, William T., Dixtnont Hosp., Dixmont.
Halpert, Louis H., 16 Duquesnc Ave., Duquesne.
Halstead, France W., Bakerstown.
Halverstadt, Charles H., Perrysville.
Hamilton, James M., W. Railroad Ave., Oakmont.
Hamma, James A., 408 Chartiers Ave., Carnegie.
Hammett, James H., Wilson.
Hainpsey, Alexander R., 806 May Bldg.
Handmacher, Benjamin B., 3617 Butler St.
Hankey, Elmer H., 1416 Penn Ave.
Hankey, Stacy M., 7086-88 Jenkins Arcade Bldg.
Harper, James W., 186 Promenade St., Crafton.
Harris, Ira C, 637 Corey Ave., Braddock.
Harrison, Ralph Hamilton, 309 Denniston Ave.
Hartley, Harold H., Green Spring Ave., Terrace.
Hartman, Clifford C, 519 N. Highland Ave.
Hartman, John C, Jr., 1716 Brighton Ave., North
Braddock.
Hartung, Frederick A., 543 Brownsville Rd., Mt.
Oliver.
Harvey, J. Paul, 300 N. Phelps St., Youngstown, O.
Harvey, Walter B., 940 Western Ave.
Hauck, Charles A., 316 Lowell St.
Hawkins, James C, 913 Fifth Ave., Coraopoli?.
Hawkins, John A., 5025 Jenkins Arcade.
Haworth, Elwood B., 145 N. Craig St.
Hayes, Charles H., 5800 Forbes St.
Hays, George L., 816 Empire Bldg.
Haythom, Samuel R., Singer Memorial Laboratory.
Hazlett, Theodore L., 626 East End Ave.
Heard, James D., Diamond Bank Bldg.
Heath, Robert M., 2423 Liberty Rd., Mt. Oliver Sta-
tion, Pittsburgh.
Hechelman, Herman H., Hotel Brighton, Atlantic
City, N. J.
Heck, Fred H., 1379 Lincoln Ave.
Heckel, Edward B., Jenkins Bldg.
Hector, Louis H., 706 Forland St., N. S.
Hegarty, John P., 819 Wylie Ave.
Heilman, Martin W., 1131 Park Ave., Tarentum.
Heisey, William C, 2123 Versailles Ave., McKeesport.
Hemphill, David E., 1432 Potomac Ave., Dormont.
Henderson, Walter Lowry, East McKeesport.
Henney, Bernard J., 323 W. Main St., Carnegie.
Henney, Patrick, 800 Island Ave., McKees Rocks.
Henninger, Charles H., Jenkins Arcade.
Henry, Exlgar S., 1100 State St., Coraopolis.
Henry, Edwin B., 1205 Chelton Ave.
Herman, Charles E., Carnegie.
Hersman, Christopher C, 2228 Carson St., S. S.
Herzstein, Harry J., 1229 Wylie Ave.
Hesser, Andrew J., 4912 Liberty Ave.
Hetzel, William B., Westing^ouse Bldg.
Hibbs, Robert C, Jenkins Ai^cade.
Hicks, Abram V., 1101 Highland Bldg.
Hieber, H. Chester, Jenkins Bldg.
Hierholzer, John C, Jenkins Bldg.
Hiett, George W., 3940 Evergreen Road.
Hill, Charles A., 5635 Callowhill St.
Hill, Ralph L., Woodville.
Hinchman, Robert S., 127 Fifth Ave., McKeesport.
Hocking, William C, 41 N. First St., Duquesne.
Hodgkins, James, 223 Boggs Ave., Mt. Washington.
Hodgson, William E., Box 382, Glassport.
Hoffman, Joseph H., 120 Cohasset St., Mt. Wash-
ington.
Hoffman, Norbert L., 120 Cohasset St.
Hogsett, Smith F., Jenkins Arcade.
Hollander, Lester, Jenkins Arcade.
Holliday, George A., 8047 Jenkins Arcade.
Holtz, Wilbur M., 150 Castle Shannon Rd.
Hood, Robert T., 308 Diamond Bank Bldg.
Hopkins, Alfred J., 403 E. E. Trust Bldg.
Hopkins, Herbert J., 403 E. E. Trust Bldg.
Hopper, Arthur W., Bridgeville.
Horwitz, Jacob J., 1517 Penn Ave.
Huffman, David C, 309 Olive St., McKeesport.
Huggms, Kaleigh K., 1018 Westinghouse Bldg.
Hughes, Reese W., Wabash Bldg.
Hunter, Andrew, 708 Peoples Bank Bldg., McKeesport.
Hunter, Clarence S., North Bessemer.
Hutchinson, Henry A., Dixmont.
Huth, John A., Natrona.
lams, J. Donald, 2863 Chartiers Ave.
Hand, Edward M., Coraopolis.
Ingram, Clarence H., 2223 Shady Ave.
Jackson, Daniel F., Jenkins Arcade.
Jackson, Joseph M., 8080 Jenkins Arcade.
Jacob, Frederick M., 4818 Baum Blvd.
Jacobowitz, Aaron, 8084 Jenkins Arcade.
Jahn, August H., 3535 Butler St
Jamison, Daniel I., 729 Lockhart St., N.S.
Jamison, John M., 1015 Highland Bldg.
Jaworski, Felix A., Locust St., McKeesport.
Jennings, Charles W., Brier Cliff Rd., Wilkinsburg.
Jennings, Samuel D., Sewicldey.
Jenny, Thomas G., Penn and Negley Aves.
Jew, Henry D., 2306 Arlington Ave.
Johnson, Lloyd W., 401 Empire Bldg.
Johnson, Samuel H., 4025 Butler St.
Johnston, Frank D., 432 Columbus Ave.
Johnston, George C, Jenkins Arcade.
Johnston, James I., 201 S. Craig St.
Johnston, James R., 276 N. Craig St.
Johnston, Robert C, Alter Bldg., New Kensington
(Westmoreland Co.).
Jones, Clement R., 816 Empire Bldg.
Jones, Enoch L., Homestead.
Jones, Herbert Leroy, 5014 Jenkins Arcade.
Jones, Wesley W., 523 Penn Ave., WilkinAurg.
Jones, William A., 181 Baldwin St., Hays.
Jones, William W., Highland Farms, North East (Erie
Co.).
Jordan, Henry D., 317 S. Millvale Ave.
Jordan, Stewart S., 1902 Jenny Lind St., McKeesport.
Joyce, Francis W., 501 Lincoln Ave., Bellevue.
Kalet, Harry J., 815 Wylie Ave.
Kamens, Alfred F., 826 Mellon St.
Kaufman, Albert S., New Kensington (Westmoreland
Co.).
Keebler, Charles Barton. McKees Rocks Trust Bldg.,
McKees Rocks.
Keller, Nile P., 630 Union Arcade.
Kellogg, Frederic S., 5510 Ellsworth Ave.
Kelly, J. Clarence, Reuben Bldg., McKeesport.
Kelso, John S., 740 California Ave., Avalon.
Kennedy, David D., 5500 Dunmoyle PI.
Kenworthy, Frank, E. E. Trust Bldg.
Kern, Frank M., 2423 Library Rd., Fairhaven.
Kerr, Harry J., 708 Chartiers Ave., McKees Rocks.
Kerr, John Cleon, 913 S. Evans Ave., McKeesport.
Kerr, J. Purd, 515 Fordham Ave. S., Hills Sta.
Kerr, Thomas R., Oakmont.
Ketterer, Clarence H., 3603 Fifth Ave.
Keyser, Charles F., IS N. Duquesne Ave., Du.iuesnc.
Kifer, Logan M., 537 Ringgold St., McKeesport.
Kilduffe, Robert A., Jr., Pittsburgh Hospital, Franks-
town Ave.
King, Russell H., 1742 Brighton Road, N. S.
King, S. Victor, Allegheny General Hospital.
King, Charles F., 522^^ Sinclair St., McKeesport.
King, Isaac K., 233 Brownsville Rdd.
King, Richard A., 2517 Perrysville Ave., N. S.
Kipp, Harold A., Mercy Hospital.
Kirch, John P., E. E. Trust Bldg.
Kirk, Donald I., 902 E. E. Trust Bldg.
Kirk, Thomas T., 4916 Liberty Ave.
Kirk, William H., Fulton Bldg.
Kline, Rosroe T., 3472 Perrysville Ave., N. S
Klinzing, Henrv. 12th floor. May Bldg.
Kneedler, G. Qyde, 501 Jenkins Bldg.
Knorr, Lawrence R., Femley, Nevada.
Koch, Scott L., Jenkins Arcade.
Digitized by
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724
THE PENNSYLVANIA MEDICAL JOURNAL
July. 1921
Kocher, Quintin S., Cecil (Washington Co.;.
Koenig, Adolpti, lUl Westinghouse Bldg.
Kohberger, Henry P., 118 S. Negley Ave.
Kolski, John J., 1704 Carson St.
Koonu, David M., 90/ Filth Ave., New Kensington
(, Westmoreland Co.).
Korhnak, August J., 1026 Talbot Ave., Braddock.
Kraft, Alfred H., 47 S. Eleventh St.
Krebs, Adolph, Jenkins Arcade.
Krepps, Allen L., 401 Bessemer Bldg.
Kridel, Louis M., i/i Semple St.
Krieger, George L., New Kensington (Westmoreland
Co.).
Kunkel, Howard W., 3701 Forbes St.
Kuntz, Benjamin, 500 W Fifty-Seventh St., New
York City.
Kvatsak, Julius Joseph, 3521 California Ave., N. S.
Lace, Walter J., Vandergrift (Westmoreland Co.).
Lacock, Lester E., 2501 Perrysville Ave.
Lamb, William Jean C, Homestead.
Lambert, Samuel Earle, 422 Frederick Ave., Sewicklcy.
Lamon, Goldson T., New Kensington (Westmoroland
Co.). '
Landon, Lyndon H., Jenkins Arcade Bldg.
Lange, J. Chris., 158 Bellefield Ave.
Lange, William J., Highland Bldg.
Langtitt, William S., Jenkins Arcade. .
Langham, William H., 811 West St., Homestead.
Larimore, Fred Campbell, 2539 Perrysville Ave.
Lasday, Louis, 5128 Second Ave.
Lauer, Cyril F., 4400 Butler St.
Lauiler, Charles A., 521 Franklin Ave., Wiljcinsburg.
Laughlin, John P., 131 N. Highland Ave, .. .
Laurent, F. Victor, 107 Morewood Ave.
Lawson, William E., Ann St., Homestead. . i ,:
Lear, Isaac N., Vandergrift (Westmoreland Cp-)-
Lebeau, Samuel I., 1536 Center Ave.
Lehner, William H., 1904 Carson St.
Lcibold, George, 1208 Itin St., N. S.
Leininger, Charles P., Fulton Bldg.
Lerch, Donald G., 3616 California Ave.
Lewin, Abraham, 1809 Carson St.
Lewin, Adolph L., 3703 Penn Ave.
Lewis, Edward C, Verona.
Leydic, Clarence L., Tarentum.
Leydic, Cyrus C, Natrona.
Lichtenfels, Frederick V., 1945 Fifth Ave.
Lichtenstein, Meyer B., iS36 Center Ave.
Lichty, John A., Fifth Ave. and Neville St.
Lindcman, Charles E., 707 E. E. Trust Bldg.
Lindsay, Charles S., 3401 McClure Ave.
Lindsay, James A., Jenkins Bldg.
Linn, George J., 7505 Rosemary St., WilkinsbiirR.
Lippincott, J. Aubrey, Jenkins Bldg.
Litchfield, Lawrence, Jenkins Arcade.
Lloyd, John G., 959 Greenfield Ave.
Lloyd, Pressley M., 6322 Stafion St.
Logan, Edward P., 516 Federal St.
Logan, James S., 516 Federal St., N. S.
Long, Herbert M., 231 Shady Ave.
Long, James McMaster, 5532 Baywood St.
Love, James H., 622 Front St., Verona.
Lowrie, Robert N., 412 Corey Ave., Braddock.
Lowrie, Walter James, 714 Braddock Ave., Braddock.
Ludwig. David B., 1119-1121 Highland Bldg.
Luke, Frank E., Highland Bldg.
Lukehart, Joseph M., 7002 Jenkins Arcade.
Lurting, Qarence W., 516 Federal St.
Luther. John M., Jenkins Arcade.
Lvon, Alvin K., 413 North Ave., Millvale.
McAboy, C. Bradford, 1301 East End Trust Rldg.
McAdams, Edward C. Frankstown and Lakcton Ave.
McAdams. Robert J., 4900 Liberty Ave.
McBride, John L.. 172 Center Ave., Emsworth.
McCaarue, Edward J.. Mercy Hospital.
McCain, Gilnin M., 7072 Jenkins Arcade.
McCarrell, James R., 1115 Bidwell St.
McCausland, William S., 10 Grant Ave., Duquesne.
McClure, James O., 436 Rebecca Ave., Wilkinsliurg.
McClymonds, Horace S., 502 Hay St., Wilkmsburg.
McCoUough, Thomas B., 816 Empire bldg.
McComb, Samuel F., 'larentum.
McCombs, William H., 26 S. fourteenth St
McConnaugtiy, james B., 5460 Penn Ave.
McConnell, Ihomas E., New Kensington (Westmore-
land Co.).
McConnell, William John, 228 First St, N. W.. Wa^h-
mgtou, D. C.
McCorkle, bamuel C, 3301 Brighton Rd., N. S.
McCorkle, W illiam P., 569 Sherwood St., Sheridan.
McCormick, Bernard J., 2406 Arlington Ave.
McCormick, Earl V., Grant St., Munhall.
McCormick, John C, 50 Shiloh St.
McCracken, William, 120 S. Negley Ave.
McCready, E. Bosworth, Keenan Bldg.
McCready, Frank L., Sewickley.
McCready, J. Homer, 816 Empire Bldg.
McCready, Joseph A., Greenwich, O.
McCready, Robert J., 909 Keenan Bldg.
McCreery, Albert H., 8133 Jenkins Arcade.
McCulloch, William P., Cheswick.
McCullough, John F., 220 S. Negley Ave.
McCune, Caleb, 901 Walnut St., McKeesport.
McCune, David P., 430 Shaw Ave., McKeesport.
McCune, Samuel G., Buena Vista.
McCurdy, Stewart L., 8103 Jenkins Arcade.
McFarland, William W., 1202 E. E. Trust Bldg.
McGarvey, Samuel C, Bridgeville.
McGeary, William J., R. D. 2, Allison Park.
McGee, Rea P., Jenkins Building.
McGrath, John F., 1434 Fifth Ave.
McGregor, William J., 744 Franklin Ave., Wilkinsbur?.
McGuire, Hugh E., Pittsburgh Life Bldg.
McKee, Carlisle E., Park Bldg.
McKee, George J., Westinghouse Bldg.
McKelvy, James P., 519 N. Highland Ave.
McKenna, William B., 5769 Baum Blvd.
McKennan, Moore S., 3612 Dawson St
McKennan, Thomas M. T., Jenkins Arcade.
McKibben, Alpheus, 127 N. Highland Ave.
McKibben, Samuel H., 1103 E. E. Trust Bldg.
McKinnon, Charles L., McKees Rocks.
McKinstry, Guy H., Aspinwall.
McLallen, James I., 801 Wood St., Wilkinsburg.
McLenahan, Thomas M., Greenfield Ave.
McMaster, Gilbert C, 319 Washington Rd.
McMasters, David M., Russellton.
McMeans, Joseph W., 5020 Liberty Ave.
McMurray, Thomas E., 553 Trenton Ave., Wilkms-
burg.
McNall, James M., P. H. S. Hospital No. 60, Otecii,
N. C.
McNaugher, Samuel N., ^341 Perrysville Ave.
McNeely, John F., MuiUiall.
McNeil, George W., Liberty Bank Bldg.
McQuaid, Joseph R., Leetsdale.
Macdonald, Clarence P., 125 Beluhoover Ave.
MacDonald, George F., Tarentum.
Macfarlane, James W., 1108 Westinghouse Bidg.
Mackrell, John S., 3944 Liberty Ave.
MacLachlan, A. Alexander, May Bldg.
Maclachlan, William W. G., 1133 Wightman St.
Madden, Francis J., 130 W. Grant Ave., Duquesnc.
Magee, J. Elmer^ Carnegie.
Magoffin, Montrose B., 4630 Fifth Ave.
Mahan, J. Clay, 2400 Berg St.. S. S.
Maits, Charles B.. 6692 Kinsman Rd.
Major, Richard S., 914 W. North Ave., N. S.
Mallison, Elizabeth C, 512 Sixth Ave., McKcesi^ort.
Malone, Harry N., 319 Park Bldg.
Manley, Thomas H., Tarentum.
Marcus, Samuel J., 1641 Fifth Ave.
Marcv. Charles H., 317 East End Ave.
Marick, Simon W., 1539 Center Ave.
Digitized by
Google
July, 1921
MEMBERSHIP LIST
725
Markel, James Clyde, Westinghouse Bldg.
Markell, William O., 413 Whitney Ave., Wilkinsburg.
Marks, Orrie Lester, 542 Brookline Blvd.
Marks, Phihp E., 580 East End Av«.
Marshall, Calvin C, Ml Charles St., Knaxville.
Marshall, Caroline S., /'045 Hamilton Ave.
Marshall, Watson, Diamond Bank Bldg.
Marshall, William N., Aspinwall.
Martin, David B. W., 516 Federal St., N. S.
Martin, George £., Duquesne.
Martin, John L., 127 N. Highland Ave.
Martin, W. Walton, Main St. and Penn Ave.
Mase, Jesse Z., 5620 Forbes St.
Mateer, Harry O., 2015 Carson St.
Matheny, A. Ralston, E. E. Trust Bldg.
Mathewson, Franklin W., Oakdale.
Mattox, Edgar E., 2102 Fifth Ave.
Maxwell, William Qark, Highland Bldg.
Mayer, Edward E., Jenkins Arcade.
Mayer, William H., 714 Jenkins Bldg.
Meanor, Harold Henderson, Coraopolis.
Mechling, Curtis Campbell, Jenkins Arcade.
Meckel, Louis O., Singer Memorial Laboratory, N. S.
Mehl, Omar H., 130 Gordon Ave., Swissvale.
Mercur, William H., 5244 Fifth Ave.
Meredith, Evan William, Jenkins Arcade.
Metzgar, Charles F., 137 S. Bryant Ave., Bellevue.
Metzgar, Daniel A., 600 Braddock Ave., Braddock.
Me-tzger, George, 1018 Chestnut St., N S.
Meyers, Gilbert B., 5074 Jenkins Arcade.
Midgley, Harry S., Atwood & Forbes St.
Miller, Franklin B., Fulton Bldg.
Miller, Harold A., Pittsburgh Life Bldg.
Miller, James M., Hickory, R. D. 4 (Washington Co.).
Miller, Laird O., 516 Federal St.
Miller, Robert T., Jr., Diamond Bank Bldg.
Miller, Thomas A., Bayne and Rogers Sts., Bellevue.
Miller, William T., 1113 Patterson Ave., McKeesport.
Milligan, Alexander M., 725 Jenkins Bldg.
Milligan, John D., 229 Yardley Way.
Milligan, Robert X., Sandusky St. and Park Way.
Milligan, Samuel C, Jenkins Bldg.
Mills, William W., 35 W. Grant Ave., Duquesne.
Mitchell, Atle«, 4125 Main St.
Mitchell, Lewis T., Aspinwall.
Mitchell, Lou M., Jenkins Bldg.
Mitchell, William T., 410 S. Pacific Ave.
Montgomery, Ellis S., 725 Jenkins Bldg.
Montgomery, W. Harry, Wall St., Pitcairn.
Moore, Charles C, 3528 Butler St.
Moore, Thomas F., 5500 Kentucky Ave.
Morgan, Joseph S., 119 Clearview Ave., Crafton.
Morris, Alanson F. B., 6901 Hamilton Ave.
Morrow, Frank L., 817 Bell Ave., N. Braddock.
Morrow, H. Wilson, Swissvale.
Morton, Charles W., 270 Tennyson Ave.
Moyer, Irwin J., 3525 Forbes St.
Moyer, Ray P., E. E. Trust Bldg.
Moyer, Sue S., 120 Electric Ave., East Pittsburgh.
Mullen, Charles E., Cambridge Springs (Crawford
Co.).
Munden, John J., 3918 Grcnet St., N. S.
Munster, James A., 716 Arch St.
Murdoch, J. Floyd, Bessemer Bldg.
Murphy, Arthur Trwm, 5313 Ellsworth Ave.
Murphy, Harry L., 2917 Zephyr Ave.
Murray, Charles K., 501 Rosswood Bldg., Wilkins-
burg.
Murray, Robert J., 42 Broad St., Sewickley.
Narr, Frederick, Passavant Hospital.
Nason, F. Thobum, Ruben Bldg., McKeespoVt.
Naylor, Mary A., 5452 Penn Ave.
Nealon, William A.. 1021 Highland Bldg.
Neely, Elmer E.. 1302 Pennsvlvania Ave.. N. S.
Neely, Frank. 3909 Ferrysville Ave., N. S.
NefT, Edward L.. 920 Park Bldg.
Nelson, Christian, 1231 Woodland Ave., N. S. '. . ,
Ncltleton, DeWitt B., Sewickley.
Nevins, Harry, 5204 Butler St.
New, Grant J. A., 917 Carson St.
Newcomb, Cyrenius J., Bellefonte, R. D. 3 (Csuter
Co.).
Newell, Joieph R., Hays.
NirhoUs, J. Calvin, 502 Braddock Ave., Braddock.
Noah, Harry Gardner, 901 Diamond Bank Bldg.
Nolan, Thomas G., 6101 Penn Ave.
Norris, Scott A., 305 Eighth St., Homestead.
Nowry, Samuel E., 405 Annie St., Wilraerding.
O'Brien, Michael E., 2808 Sarah St.
Ohail, Joseph C, 41;i W. North Ave., N. S.
O'Hara Warren T., New Kensington (Westmoreland
Co.).
Ohlman, Isaac L., 8122 Jenkins Arcade.
Opipari, Archil li U., 31 Chatham St.
Orbin, Walter B., 2805 W. Liberty Ave.
Ord, Edward Y., 1701 Huey St., McKeosport.
Orr, Charles A., Crafton.
Orris, Charles S., Brackenridge.
Osterloh, Charles T., 300 E. North Ave., N. S. .
Owens, Charles K., Jenkins Arcade.
Owens, John R., 3337 Dawson St.
Oyer, Harry W., Jenkins Bldg.
Pa^e, Claude W., McKees Rocks;
Palmer, Chaunccy L., Diamond Bank Bldg.
Parke, Delos H., McKean Bldg., New Kensington
(Westmoreland Co.).
Parkin, Edwin H., New Kensington.
Patterson, Ellen James, Westinghouse Bldg.
Patterson, Fred L., Coraopolis.
Patterson, John M., Imperial.
Pearson, Eugene O., 502 Semple St.
Perkins, David M., 516 Federal St., N. S.
Permar, Howard H., Dept. of Pathology, University
of Pittsburgh.
Pershing, Frank S., 786 Penn Ave., Wilkinsburg.
Pessalano, Frank J., 876 Fifth Ave., .""Jew Kensit-gton
(Westmoreland Co.).
Peterson, Albert A., Elizabeth.
Pettit, Albert, Westinghouse Bldg.
Phillips, John S., 614 Chestnut St, N. S.
Phillips, Nathan F., 410 Washington Rd.
Phillips, R. J., 67 Amanda Ave.
Phillips, Samuel R., 240 Charles St.
Pierce, Amos M., West Elizabeth.
Pierce, Glen McK., 3408 Versailles Ave., McKeesport.
Piper, Elmer N., New Kensington (Westmoreland
Co.).
Plumer, John S., Center and Plumer Sts., Emsworth.
Plyler, James I., 7217 Bennett St.
Pochapin, Irwin M., 1317 Fifth Ave.
Polk, Oscar I., 874 Braddock Ave., Braddock.
Pollock, Harry O., 207 Marguerite Ave., WilmerdinR.
Pool, Stewart N., Highland Bldg.
Porter, John, 1000 Park Ave., McKeesport.
Potts, James A., 15 Shiloh St.
Price, Albert D., 127 Hazelwood Ave.
Price, Charles R., 1620 Fifth Ave.
Price, Henry T., 1011 Westinghouse Bldg.
Proescher, Frederick, P. O. Box 303, Sioux City, Iowa.
Purdy, J. Edwin, Mercy Hospital.
Purman. John, 100 W. Eighth St., Homestead.
Pyle, William T., Lynn Bldg., Swissvale.
Radin, Samuel P., 413 E. Sixth St., Erie (Erie Co.).
Rail. George W., 6101 Penn Ave.
Ralston, B. Stewart, Neville St. and Center Ave.
Ramsey, Harvey Edwin, 3715 California Ave., N .S.
Ramsey, William S., 1200 State Ave., Coraopolis.
Rankin. Charles A., 1016 Walnut St., McKeesiW
Ratner, Simon H., 5144 Butler St.
Ranch Harvey M., 743 Warrington Ave.
Ray. William B.. Jenkins Arcade.
Raybeck. Ralnh T.. 914 North Ave.. N. S.
Read. John, 641 Walnut St.. McKeesport.
Rectenwald, Daniel L., 747 Warrington Ave.
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THE PENNSYLVANIA MEDICAL JOURNAL
July, 1921
Rectenwald, William Edward, 2600 Brownsville Rd..
Mt. Oliver Sta.
Rectenwald, John J., 132 Brownsville Rd.
Rectenwald, Lawrence E., 1820 Ley St., N. S.
Redmond, Maurice S., 331 S. Pacific Ave.
Reed, Charles L., 613 Jenkins Bldg.
Reed, I. Bebout, 11 Emily St., Crafton.
Reed, John C, 39 N. Duquesne Ave., Duquesne.
Reed, Joseph M., Diamond Bank Bldg.
Rees, David L., Jenkins Arcade.
Reif, Charles E., 616 Chestnut St., Allegheny.
Resmer, Norbert J., 315 Brownsville Rd.
Ressa, Daniel A., 7618 Bennett St.
Reusch, George F., 1155 Liberty Ave.
Rhodes, Frederick A., 5119 Jenkins Arcade.
Ribetti, G. Thomas, 933 Bedford Ave.
Ridley, DeWayne G., Mercy Hospital.
Ricketts, John G., 199 Steuben St., W. E.
Riethmuller, Albert Herman, 425 Grant St., Millvale.
Riggs, Elliott S., 38 Prospect Ave., Washington (Wash-
ington Co.).
Rimer, Frank H., Municipal Hospital.
Rinard, Charles C., Homestead.
Rinehart, Stanley M., Jenkins Arcade.
Ritchey, Elmer C, 214 Charles St.
Ritchey, John B., 1264 N. Catalina Ave., Pasadena,
Calif.
Rittenhouse, Harry H., Federal.
Robinson, Edith A. C, 7105 Monticello St.
Robinson, James W., 4439 Grant Blvd.
Rpbinson, Ralph V., Jenkins Arcade.
Robinson, Wilton H., Jenkins Arcade.
Rock, Norbert F., 2348 California Ave., N. S.
Rodgers, William H., 1421 Lincoln Ave.
Rohm, Uriah F., 217 E. Main St., Cam^ie.
Roose, Arthur E., 201 Beech St., East Pittsburgh.
Rosenberg, Nicholas L., 630 Fulton Bldg.
Ross, William F., 307 Freeport St., Aspinwail.
Rossiter, Frank S., 7339 McClure Ave., Swissvale.
Rowan, Charles, 269 Main Ave.
Rowland, Ivo E., Elizabeth.
Ruben, Jacob A., Jenkins Arcade.
Rubenstein, Louis G., Braddock.
Rudolph, Franklm W., 516 Federal St., N. S.
Rugh, John B., 430 Second St., Pitcairn.
Sable, Daniel E., 235 N. Dithridge St.
Sadowski, Leon, 2625 Penn Ave.
Sahm, William K. T., 5965 Adier St;
Sakarraphos, Stelios N., 1007 Wylie Ave.
Saling, John P., 2320 Carson St., S. S.
Sandblad, Andrew G., 728 S. Union Ave., McKeesport.
Sandels, Christoi^er C, Westinghouse Bldg.
Sands, Robert M., 4300 Butler St.
Sanes, K. Isadore, 519 Jenkins Bldg.
Sankey, Thomas M., 701 Trenton Ave., Wilkinsburg.
Saska, August, 519 Eighth St., Homestead.
Schaefer, Arthur P., 821 Lockhart St.. N. S.
Schaefer, Charles N., Jenkins Arcade.
Schatzman, Edward P., 710 Foreland St., N. S.
Schein, J. Jay., 1908 Carson St., S.S.
Schildecker, Charles B., Park Bldg.
Schill, Joseph J.. 3709 Butler St.
Schlegel, Alvin S., 802 Heberton Ave.
Schleiter, Howard G., 5004 Jenkins Arcade.
Schlesinger, Henry, Sharpsburg.
Schlotbom, Max G., 2708 Penn Ave.
Schmidt. .Mbert T., 612 Penn Ave.. Turtle Creek.
Schonfield. Moses, 432 Union Arcade.
Schoyer, George Shires, Highland Bldg.
Schrack, Frank M.. 2417 Carson St.
Schubb, Thomas. Highland Bldg.
Schuyler, Annie, 525 Woodboume Ave., S. Hills.
Schwartz, Lorraine L., 637 Union Arcade.
Scott, Zaccheus R.. Westinghouse Building.
.Seedenbere. Jesse P.. 12 Roselawn Terrace.
Seegman. Simon, 8113 Jenkins Arcade.
Seipel. John H., 816 Empire Bldg.
Seitz, George C, 2220 Woodstock Ave., Swissvale.
Seville, David Walter, 7 Sprague Ave., Bellevue.
Shaffer, David H., 203 Masonic Bldg., McKeesport.
Shaffer, Phineas J., 1^ S. Thirteenth St.
Shaffer, P. T. Bamum, Elizabeth.
Shallcross, William G., Highland Bldg.
Shanor, Charles K., 333 Beaver St., Sewicklcy.
Shapira, Abraham, 4767 Liberty Ave.
Shaw, Henry A., 2223 Carson St.
Shaw, James P., 211 Frick Bldg.
Shepard, Jackson B., 6449 Frankstown Ave.
Sheppard, Thomas T., 1015 Highland Bldg.
Sherman, William O., Carnegie BI^E.
Sherrill, Alvin W., 6200 Sellers St.
Shillito, Nicholas G. L., May Bldg.
Shultz, Charles £., Castle Shannon.
Sieber, Paul R., 7 Highland Ct.
Sigal, Harry M., 2139 Wylie St.
Sigmann, Alfred S., 404 Bessemer Bldg.
Silman, Charles N.,992 Lilac St.
Silsby, Frederick W., 1004 Garfield St., Tarentiim.
Silver, David, Jenkins Arcade.
Simon, David L., Jenkins Arcade.
Simonton, Thomas G., 5321 Fifth Ave.
Simpson, Frank F., Jenkins Arcade.
Simpson, John Reid, Westinghouse Bldg.
Simpson, Sumner C, East End Trust Bldg.
Singley, John DeV., 812 N. Highland Ave.
Sloan, Edgar H., 7435 Church Ave., Ben Avon.
Slocum, Morris A., 378 Butler St., Etna.
Smeltz, George W., 1018 Westinghouse Bldg.
Smith, Charles H., Arnold (Westmoreland Co.).
Smith, Erie F., Oakmont.
Smith, H. Milton, 1346 Walnut St., McKeesport.
Smith, Jacob C, Tarentum.
Smith, John L., 11 Emily St., Crafton.
Smith, Joseph B., 828 Braddock Ave., Braddock.
Smith, LaMonier, 319 Park Bldg.
Smith, Lawrence D., Pitcairn.
Smith, Louis N., 2014 Noble St., Swissvale.
Smith, Stanley S., 613 Jenkins Bldg.
Snedden, Alexander R., McKeesport.
Snitzer, Henry M., 1536 Center Ave.
Snowden, Roy Ross, Jenkins Arcade.
Snowwhite, Thomas H., 633 Braddock Ave., Braddock.
Snyder, Marchand, 261 McCargo St., New Kensington
(Westmoreland Co.).
Snyder, William J. K., Avalon.
Soflfel, August, 123 Shiloh St.
Sohn, Charles, 4902 Liberty Ave.
Speer, Harvey B., 1100 State St., Coraopolis.
Spiro, Marcus, 1457 Bamsdall St.
Sprowls, Garrett E.. 1000 Fifth Ave., New Kensington
(Westmoreland Co.).
Stahlman, Thomas M., 1111 Westinghouse Bldg.
Stenton, Anna M., 3501 Fifth Ave.
Stanton, Charles C., Jenkins Arcade.
Stanton, James N., Jenkins Arcade.
Staufft, Orson T., 1438 Columbus Ave.
Steedle, Joseph G., 1037 Charticrs Ave., McKees Rocks.
Steele, Paul B., 12 Lawson Ave., Crafton.
Steele, Robert L., 606 Locust St., McKeesport.
Steffler, Samuel S., 5012 Penn Ave.
Steffy, John L., Ill Brookline Blvd.
Steim, Charles J., 436 Sixth Ave.
Steim, Joseph M., New Kensington (Westmoreland
Co.).
Steinmetz. Olive B., Eighth and Ann Sts., Homestead.
.Sterrett, William J., Jenkins Arcade.
.'Stevenson, Alexander M.. Jenkins Arcade.
Stevenson, Ellerslie W., Farmers' Bank Bldg.
Stevenson, James Wylie, 1111 N. Park St., McKees-
port.
Stewart. Achfson. Union Arcade Bldg.
Stewart, T. Boyd D., Wilson.
Stewart, Richard C. M.. 6101 Broad St.
Stewart, Wylie J., 114 Fourth Avenue, Coraopolis.
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July, 1921
MEMBERSHIP LIST
727
Stieren, £dward, Union Arcade.
, btimson, (jeorge W., Jenkins Arcade.
Stotler, Fulton R., 611 Penn Ave., Wilkinsburg.
btover. Miles E., 519 Allegheny Ave., N. S.
istraessley, Clarence M., 6^l Pressley St., N. S.
Stncidand, George W., 6266 Frankstown Ave.
Sturgis, William W., Glenshaw.
t>turm, Samuel A., 5118 Jenkins Arcade.
btyDr, Charles J., 865 Lockhart St.
btybr, Joseph, Jbessemer Bldg.
Sullivan, Herbert H., 1004 Homewood Ave.
Sumney, Frank F., Maple Ave., Dravosburg.
Sunstem, Noah, 209 Locust St., McKeesport.
Sutton, Edward Lincoln, Lincoln Ave., Bellevue.
S wanton, Robert V., 44 S. Pacific Ave.
Swmdler, Charles M., 1027 Carnegie Bldg.
Swope, Lorenzo W., Park Bldg.
Taylor, Ann Gray, 501 Lincoln Ave., Bellevue.
Taylor, Edytha £., 11 Crafton Ave., Crafton.
Taylor, Martin C, 415 Warrington Ave.
Taylor, Robert L., 4740 Liberty Ave.
Taylor, William V. M., 629 Walnut St., McKeesport.
Terheyden, William A., 4810 Liberty Ave.
Thomas, Clarence M., 25 Nobles Lane.
Thomas, David O., 889 Fifth Ave., New Kensington
(Westmoreland Co.).
Thomas, Vernon D., Highland Bldg.
Thompson, Elmer J., 1300 Pennsylvania Ave.
Thompson, J. Calvin, 503 Union Ave., N. S.
Thompson, Lloyd L., 305 E. Eighth Ave., Homestead.
Thompson, William H., 1203 Monterey St.
Thoms, Joseph F., 1515 Lowrie St., N. S.
Thome, John M., 7036 Jenkins Arcade.
Thunhurst, Wilford L., 1112 Swissvale Ave., Wilkins-
burg.
Titus, Paul, Highland Bldg.
Todd, Frank L., 516 Federal St.
Todd, Grover C, 6357 Alderson Ave., E. E.
Tomlinson, William, 606^ Penn Ave., Turtle Creek.
Torrens, Adelbert E., 507 Perrysville Ave., West View.
Treshler, Harry J., 623 Herron Ave.
Trevaskis, Abraham L., 508 Penn Ave., Turtle Creek.
Trevaskis, Albert R., East Pittsburgh.
TroUky, Harvey E., 6400 Forward St.
Truschel, Eugene J., 207 Liberty Bank Bldg.
Tufts, Stewart W., Highland Bldg.
Turfley, George G., 2555 Center Ave.
Tumbull, Thomas, Jr., 835 Western Ave, N. S.
Turner, Hunter H., 501 Jenkins Bldg.
Ungerman, Frank G., 409 Locust St., McKeesport.
Updegraflf, Harry C, 2200 Southern Ave., Carrick.
Utley, Frederick B., 1126 Highland Bldg.
Van Home, Thomas C, 6510 Frankstown Ave.
Van Kirk, Herbert S., 219 Sixth Ave., McKeesport.
Van Kirk, Vite E., Union Arcade.
Vates, Charles W., P. O. Bldg., Mt. Oliver.
Vaux, Carey J., 526 Larimer Ave.
Vaux, David William, 4300 Butler St.
Vaux, George H., 5350 Liberty Ave.
Wade, Francis H., Wadehurst, Cambridge, Mass.
Wagener, Carl K., 312 Hutchinson Ave., Swissvale Sta.
Wagner, Albert A., 812 Cedar Ave., N. S.
Wagner, John H., Highland Court No. 7.
Wakefield, Qark, 3420 Butler St.
Wakefield, John G., R. D. 1, Wilkinsburg.
Walker, Granville H., 532 Lincoln Ave., Bellevue.
Walker, William K., Westinghouse Bldg.
Wallace, James O., 7008 Jenkins Arcade.
Wallace, William C, Ingram.
Waller, Mil ford M., 286 Southern Ave.
Wall is, Alfred W.. 125 Hazel wood Ave.
Walls, E. Slifer. Highland Bldg.
Walsh, Arthur F., Linwood Ave., Crafton.
Walters, DeForest E., 446 Atlantic Ave., McKeesport.
Walters, George W., 3222 Forbes St.
Walters. John, 316 Beaver St., Sewickley.
Walz, Frank J., Highland Bldg.
Warner, Elton S., Wilkinsburg Bank Building, Wil-
kmsburg.
Watson, Charles M., 516 Federal St., N. S.
Watson, William S., Jenkins Bldg.
Weamer, John A, 411 Third Ave., Tarentum.
ir,' ji^jTcisrst^."' ^^ '*^' ^-"»--
Wechsler, Benjamin B., 549 Neville St
w,*i*'.f •,f*'*"^""> 1554 Center Ave.
Weddell, Howard R., 219 Sixth Ave., McKeesport
We. Grover C, 4704 Fifth Ave. """^^^^^■
Weill, Nathan J., Jenkins Arcade.
Weimer, Edgar S., 1220 Highland Bldg.
Wemberg Max H., 6079 Jenkins Arcade.
Weiss, Edward A., Jenkins Bldg.
Weiss, Harry, Jenkins Arcade.
Weiss, Louis, 215 Electric Ave.. East Pittsburgh
Weisser, Edward A., 806 May BldK
Welch, John C., 679 Lincoln Ave.? Bellevue.
wfll^*" w'^'i,"*'*^'^ 9- ^"» Westinghouse Bldg.
Wesley, \yi ham H., 6101 Penn Ave.
Wessels, John L., 711 Sandusky St., N S
Westervelt Henry C 5306 Westminster Place.
wk'I*^"!.*' ?*""?? **•• 804 Wood St., Wilkinsburg
Whitehead, Ira B., 1600 Baltimore Ave. ""'""'S'-
Wholey, Cornelius C 818 Westinghouse Bldg.
Wiant, Meade, 7225 Kelly St. '^
Wible, Elmer E., Diamond Bank Bldg.
^»"e.E. Robert, 220 W. North Ave.
Wignall Honice L. W., 813 Wylie Ave.
Wi ey, Joseph C, 224^ Fifth Ave., McKeesDort
Wi etts, Ernest W., Diamond Bank 8% "^ *'
Wi etts, Joseph E., 5150 Jenkins Arcad^
Wi lams, Isadore, 2223 Carson St.
Wi hams, John A., 206 W. arson St.
Wijiams, Roger, 6101 Penn Ave.
Williams, Victor A., Liberty Bank Bldg.
Wi son, John M., 1111 Highland Bldg
Wi son, John V., 1332 Juniata St., N. S
'^(to.aTndV.r ^''* '''"■' ""^ ^^'^'-^^
Winter, William J., 1718 East St., N. S
Winters, George R., 112 Cohasset St.
Wirtz, Charles Wilmer, 703 E. North Ave.
Wishart, Charles A., Jenkins Arcade.
Witherspoon, Walter, Indianola, Pa
»r'^f}; ^/T"*^ F-. 1516 Juniata St.
W°tt • ?'?"i E. 340 Lincoln Ave., Bellevue.
Wohlwend, Frederick, Tarentum.
Wolf, Jacob, Jenkins Bldg.
^(filav^cS "■' ^ Maplewood Ave., Ambridge
^wlsid^dVr ™ ^''■' ^^* ^™""«'^"
Wood, Benjamin B., 2il9 Fifth Ave.
Wood, William H., Peoples Bank Bldg., Tarentum. ,
Woodbum, Wilton A., 415 Brushton Ave
Woods, Edward B., Highland Bldg.
Woodward, William M., 607 Fifth Ave., McKeesport
Worrell. John W., 110 S. Fairmount Ave. "
Wright, George J., 5700 Wilkins Ave.
Wuerthele, Herman W., 161 Greenfield Ave
Wycoff. George R., 718 Broadway, McKees Rocks.
WycoflF, William A., 7211 Frankstown Ave.
Wymard, William H., 721 N. Homewood Ave
Yoho, Charles E., 5536 Kentucky Ave.
Yorty, Valentine J., 7231 Race St.
Zabarenko, Samuel, 2322 Carson St.
Zeckwer, Isolde T., 135 N. Craig St.
Zeedick, Peter I., 340 Atwood St.
Zeller, Albert T.. 605 Locust St., McKeesport.
Zeok, John, 212 Eleventh St., Braddock.
Zieg, George A., 802 Cedar Ave., N. S.
Ziegler, Charles E., 4716 Bayard St.
Zinsser, Harry F., 5134 Butler St.
Zugsmith, Edwin, Jenkins Arcade. , ,: J
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THE PENNSYLVANIA MEDICAL JOURNAL
JiTUY, 1921
ZurHorst, Edward William, 1463 Green Mount Ave.,
Dormout.
ARMSTRONG COUNTY SOCIETY
(Organized March 28, 1876.)
President... George S. Morrow, Dayton.
1st V.Pres.. Edward H. McClister, Kittanning.
^dV.Pres... David H. Riffer, Leechburg.
Sec.-Trcas.
&Rept Jay B. F. Wyant, Kittanning.
Censors t*red C. Monks, Kittanning.
David H. Riffer, Leechburg.
Charles A. Rogers, Freeport.
S. E. Ambrose, Rural Valley.
Albert E. Bower, Ford City.
Committee on Public Policy and Legislation:
T. N. McKee, Kittanning.
J. D. Orr, Leechburg.
Jesse E. Ambler, Ford City.
Prog. Com.. Fred C. Monks, Kittanning.
John M. Cooley, Kittanning.
Jesse E. Ambler, Ford City.
Official Publication: The Bulletin.
Issued Monthly.
Editor: Jay B. F. Wyant.
Stated meetings at Steim Hotel, Kittanning, first
Tuesday of each month. Election of officers in Janu-
ary.
MEMBERS (60)
Allison, Harry W., Kittanning.
.Mlison, James G., McGrann.
Allison, L. Dent, Kittanning.
Ambler, Jesse E., Ford City.
Ambrose, Samuel E., Rural Valley.
Aye, Thomas L., Brackenridge (Allegheny Co.).
Barton, Blain B., Adrian.
Bierer, William J., Kittanning.
Bower, Albert E., Ford City.
Clampbell, Oren C., Ford City.
Clark, Omer C, Worthington.
Cooley, John M., Kittarming.
Deeraar, John T., Kittanning, R. D. 1,
Deemar, Roscoe, New Kensington (Westmoreland
Co.).
Fleming, Edward L., Dayton.
Furnee, Charles H., Kittanning.
Giarth, David I., Ford City.
Hamilton, William H., Joh(ietta.
Hargreave, James H., Kelley Station.
Heilman, Frank W., Kittanning.
Henry, Thomas J., Apollo.
Holland, Harry A., Sagamore.
Hunter, John C., Apollo.
James, John A., Yatesboro.
Jessop, Charles J., Kittanning.
Keeler, Charles E., Elderton.
Kelley, James A., Whitesburg.
King, Jesse H., Worthington.
Kiser, John K., Kittanning.
Knight, George A., Kaylor.
Kroh, Laird F., Rural Valley.
Lawson, Eleanor J. Hetrick, Kittanning.
Leech, William W., Apollo.
Longwell, Benjamin J., Seminole, R. D. 1, New Beth-
lehem (Clarion Co.).
McCafferty, William H., Freeport.
McClister, Edward H., Kittanning. . .
McKee, Thomas N., Kittanning.
McLaughlin, Charles M-, Freeport.
McNeil, Arthur R., Cadogen.
Mead, Ralph K., Sagamore.
Monks, Frederick C, Kittanning.
Morrow, George S., Dayton.
Newcome, Thomas H., Redbank (Clarion Co.).
Orr, Joseph D., Leechburg.
Parks, Clarence C, Leechburg.
Powers, Henry K., New Kensington (Wcstm. Co.).
Ralston, William H., Freeport, R. D. 1.
Riffer, Davis H., Leechburg.
Roderick, Robert D., Yatesboro.
Rogers, Charles A., Freeport.
Sedwick, Andrew, Kittanning.
Stone, Henry B., Kittanning.
Tarr, Robert F., Kittanning.
Townsend, A. Howard, Apollo.
Ward, James, Yatesboro.
Welsh, Howard M., Leechburg.
Whann, John Chickasaw.
White, Charles A., Templeton.
Winters, Ellis C, Ford Ci^.
Wyant, Jay B. F., Kittanning.
BEAVER COUNTY SOCIETY
(Organized Nov. 23, 1855.)
President... Harry W. Bemhardy, Rochester.
V.Pres Albert N. Meltott, Ambridge.
Sec.-Trcas.... Boyd B. Snodgrass, Rochester.
Reporter Fred B. Wilson, Beaver.
Censors Bert C. Painter, New Brighton.
Milton L. McCandless, Rochester.
Fred B. Wilson, Beaver.
Committee on Public Policy and Legislation:
Cieorge J. Boyd, Beaver Falls.
Bert C. Painter, New Brighton.
Stated meetings held in the Welcome Qub, Roch-
ester, on the second Thursday of each month, at 3:30
p. m. Election of officers in January.
MEMBESS (60)
Ague, John B., Beaver Falls.
Allen, John J., Monaca.
Aten, Ernest J., Ambridge.
Beitsch. William F., 1216 Sixth Ave., Beaver Falls.
Bcrnhardy, Harry W., Rochester.
Boal, G. Fay, Baden.
Boal, John H., Freedom.
Boyd, George J., Beaver Falls.
Buck, Clarence J., Beaver Falls.
Bums, Emmett S., Beaver Falls.
Cloak, Andrew B., Freedom.
Cornelius, Margaret I., Beaver.
Daugherty Charles B., Beaver.
Elliott, Washington F., Beaver Falls.
Forcey, Charles B., Ambridge.
Gilliland, J. Frank, Beaver Falls.
Glatzau, Lewis W., Midland.
Gormley, James R., Monaca.
Grazier, Harry L., Woodlawn.
Heller, Percy K., Freedom.
Herriott, Walter H., Freedom.
Jackson, John M., Beaver Falls.
Jones, Harry B., Woodlawn.
Kirchner, Henry S., Ambridge.
Lacy, Henry C, New Brighton.
Louthan, James S., Beaver Falls.
McCandless, Milton L., Rochester.
McCaskey, Francis H., Freedom.
McCormick, George L., Beaver Falls.
McGeorge, C. S., Ambridge.
McGogney, Clyde B., Midland.
McKinley, Andrew S., Monaca.
Martsolf, Philip F., New Brighton.
Mead, Harry B., New Brighton.
Meaner, William C, Beaver.
Mellott, Albert N.. Ambridge.
Miller, John L.. Aliauippa.
Miller, Leroy B., New Brighton.
Moore, Chalmers B., New Galilee.
Moore, Dnrius C, Monaca.
Moore, Harry E., Ambridge.
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July, 1921
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729
Norton, Roy R., New Brighton.
Ochsenhirt, Norman C, Enon Valley.
Painter, bert C, New Brighton.
Patterson, Robert M., Beaver Falls.
Peirsol, Scudder H., jr., Rochester.
Rose, Walter A., Rochester.
Scroggs, Joseph H., Beaver.
Shugert, Guy S., Rochester.
Simpson, Theodore P., Beaver Falls.
Smith, Perry Clare, Ambridge.
Sncdgrass, Boyd B., Rochester.
Snodgrass, Bruce H., Beaver Falls.
Stevens, John A., Woodlawn.
Stevenson, John D., 377 Third St., Beaver.
Straessley, Edward C, Beaver Falls.
Strouss, Ulysses S., Beaver.
Wickham, John J., Rochester.
Wilson, Fred B., Beaver.
Wilson, Jefferson H., Beaver.
BEDFORD COUNTY SOCIETY
(Organized July 29, 1904.)
President... Frank S. Campbell, Hopewell.
Sec, Treas.
&Rept Norman A. Timmins, Bedford.
Censor Walter F. Enfield, Bedford.
Committee on Public Policy and Legislation:
William C. Miller, State Dept. of Health,
Harrisburg (Dauphin Co.).
Walter F. Enfield, Bedford.
Harry I. Shoenthal, New Paris.
Stated meetings bi-monthly in Bedford or in other
places as may be determined by vote of the society.
Election of officers in January.
MEMBERS (16)
Ayres, Wilmot, Bedford.
Brant, Maurice V., Caimbrook (Somerset Co.).
Brumbaugh, S. Clarence, Windber (Somerset Co.).
Campbell, Frank S., Hopewell.
Cornelius, Thome, Riddlesburg.
Enfield, Walter F., Bedford.
Hanks, Jason G., Everett.
Lindsey, James W., Imler.
Miller, Abram M., Hyndtnan.
Miller, William C, State Dept. of Health, Harrisburg
(Dauphin Co.).
Nycum, William E., Everett.
Shoenthal, Harry I., New Paris.
Smith, Edmund L., 211 S. Juliana St., Bedford.
Stayer, Irvin C, Woodbury.
Strock, Henry B., Bedford.
Timmins, Norman A., Bedford.
BERKS COUNTY SOCIETY
(Reading is the post office when street address only is
given.)
Abner H. Bauscher, 336 N. Fifth St.
.Harry F. Rentschler, 228 N. Sixth St.
.George G. Wenrich, Grandview Sanator-
ium, Wemersville.
John E. Livingood, 249 N. Fifth St.
.Robert M. Alexander, S. W. Cor. Sixth
and Elm Sts.
.David S. Grim, 232 N. Sixth St.
Clara Shelter Reiser, 36 N. Tenth Street.
.Charles D. Werley, 307 S. Sixth St.
Irvin H. Hartman, 2S] N. Fifth St.
Daniel Longaker, 812 N. Fifth St.
.Charles W. Bachman, 221 N. Sixth St.
Israel Qeaver, 223 S. Fifth St.
S. Banks Taylor, 126 Oley St.
Harry F. Rentschler, 228 N. Sixth St.
David S. Grim, 232 N. Sixth St.
President. .
IstV.Pres.
2dV.Pres..
Secretary . .
Treasurer. ..
Librarian . .
Reporter..
Censors.. .
Trustees.
Committee on Public Policy and Legislation:
Chas. D. Werley, 307 S. Sixth St.
Harry B. Schaeffer, Shillington. '
Henry W. Saul, Kutztown.
Ira G. Shoemaker, 19 S. Ninth St.
Leon C. Darrah, 300 N. Fifth St.
Official Publication : Bulletin of the Berks County Medi-
cal Society.
Issued Monthly.
Editor : John E. Livingood, 249 N. Fifth St.
Stated meetings at Medical Hall, Reading, the sec-
ond Tuesday of each month at 3 p. m. Election of
officers in December.
MEMBERS (131)
Alexander, Robert M., S. W. Cor. Sixth and Elm Sts.
AUen, H. Melvin, 422 Walnut St.
Ammarell, Winfield H., Birdsboro.
Bachman, Charles W., 221 N. Sixth St.
Bagenstose, Harry W., West Reading.
Bankes, Claude W., 212 N. Sixth St.
Basler, William, West Leesport.
Bauscher, Abner H., 336 N. Fifth St.
Becker, John N., 322 N. Ninth St
Bertolet, John M., 1333 Perkiomen Ave.
Bertolet, Walter M., 141 N. Fifth St.
Bertolet, William S., 2^ N. Sixth St.
Bertolette, Daniel N., 127 S. Sixth St.
Borneman, John S., Boyertown.
Bower, John L., Broad St. Station P. R. R., Philadel-
phia (Phila. Co.).
Brunner, H. Philemon, 122 Oley St.
Brunner, Stanley A., Krumsville.
Bucher, Hiester, 142 S. Fifth St.
Burkholder, Samuel G., 613 Walnut St.
Cahn, Morris L., 551 N. Eleventh St.
Cantough, Charles S., 322 N. Fifth St.
Cleaver, Israel, 223 S. Fifth St.
Colletti, Ferdinando, 15 N. Fourth St.
Darrah, Leon C, 300 N. Fifth St.
DeLong, Eugene R., Geiger's Mills.
Dietrich, Charles J., 206 W. Oley St
Dries, Charles L., Eshbach.
Dunkelberger, Nathaniel Z., Kutztown.
Fahrenbach, George W., Bemville.
Feick, John F., 643 N. Ninth St.
Fisher, William E., 151 W. Buttonwood St.
Fitigerald, Lawrence, Temple.
Fox, Oscar E., 232 N. Fifth St. ';
Frankhauser, Fremont W., 6 N. Ninth St.
Gable, Frank J., 104 S. Fourth St.
Gearhart, Malcolm Z., 330 N. Fifth St.
Gehris, Oscar T., Fleetwood.
Gerhard, James R., 540 Center Ave.
Gorman, Leo R., 522 N. Tenth St.
Griesemer, Wellington D., 1216 Perkiomen Ave.
Grim, David S., 232 N. Sixth St.
Gruver, Martin E., 247 N. Fifth St.
Gryczka, Frank B., 148 S. Ninth St.
Hain, Ira J., 1119 N. Ninth St.
Harding, Ralph A., 152 Douglas St.
Hartman, Irvin H., 237 N. Fifth St.
Haws, Ralph J., 418 N. Tenth St.
Henderson, Robert J., 518 Franklin St.
Henry, Charles P., 201 Am. Cas. Bldg., Sixth and
Washington Sts.
Hertzog, C. Frank, Oley.
Hetrich, George, Birdsboro.
High, Isaac B., Shillington.
Hill, Samuel S., Wemersville.
Hirshland, Harold, 1019 Penn St.
Horn, John H., Womelsdorf.
Hunsberger, William E., Maiden Creek.
Huyett, M. Luther, 334 N. Fifth St.
Jameson, William B., Sanatorium, Handiurg.
Kaucher, Clifford L., Colonial Trust Bldg.
Kauffman, John W., 814 N. Eleventh St.
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TM^ PENNSYLVANIA MEDICAL JOURNAL
July, 1921
Kehl, George W., 313 N. Fifth St.
Keiffer, Elmer C, 900 N. Fifth St.
Kistler, Chester K., 800 Franklin St.
Knoll, Frederick W., 754 N. Tenth St.
Krick, Waiiam F., 340 N. Fifth St.
Kurtz, J. Ellis, 22 S. Fifth St.
Lebkicker, Wellington A., 25 S. Fif A St.
Lechner, Leroy Y., Bechtelsville.
LeFevre, Rufus E., 138 S. Eighth St.
Leinbach, Howard Milton, 323 N. Fifth St.
Leiscr, William, III, 336 N. Ninth St.
Lerch, Charles E., Wyomissing.
Levan, George K., 300 S. Fifth St.
Light. Israel K., 350 N. Sixth St.
Livingood, John E., 249 N. Fifth St.
Livingood, Louis J., Womelsdorf.
Livingood, William W., Robesonia.
Long, William S., 208 N. Sixth St.
Longaker, Daniel, 812 N. Fifth St.
Loose, Charles G., 120 N. Fifth St
Lytle Frank P., Birdsboro.
Mattemes, James G., Sinking Spring.
Hcter, Edward G., 948 Penn St.
Miller, Howard U., Mount Penn. . ,
Moyer, Donald G., 1153 Penn Ave., Wyomissing.
Muhlenberg, Heister H., 34 S. Fifth St.
Nead, Daniel W., 816 N. Fifth St.
Orff, John Henry, Wyomissing.
Overholser, George W., 309 N. Nmth St
Potteiger, George F., Hamburg.
Rager, Samuel E., Kutztovim.
Reber, Conrad S., 542 Penn Ave.. West Reading.
Reeser, Howard S., Ill S. Fifth St.
Rentschler, Harry F., 228 N. Sixth St
Rhode, Homer J., 220 N. Sixth St.
Roland, Charles, 105 S. Fifth St.
Rorke, John H., 342 N. Fifth St.
Runyeon, Frank G., 1361 Perkiomen Ave.
Saul, Henry W., Kutztown.
Schaeffer, Harry B., Shillington.
Schlappich, Charles E., Birdsboro.
Schlemm, Horace E., 25 S. Fifth St.
Schmehl, Seymour T., 717 Washington St.
Scholten, Ernest R., 909 N. Fifth St.
Shearer, Christopher H., 206 N. Fifth St.
Shearer, Wayne L., 101 W. Greenwich St.
Shenk, George R., 116 S. Ninth St
Shetter-Keiser, Clara, 36 N. Tenth St.
Shoemaker, Ira G., 19 S. Ninth St.
Smith, Charles F., Topton.
Sondheim, Sidney J., 1044 N. Tenth St.
Stamm, Allison A., Mohnton.
Stites, Thomas H. A., R. D. 3, Nazareth (Northamp-
ton Co.).
Stockier, Joseph. 249 N. Fifth St.
Taylor, S. Banks, 126 Oley St.
Wagner, Jesse L., 152 N. Sixth St.
Wagner, John R., Hamburg.
Wagner, Levi F., 610 N. Tenth St.
Wanner, Abram K., 121 N. Fourth St.
Wanner, H. Herbert. 1533 Perkiomen Ave.
Way, Leland F., Reading Hospital.
Wenger, Le Roy J., 1108 N. Eleventh St.
Wenrich, George G., Grandview Sanatorium, Wemers-
vill«.
Wenrich, John Adam, Grandview Sanatorium, Wer-
nersvillc.
Werley, Charles D., 307 S. Sixth St.
Werley, Walter W., 309 S. Sixth St.
Wheeler, Lucia Anna, State Hospital, Wemersville.
Wickert, Victor W., 1009 Penn St
Winston, Gilbert I., 344 N. Fifth St.
Womer, Frank, 216 N. Sixth St.
Ziegler, John G., Lt. C. M. C. U. S. N., U. S. N.
Hospital, Guam.
BLAIR COUNTY SOCIETY
(Organized July 25, 1848.)
(Altoona is the post office vihea street address only is
given.)
President... Albert S. Obum, 701 Seventh Avenue.
1st V.Pres.. Augustus S. Kech, 1209 Sixteenth St
2d V.Pres... David F. Glasgow, Tyrone.
Sec.-Treas...(3iarles F. McBumey, 604 Ninth St
Cor. Sec. &
Rept James S. Taylor, 1123 Twelfth Ave.
Censors James E. Smith, 410 Fourth St
Samuel L. McCarthy, 1205 Fourteenth
Ave.
W. Albert Nason, Roaring Spring.
Official Publication: Blair County Medical Bulletin.
Issued Monthly.
Editor: James S. Taylor, 1123 Twelfth Ave.
Stated meetings held in Community Hall, City
Building, Altoona, the fourth Tuesday of each mondi
except September, in which month meeting is held on
third Thursday at 3 p. m.
UEMBEKS (86)
Alleman, George E., 2314 Broad Ave.
Allen, David E., 1325 Eighth Ave.
Bliss, Gerald D., 1220 Thirteenth Ave.
Bloomhardt, Fred H., Lt. Col., Camp Benning, Ga.
Blose, Joseph U., 401 Howard Ave.
Bonebreak, John S., Martinsburg.
Brotherlin, Henry H., Hollidaysburg.
Brubaker, John L, Juniata.
Brumbaugh, Arthur S., 1405 Tenth St.
Burket, Clair W., 523 Fourth St
Calvin, Webster. 510 Allegheny St, Hollidaysburg.
Confer, D. Clarence, Duncansville.
Crawford, Luther Fleck, Tyrone.
Dandois, George F., Martinsburg.
Davies, Sarah M., 1307 Twelfth Ave.
Eldon, Roswell T., 1624 Eleventh Ave.
Findley, Joseph D., 1123 Thirteenth Ave.
Frye, J. Qarence, Williamsburg.
Galbraith, John H., 1123 Thirteenth Ave.
(5ettemy, Ralston C, 310 Fourth St
Glasgow, David Fulkerson, Tyrone.
Glover, Samuel P., 1118 Twelfth Ave.
Gracchelli, Peter, 1324 Eighth Ave.
Grounds, Wilbert L., Roaring Spring.
Haberacker, Eugene O. M., 2222 Seventh Ave.
Hair, Wilfred L., Roaring Spring.
Handwork, Andrew Jackson W., 1320 Ninth St
Harlos, William P., 1428 Twelfth Ave.
Hendricks, Charles S., 508 Second St., Juniata.
Hill is, Robert J., N. W. (>)r. Fourth Ave. and Sixtli
St., Juniata.
Hogue, John D., IW'A Thirteenth Ave.
Hoover, Ernest J., 2318 Eighth Ave.
Howell, William H., 1117 Twelfth Ave.
Hull, Logan E., 1219 Thirteenth Ave.
Isenberg, Joseph L., Blair County Hospital, Hollidays-
burg.
Johnston, Charles O., Claysburg.
Jones. Henry O., 1325J4 Twelfth Ave.
Kauffman, David, 1116 Twelfth Ave.
Keagy, Frank, 401 Fourth Ave.
Kech, Augustus Sheridan, 1209 Sixteenth St.
Levengood, Brooklyn B., Bellwood.
Loudon, Edward W., 3945 Burgoin Road.
Lowrie, William L., Tyrone.
McBumey, Charles F., 604 Ninth St.
McCarthy, Samuel L., 1205 Fourteenth Ave.
McKee, Lewis E., 1103 Thirteenth Ave.
McNaul, Caleb G., Juniata.
Magee, Richard S., 1320 Ninth St
Meminger, William H., Juniata.
Metzgar, Carl H., 1424 Twelfth Ave.
Miller. Edwin B., 1903 Seventh Ave. i
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July, 1921
MEMBERSHIP LIST
731
Miller, Homer C., 1202 Sixteenth St.
Mottitt, Harold F., 922 Seventeenth St
Montgomery, Chalmers, Box 547.
Morrow, Emory H., 1506 ThirteenA Ave.
Morrow, J. Robert, 941 Seventeenth St.
Morrow, William H., Bellwood.
Musser, Walter Scott, Tyrone.
Nason, John B., Tyrone.
Nason, W. Albert, Roaring Spring.
Neff, Elmer E., 813 Eighth Ave.
Noss, Charles W., 1118 Seventh Ave.
Obum, Albert S., 701 Seventh Ave.
Otterbein, Frederick, 324 Sixth Ave.
Pershing, Paul Frederick, 1203 Seventli Ave.
Preston, Waldo E., Hollidaysburg.
Reith, Emil, Central Trust BIdg.
Robinson, William H., Roaring Spring.
Robison, Clair E., 930 Seventeenth St.
Replogle, Henry B., 616 Fourth St.
Shultz, Charles Lytle, 3613 Woodland Ave., Phila.
(Phila. Co.).
Smith, James E., 410 Fourth St.
Snyder, Claude Edwin, 831 Sixth Ave.
Snyder, John R. T., 404 Howard Ave.
Sommer, Henry J., Jr., Blair County Hospital, Hol-
lidaysburg.
Spanogle, Albert L., 1226 Seventh Ave.
Stayer, Andrew S., Nat. Military Home, Kansas.
Stonebreaker, Samuel L., Tyrone.
Tate, George F., 26 S. Beaver St., York (York Co.).
Taylor, James S., 1107 Thirteenth Ave.
Thomas, Herbert C, 2413 Broad Ave.
Walton, Louis S., Central Trust Bldg
Watson, James G., Juniata.
West, Harry W., 1905 Eighth Ave.
Whittaker, Ralph R., Williamsburg.
Wilson, Thomas L., Bellwood.
DeWan, Charles H., Sayjc.
Down, Howard C, Towanda.
Durga, Gideon W., LeRaysville.
Everitt, John E., Sayre.
Glover, Henry A., Nichols, N. Y.
Gustin, Grant H., Sylvania.
Guthrie, Donald, Sayre.
Haines, Carlyle N., Sayre.
Haines, Charles A., Sayre.
Haines, John F., Monroeton.
Harshberger, W. Frank, New Albany.
Hawk, Cieorge W., Sayre.
Higgins, John M., Sayre.
Inslee, Fayette Lane, LeRaysville.
Johnson, Thomas B., Towanda.
Johnson, T. Benj., Jr., Towanda.
Kenyon, Charles L., Monroeton.
LaPlant, Hiram D., Sayre.
Lee, John C, Wyalusing.
Lundblad, Walter E., Sayre.
Means, Charles S., Towanda.
Moyer, Walter S., Sayre.
Parks, Arthur Lloyd, Rome.
Parsons, James W., Canton.
Person, Russell H., Burlington.
Phillips, John W., Troy.
Pratt, C. Manville, Towanda.
Pratt, D. Leonard, Towanda.
Reed, Charles, Towanda.
Rice, Frederick W., Sayre.
Schwartz, Philip H., Towanda.
Stevens, Cyrus Lee, Athens.
Sumner, Porter H., Camptown.
Terry, George H. B., Camp Meade, Md.
Weinberger, Nelson S., Sayre.
Woodbum, Charles M., Sayre.
BRADFORD COUNTY SOCIETY
(Organized Sept. 20, 1849.)
President... Philip H. Schwartz, Towanda.
1st V. Pres. .Howard C. Down, Towanda.
2d V. Pres. .Grant H. Gustin, Sylvania.
Sec.-Rept. . .Cyrus Lee Stevens, Athens.
Treasurer. . .(jharles M. Woodbum, Sayre.
Censors Grant H. Gustin, Sylvania, 1 yr.
C. Melvin Coon, Athens, 2 yrs.
Alpheus E. Dann, Canton, 3 yrs.
Committee on Public Health Legislation:
Donald Guthrie. Sayre.
Mahlon B. Ballard, Troy.
Cyrus Lee Stevens, Athens.
Exec. Com. .. Philip H. Schwartz, Towanda.
Cyrus Lee Stevens, Athens.
John M. Higgins, Sayre.
Stated meetings the second Tuesday of each month
at 1 :30 p. m., in the Court House, Towanda, unless
otherwise ordered. Election of officers in January.
MEMBERS (51)
Badger, Samuel W., Athens.
Ballard, Mahlon B., Troy.
Barker, Perley N., Troy.
Bevan, Daniel L., Leroy.
Bird, Arthur J., New Albany.
Boyer, George E., Troy.
Campbell, William R., East Smithficld.
Carpenter, Philo S., Laquin.
Chamberlain, John W., Wyalusing.
Conklin, Gustavus, Orwell.
Coon, C. Melvin, Athens.
Coughlin. Alfred G., Athens.
Daly, John Edward, Ulster.
Dann, Alpheus E., Canton.
Davison, Willis T., Canton.
BUCKS COUNTY SOCIETY
(Organized June 14, 1848. Reorganized Oct. 31, 1862.)
President.. .Frank Lehman, Bristol.
1st V. Pres.. John J. Sweeney, Doylestown.
2d V. Pres... Herman C. Grim, Trumbauersville.
Sec.-Treas.
&Rept.... Anthony F. Myers, Blooming Glen.
Censors Geo. M. Grim, Ottsville.
Wm. R. Cooper, Point Pleasant.
Howard Pursell, Bristol.
Committee on Public Policy and Legislation:
James F. Wagner, Bristol.
Chas. B. Smith, Newtowrn.
Alfred E. Fretz, Sellersville.
Official Publication: Bucks County Monthly.
Issued Monthly.
Editor: Anthony F. Myers, Blooming Glen.
Stated meetings at 12 m., the second Wednesday in
February at Newton; in May at Bristol; in Augtist at
Quakertown ; in November at Doylestown. Election of
officers in November.
MEMBERS (81)
Abbott, Charles Shewell, 705 Radcliffe St., Bristol.
Abbott, Joseph de Benneville, Bristol.
Althouse, Albert C, Dublin.
Bassett, Henry Linn, Yardley.
Biehn, Andrew C, Quakertown.
Boring, H. Bruce, Richlandtown.
Brewer, George N., Plumsteadville.
Brown, Walter H., c/o Rockefeller Foundation, 3
Rue de Berri, Paris, France.
Burkhardt, (Hiarles N., Chalfont.
Bush, Irvine M., 339 Dorrance St., Bristol.
Carrell, Tohn B., Hatboro (Montgomery Co.).
Collins, James, 557 Bath St., Bristol.
Cooper, William R., Point Pleasant.
Cope, F. Gumey, Upper Black Eddy.
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THE PENNSYLVANIA MEDICAL JOURNAL
July, 1921
Crater, John Simpson, 563 Bath St., Bristol.
Crewitt, John A., Newtown.
Crouthamel, Joseph F., Souderton' (Montgomery Co.).
bjiton, George A., Morrisville.
Erdman, William S., Buckingham.
Erdman, Wilson S., Uuakertown.
t'eigley, Harvey P., (Juakertown.
Fell, John A., Doylestown.
Fleckenstme, Horace, Newportville.
Fox, George T., 303 Radcliffe St., Bristol.
Fretz, Ahred E., Sellersville.
Fretz, Clayton D., Sellersville.
Fretz, Oliver H., Quakertown.
Fretz,. S. Edward, Box 15, Whitestone, L. I., N. Y. C.
Grim, George M., Ottsville.
Grim, Herman C, Trumbauersville.
Hellyer, Howard A., Penns Park.
Hennigh, George B., Perkasie.
Hutf, Irwin F., Sellersville.
Huntsman, Edwin S., Hulmeville.
Johnson, Erwin T., Hilltown.
Jourdan, Victor J. P., 229 Washington Ave., Bristol.
Klenk, James M., TuUytown,
Kline, Horace F., Frederick, Md.
LeCompte, William C, 430 Radcliffe St., Bristol.
Lehman, Frank, 320 Radcliffe St., Bristol.
Leinbach, Samuel A., Quakertown.
Lovett, Henry, Langhome.
MacKenzie, Arthur L., Eddington.
Mcllhatten, Samuel Patterson, Ivyland.
Magill, Roscoe C, Newhope.
Moyer, William G., Quakertown.
Murphy, Felix A., Doylestown.
Myers, Anthony F., Blooming Glen.
O'Connell, Austin, Bucksville.
Osborne, Richard H. G., 2227 Lincoln Way, San Fran-
cisco, California.
Packer, Jesse E., Newtown.
Parker, George A., Jr., Newtown.
Paulus, Clarence A., Telford.
Peters, Byron M., Jenkintown (Montgomery Co.).
Plymire, L SwarU, 338 S. Lawrence St., Phila. (Phila.
Co.).
Pownall, Elmer E., Richboro.
Pursell, Howard, 200 Mill St., Bristol.
Rich, Edward Y., Marietta (Lancaster Co.).
Richards, James N., Fallsington.
Ridg«, Samuel LeRoy, Langhome.
Scott, J. Ernest, Newhope.
Smith, Charles B., Newtown.
Smith, Edwin L., Hatboro (Montgomery Co.).
Stoumen, Samuel, Springtown.
Strouse, Otto H., Perkasie.
Swartzlander, Frank B., Doylestown.
Swartzlander, Joseph R., Doylestown.
Sweeney, John J., Doylestown.
Thomas, Harry L., Langhome.
Wagner, James, 431 Radcliffe St., Bristol.
Walter, Charles A., Glenside (Montgomery Co.).
Walter, J. Willis, Point Pleasant.
Walton, Levi S., Jenkintown (Montgomery Co.).
Wareham, Arthur, Morrisville.
Watson, Franklin, Willow Grove.
Webb. Harvey D., Bristol.
Weierbach, John A., Quakertown.
Weisel, William F., Quakertown.
Wilkinson, William T., Sellersville.
W^illiams, Neri B., Perkasie.
Windber, I..awrence J., Andalusia.
2d V.Pres... Willis A. McCall, 215 S. Main St
Sec.-Rept L. Leo Doane, Reiter Bldg.
Treasurer... M. Edward Headland, 216 Center Ave.
Librarian... Robert B. Greer, 371 N. Main St.
Censors William B. Clark, 135 S. Main St
James B. Christie, Petersville.
Ephraim E. Campbell, Butler.
Committee on Public Policy and Legislation:
J. Clinton Atwell, 315 N. Main St .
Elgie L. Wasson, Co. Natl. Bank Bldg.
Stated meetings in the University Club Rooms,
Campbell Building, Butler, the second Tuesday in each
month at 8 :30 p. m. Election of officers in January.
MEMBERS (49) .
Allison, Robert L., E^u Claire.
Atwell, J. Clinton, 315 N. Main St.
Beatty, George M., Chicora.
Boyle, James C, 121 E. Cunningham St.
Brandberg, Guy A., 358 Center Ave.
Campbell, Ephraim E., Ill S. Main St.
Campbell, John S., Portersville.
Campbell, William B., Prospect.
Christie, James L., Petersville.
Clark, William B., 135 S. Main St.
Cowden, John V., 228 S. Main St.
DeLong, Francis E., Boyers.
De Wolfe, Charles L., Ciiicora.
Doane, L. Leo, Reiter Bldg.
Dombart, Nicholas A., Evans City.
Dunkle, John M., 119 Diamond St., E.
Klrick, Robert B., Petrolia.
Fulton, Samuel R., Harrisville.
Greer, Robert B., 371 N. Main St
Grossman, Robert J., 408 Center Ave.
Grossman, William J., 312 W. Jefferson St.
Hazlett, Leslie R., Box 643.
Headland, M. Edward, 216 Center Ave.
Heilman, Arthur M., 330 N. Main St.
Hockenberry, W. Rush, Slippenr Rock.
Imbrie, Qarence E., 327 N. Main St.
Lasher, Weston W., Saxonburg.
McCall, Willis A., 215 S. Main St
McCandless, Dwight L., 141^ S. Main St
Maxwell, Thomas McCullough, W. Cunningham St.
Mer'shon, Edwin U. B.. Saxonburg.
Padilla, Alfonso M., 315 N. Main St
Purvis, Joseph D., 128 S. Main St.
Quigley, James E., Butler.
Robb, Claude A., 138 N. Main St
Scott William McC, Marwood.
Stackpole, Ray L., Reiter Bldg.
St. Clair, Harry P., 213 S. Main St.
St. Clair, Mary P. Brooke, 128 S. Main St
Simpson, Egbert R., 213'4 S. Main St
Stepp, Lawrence H., Mars.
Stewart, Arthur I., Harmony.
Thompson, Raymond A., 110 S. Main St
Walker, Ralph, Main and Diamond St.
Wasson, Elgie L., Co. Natl. Bank Bldg.
Williams, Olin A., 128 S. Main St.
Wilson, Harry M., Evans City.
Young, Clinton M., Queens Junction.
Ziegler, Alfred Henry, 112 Washington St.
BUTLER COUNTY SOCIETY
(Organized Jan. 3, 1867.)
(Butler is the post office when street address only is
given.)
President... Alfred H. Ziegler, 112 Washington St
1st V.Pres.. John V. Cowden, 228 S. Main .St
CAMBRIA COUNTY SOCIETY
(Organized 1852. Reorganized 1868 and 1882.)
(Johnstown is the post office when street address only
is given.)
President... Olin G. A. Barker, 804 Johnstown Trust
Building.
I St V.Pres.. Thomas E. Mendenhall. "The Rocks."
2d V.Pres... Daniel S. Rice, Ebensburg.
Sec-Trcas.. T. Walter Bancroft, 410 Lincoln St
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July. 1921
MEMBERSHIP LIST
733
Censors Harry J. Cartin, 331 Lincoln St.
Guy R. Anderson, Bamesboro.
Sylvester S. Kring, Johnstown Trust
Building.
Couiinittee on Public Policy and Legislation:
Harry M. Stewart, 406 Main St.
Jacob D. Keiper, First Nat. Bank Bldg.
Edward Pardee, South Fork.
Committee on Health and Public Instruction:
Henson F. Tomb, 132 Jackson St
William E. Grove, 181 Fairfield Ave.
Frank U. Ferguson, Gallitzin.
Program and Elxecutive Committee:
Olin A. G. Barker, 804 Johnstown Trust
Building.
J. Walter Bancroft, 410 Lincoln St.
William O. Lubken, Vine and Franklin
Sts.
Official Publication: The Medical Comment.
Issued Monthly.
Editor : Joseph J. Meyer, 425 Lincoln St.
Stated meetings every second Thursday at 8 :30 p. ni.,
at Chamber of Commerce Rooms, Fort Stanwix Hotel,
Johnstown. Officers elected in December and installed
ill January.
MEMBERS (120)
Anderson, Guy R., Bamesboro.
Baback, Martin E., 123 Broaid St.
Bancroft, John Walter, 410 Lincoln St.
Barbouhr, Michael A., 130J^ Market St
Backer, Olin G. A., 804 Johnstown Trust Bldg.
Bamett, George W., 414 Lincoln St.
Barr, John W., Nanty Glo.
Basil, Arthur A., 219 Market St.
' Beatty, Arthur W., Colver.
Bennett, Harry J., Ebensburg.
Benshoff, Arthur M., 506 Thirteenth St., Windber
(Somerset Co.).
Bergstein, Alfred M., Gallitzin.
Bishop, Frank G., Ebensburg.
Blair, Walter A., Spangler.
Bowers, Benjamin F., St. Benedict
Bowman, Kent A., 223 Market St.
Boyer, Edwin C, 244 Market St.
Brallier, Stanley A. E., 312 Green St., Conemaugh.
Braude, Bennett A., 338 Locust St
Brinham, Alfred W., Scalp Level.
Burkhart, Ephraim J., 189 Fairfield Ave.
Buzzard, Josiah F., Portage.
Cartin, Harry J., 331 Lincoln St.
Clayboume, Moses, 364 Bedford St
Cleaver, Philip R., Johnstown Trust Bldg.
Conrad, Earl K., 514 Franklin St.
Cowen, Melvin E., Sanitarium, Cresson.
Curtis, Kim D., Revloc.
Custer, Charles C, State Sanatorium, Cresson.
Davis, Robert C, 413 Locust St.
Davison, Seward R., 225 Market St.
Dickinson, E. Pope, St. Michael.
Difenderfer, Herman G., Beaverdale.
Donlan, Francis A., Lilly.
Dunnick, Milton C, Nanty Glo.
Dunsmore, Albert F., Bamesboro.
Ealy, Edwin T., Bamesboro.
Fcrjfuson, Frank U., Gallitzin.
Fichtner, Albon Ellsworth, First St., Conemaugh.
Fichtner, Albon S., 119 F St
Fisher, Daniel E., Necdmore (Fulton Co.).
Fitzgerald. Clyde A., South Fork.
Garman, Harry F., Emeigh.
Gearhart, Sylvester C, Blandburg.
George, William J., 305 Pine St
Ginsburg, Louis, 435 Franklin St.
Griffith, Harvey M., 431 First St., Conemaugh.
Griffith, William S., 600 Franklin St.
Grove, William E.. 181 Fairfield Ave.
Gurley, Lycurgus M., City Hall Sq.
Harman, Charles E., 531 Locust St.
Harris, Clarence M., 604 Johnstown Trust Bldg.
Hay, George, 444 Lincoln St
Hays, Charles Elliott, Johnstown Trust Bldg.
Healey, Bernard C, Bamesboro.
Helfrick, T., Orlando, Spangler.
Helsel, William L., Scalp Level.
Hill, Homer L., 1311 Franklin St
Homick, Leo W., 536 Vine St
Horowitz, Max, 402 Broad St
JeflEerson, James, 415 Locust St.
Jones, Emlyn, 207}^ Market St.
Jones, Leighton Wherry, 434 Lincoln St
Keflfer, Winter O., Frugality.
Keiper, Jacob D., First Nat. Bank Bldg.
Kress, Frederick C, 436 Franklin St.
Kring, Sylvester S., Johnstown Trust Bldg.
Krumbine, George W., Asheville.
Leech, A. Wallace, Beaverdale.
Livingston, Frank J., Salix.
Longwell, Benton Elkins, 441 Locust St.
Lowman, John Bodine, 114 Market St.
Lubken, William Oscar, Vine and Franklin Sts.
Lynch, James A., Cresson.
McAneny, John B., USyi Broad St
McCoy, Clayton L., Hastings.
Martin, George, 445 First St., Conemaugh.
Matthews, William E., 425 Lincoln St.
Mayer, Louis H., Jr., 228 Market St
Mayer, William F., 228 Market St
Mendenhall, Thomas E., "The Rocks."
Meyer, Joseph J., 425 Lincoln St.
Miller, Harry H., 245 Ohio St.
Millhoff, Clarence B., 627 Franklin St.
Miltenberger, Arthur, 248 Market St.
Monahan, James J., Johnstown Trust Bldg.
Nickel, Harry G., Farmers T. and M. Bldg.
O'Connor, James Joseph, 706 Hemlock St., Gallitzin.
Pardoe, Edward, South Fork.
Parker, Ray, Ehrenfeld.
Penrod, Harry Hartzell, 409 Vine St.
Porch, Latchaw Lynn, 221 Broad St
Powelton, Darwin T., 541 Vine St
Prideaux, Harry T., Cresson.
Prideaux, William A., Expedit
Pringle, William N., 413 Locust St
Ray, Daniel Pattee, 441 Vine St.
Raymond, Walter C, 303 Bedford St
Reddy, William J., 115^ Broad St
Repk>gle, JosejA P., Porch Bldg.
Rice, Daniel, Ebensburg.
Ru^, Calvin C, 342 Main St.
Sagerson, John Leo, 431 Lincoln St.
Sagerson, Robert J., 340 Lincoln St
Salus, Henry W., 420 Franklin St,
Scharmann, Frank G., 411 Main St.
Srhill, Francis, 111 Jackson St. ,
Schilling, Francis M., 923 Second Ave., Westmount,
Johnstown.
Schultz, Merritt B., 600 Park Ave.
Shank, Orlando J., Windber.
Sloan, Ira E., Main and Franklin Sts.
Somerville, Harry, Chest Springs.
Spicher, Clarence C, 566 Park Ave.
Stayer, Maurice, 267 Fairfield St.
Stewart, Harry Myrrell, 406 Main St.
Taylor, J. Swan, 408 Franklin St.
Tomb, Henson F., 132 Jackson St.
Turnbull, William G., Cresson.
Wheeling, William S., Windber (Somerset Co.).
Woodroff, John B., Vine and Market Sts.
CARBON COUNTY SOCIETY
(Organized April 20, 1881.)
President. . .John K. Henry, Mauch Chunk.
1st V.Pres.. Edward F. Eshleman, Palmerton.
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2d V. Pres... Jacob H. Behler, Nesquehoning.
Sec.-Treas.. .Jacob A. Trexler, Lehighton.
Censors Charles T. Horn, Lehighton.
Jacob H. Behler, Nesquehoning.
David F. Dreibelbis, Lehighton.
Stated meetings are held at Mauch Chunk and Le-
highton the third Wednesday at 3 p. m., of January,
March, May, July, September and November. Elec-
tion of officers in November.
MEMBERS (29)
Armstrong, Alexander, White Haven (Luzerne Co.).
Balliet, Calvin J., Lehighton.
Batchelor, Roger P., Palmerton.
Behler, Jacob H., Nesquehoning.
Bellas, Joseph J., Lansford.
Bray, Edward G., E^st Mauch Chunk.
Christman, Robert A., Weissport.
Dreibelbis, David F., Lehighton.
Druckenmiller, Stanley F., Lansford.
Eshleman, Edward F., Palmerton.
Freyman, Ira E., Weatherly.
Haberman, Charles P., Weissport.
Henry, John K., Mauch Chunk.
Hoffmeier, Howard T., Mauch Chunk.
Horn, Charles T., Lehighton.
Kasten, William H., Lansford.
Kistler, Clinton J., Lehighton.
Kistler, Edwin H., Lansford.
Kistler, Robert N., Lansford.
Long, Wilson P., Weatherly.
McDonald, John J., Nesquehoning.
Quinn, John J., I^sford.
Rupp, Roger R., Lehighton.
Sittler, Albert M., Bowmanstown.
Sittler, Warren C., Lehighton, R.
Trexler, Jacob A., Lehighton.
Wasser, John E., East Mauch Chunk.
Young, J. Harrington, Lansford.
Zern, Jacob G., Lehighton.
D. I.
CENTER COUNTY SOCIETY
(Organized April 4, 1876.)
President... Joseph P. Ritenour, State College.
1st V. Pres.. Harold H. Longwell, Center Hall.
2d V. Pres... James C. Rogers, Belief onte.
Sec.-Treas.. Mel vin Locke, Beliefonte.
Reporter James L. Seibert, Beliefonte.
Committee on Public Policy and Legislation:
David Dale, Beliefonte.
Melvin Locke, Beliefonte.
Marvin W. Reed, Beliefonte.
Censors Harvey S. Braueht, Spring Mills.
Peter H. Dale, State College.
James R. Bartlett, Beliefonte.
Stated meetings the second Wednesday of each
month at 10:30 a. m., in the Court House, Beliefonte.
Election of officers in January.
MEMBERS (28)
Allison, John R. G., Millheim.
Bartlett, James R., R. F. D., Beliefonte.
Braueht, Harvey S., Spring Mills.
BrockerhofF, Joseph M., Beliefonte.
Dale, David, Beliefonte.
Dale, Peter HofTer, State College.
Foster, John V., State College.
Frank, George S., Millheim.
Glenn, Grover Cleveland, State College.
Glenn, William S., State College.
Glenn, William S., Jr., State College.
Harris, Edward H., Snow Shoe.
Irwin, William U., Beliefonte.
Kidder, Lincoln E., State College.
Kurtz, Walter J., Howard.
Locke, Melvin, Beliefonte.
Longwell, Harold H., Center Hall.
McEntire, Oscar W., Howard.
Musser, C. Sumner, Aaronsburg.
Reed, Marvin W., Beliefonte.
Ritenour. Joseph P., State College.
Rogers, James C, Beliefonte.
Russell, Edward A., Fleming.
Sebring, John, Beliefonte.
Seibert, James L., Beliefonte.
Woods, George H., Pine Grove Mills.
Yearick, George T., Center Hall.
Young, Robert J., Snow Shoe.
CHESTER COUNTY SOCIETY
(Organized Feb. 5, 1828.)
President... Willis N. Smith, Phoenixville.
1st V. Pres.. W. Wellington Woodward, West Chester.
2d V. Pres... Jackson Taylor, Coatesville.
Sec.-Treas... Joseph Scattergood, West Chester.
Reporter — Henry Pleasants, Jr., West Chester.
Censors Edward Kerr, East Downingtown.
S. Horace Scott, Coatesville.
Charles E. Woodward, West Chester.
Committee on Public Health Legislation:
John A. Farrell, West Chester.
Edward Kerr, East Downingtown.
Joseph Scattergood, West Chester.
Exec. Com. .Willis N. Smith, Phoenixville.
Howard Y. Pennell, East Downingtown.
Joseph Scattergood, West Chester.
Official Publication: The Medical Reporter.
Issued Monthly.
Editor: William T. Sharpless, West Chester.
Stated meetings at 3:15 p. m. on the third Tuesday
of each month at West Chester. Election of officers
in January.
MEMBERS (74)
Aiken, Thomas Gerald, Berwyn.
Baker, Fred L., Army Res. Dep., New Cumberland.
Betts, William W., Oiadds Ford (Delaware Co.).
Bremerman, Laban T., Downingtown.
Brower, Charles J., Spring City.
Bullock, Charles C, West Chester.
Carey, Robert B., Glenlock.
Cassel, Wilbur F., Spring City.
Catanach, Norman G., West Chester.
Cressman, George S., Pughtown, R. D., Spring City.
Davis, Howard B., Downingtown.
Davis, John H., Coatesville.
Dietterich, Charles D., R. D. 3, Pottstown.
Dietrich, George E., Coatesville.
Elhringer, Qyde E., West Chester.
Evans, John K., Malvern.
Ewing, William B., West Grove.
Farrell, John A., West Chester.
Francis, William G., Coatesville.
GifFord, U. Grant, Kennett Square.
Greenfield, William, Chester Coimty Hospital, West
Chester.
Hamilton, William L., Malvern.
Hammers, James S., Embreeville.
Heagey, Henry F. C., Cochranville.
Hemphill, Joseph, Jr., West Chester.
Hughes, Robert C., Paoli.
Hutchinson, D. Edgar, East Downingtown.
Jacobs, Francis B., 102 S. High St., West Chester.
Johnson, J. Huston, Glen Moore.
Kerr, Ejdward, East Downingtown.
Keylor, Josiah B., Cochranville.
Klevan, Oscar Jesse, 212 West Miner St., West Ches-
ter.
Kurtz, Qarence S., Malvern.
McKinstry, Herbert S., Kennett Square.
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Magraw, George T., Avondale.
Margolies, Michael, Coatesville.
Maxwell, James Rea, Parkesburg.
Mellor, Howard, West Chester, R. D.
Merrycnan, John W., Kennett Square.
Murphy, Walter A., Parkesburg.
Patrick, EUwood, West Oiester.
Patrick, Jesse K., West Chester.
Pennell, Howard Y., East Downingtown.
Perdue, William R., West Chester, R. D. 5.
Perkins, J. Ashbridge, Coatesville.
Pleasants, Henry, Jr., West Chester.
Reeder, Jeremiah V., Phoenixville.
Rettew, David P., 323 E. Chestnut St., Coatesvine.
Reynolds, Duer, Kennett Square.
Richmond, Thomas S., Guthriesville.
Rothrock, Harry A., West Chester.
Rothrock, Josejji T., West Chester.
Rulon, Samuel A., Plioenixville.
Scattcrgood, Jose^, West Chester.
Scott, J. Clifford, Oakboume.
Scott, S. Horace, Coatesville.
Sharpless, William T., West Chester.
Smith, Harry T., Elverson.
Smith, Mary H., Parkesburg.
Smith, Willis N., Phoenixville.
Spangler, John L., Devon.
Stone, Charles H., Coatesville.
Taylor, Jackson, Coatesville.
Taylor, James T., Pomeroy.
Thomas, John G., Newtown Square (Delaware Co.).
Walker, James B., Mendenhall.
Warren, B. Harry, West Chester.
Webb, Walter, West Chester.
Wells, Frank H., Chester Springs.
West, Frederick B., Kemblesville.
Wherry, C. Norwood, 738 Walnut St., Columbia (Lan-
caster Co.).
Williams, Delia Hannah, Berwyn.
Woodward, Charles E., West Chester,
Woodward, W. Wellington, West Chester.
CLARION COUNTY SOCIETY
(Organized May S, 186S.)
President. ..James M. Hess, Tylersburg.
V. Pres Charles V. Hepler, New Bethlehem.
Secretary. . .Charles C. Ross, (Clarion.
Treasurer... Benjamin G. Wilson, Clarion.
Reporter — Sylvester J. Lackey, Clarion.
Censors Albert J. Hepler, New Bethlehem.
George B. Woods, Curllsville.
Prog. Com.. Benjamin G. Wilson, Clarion.
John T. Rimer, Clarion.
Committee on Public Policy and Legislation :
Albert J. Hepler, New Bethlehem.
George B. Woods, Curllsville.
William C. Keller, New Bethlehem.
Stated meetings at selected places the fourth Tuesday
in April, July and October. Annual meeting at Clarion
the fourth Tuesday of January.
MEMBERS (31)
Aaronoff, Joseph, Shippensville.
Booth, Fred K., 302 Corbet St., Tarcntum (Allegheny
Co.).
Camp, John N., Foxburg.
Qover, Cuvier L., Knox.
Dillenbeck, Charles O., Strattonville.
Fitzgerald, Charles A., Clarion.
Harter, Thomas H., East Brady.
Hepler, Albert J., New Bethlehem.
Hepler, CHiarles Verne, New Bethlehem.
Hess, Henry N., Fryburg.
Hess, James M., Tylersburg.
Hoffman, Charles W., Rimersburg.
Hoover, Albert M., Parkers Landing (Armstrong Co.).
Huston, Charles C, Knox.
Kahle, I. Dana, Knox.
Kahle, Harold H., Leeper.
Keller, William C, New Bethlehem.
Lackey, Sylvester J., Clarion.
McAninch, David Lewis, Lamartine.
Meals, Nelson M., Callensburg.
Miller, John B., Sligo.
Phillips, Franklin Pierce, Box 555, Franklin, Pa.^
Rimer, John T., Qarion.
Ross, Charles C, Garion.
Sayers, Clement E., Hawthorn.
Stute, John E., Parkers Landing (Armstrong Co.).
Summerville, John F., Monroe.
Walker, Byron P., West Monterey.
Wellman, Harrison M., St. Petersburg.
Wilson, Benjamin G., Clarion.
Woods, George B., Curllsville.
CLEARFIELD COUNTY SOCIETY
(Organized Sept. 27, 1864. Chartered May 8, 1894.)
(Clearfield is the post office when street address only is
given.)
President. . .Luther W. Quinn, Dubois.
1st V. Pres.. Austin C. Lynn, 122 Presqueisle St.,
Philipsburg (Center Co.).
2d V. Pres.. .Michael C. Dinger, Morrisdale.
Secretary.,. John M. Quigley, 922 Dorey St.
Treasurer... Ward O. Wilson, 210 N. Second St.
Ed. Rept J. Hayes Woolridge, Cor. Third and Mar-
ket Sts.
Censors George B. Kirk, Kylerstown.
Samuel D. Bailey, 119 Walnut St.
J. Frank Rowles, Mahaffey.
Committee on Public Policy and Legislation:
Samuel J. Waterworth, 102 S. Second St.
William B. Henderson, Philipsburg (Cen-
ter Co.).
Lever F. Stewart, 108 N. Second St.
Exec. Com. . Luther W. Quinn, Dubois.
J. M. Quigley, Clearfield.
William E. Reiley, 8 Turnpike Ave.
Official Publication: Clearfield County Medical Society
Bulletin.
Issued Monthly.
Editor: J. Hayes Woolridge, Cor. Third and
Market Sts.
Stated meetings second Wednesday of -each month at
various places in the coimty. Election of officers in
January.
MEMBERS (59)
Andrews, Warren W., Philipsburg (Center Co.).
Bailey, Samuel D., 119 Walnut St.
Baker, George E., Houtzdale.
Brockbank, John I., Dubois.
Browne, William C, Bumside.
Comely, James M., Madera.
Cowdrick, Arthur D., 108 N. Second St.
Dale, John, Philipsburg (Center Co.).
Derick, Alma Read, Bellwood (Blair Co.).
Dinger, Michael C, Morrisdale.
Erhard, Elmer S., New Millport.
Falconer, William G., Olanta, R. D. (P. O.).
Flegal, Irwin Scott, Karthaus.
Frantz, J. Paul, 213 N. Second St.
Gann, George Willard, 42 W. Long Ave.. Dubois.
Ginter, James E., McEwen Bldg., Dubois.
Gordon, John W., 206 Locust St.
Harman, L. Cooper, Philipsburg (Center Co.).
Harper, Francis Watts, Irvona.
Hayes, Senes E., Brynedale (Elk Co.).
Henderson, James L., Osceola Mills (Life Member).
Henderson, William B., Philipsburg (Center Co.).
Henritzy, Oscar E., Winburne.
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Houck, Earl E., Dubois.
Houck, Willis A., Dubois.
Hurd, Michael W. MahafFey.
Jackson, Robert, Osceola Mills.
Jenkins, George C, 702-706 State St., Curwensville.
Jones, Evan L., Philipsburg (Center Co.).
Kirk, George B., Kylertown.
Lewis, Homer H., Surveyor.
Lynn, Austin C, 122 Presqueisle St., Philipsburg (Cen-
ter Co.).
McGirk, Charles E., Philipsburg (Center Co.).
Mauk, George Edmund, Woodland.
Miller, Frank Klare, Madera.
Miller, James A., Grampian.
Miller, Summerfield J., Madera.
Morris, Samuel J., Houtzdale.
Patterson, Floyd G., Box 411, Dubois.
Piper, William S., 210 N. Second St.
Quigley, John M., 922 Dorey St.
Quinn, Luther W., Box 273, Dubois.
Reiley, William E., 8 Turnpike Ave.
Ricketts, George Allen, Osceola Mills.
Rowles, J. Frank, Mahaffey.
Rowles, Lewis C, 200 N. Second St.
Shivery, George B., Woodland.
Stalberg, Isaac, Furnace Run (Armstrong Co.).
Stalberg, Samuel, Boardman.
Stewart, Lever F., 108 N. Second St.
Sullivan, John C, Dubois.
Thompson, Harry H., Philipsburg (Center Co.).
Waterworth, Samuel J., 102 S. Second St.'
Williams, Richard Lloyd, Houtzdale.
Wilson, Ward O., 210 N. Second St.
Woodside, Harry A., 112 S. Second St.
Woodside, Horatio L., Bigler.
Woolridge, J. Hayes, Cor. Third and Market Sts.
Yeaney, Gillespie B., Ill S. Second St.
Tibbins, Perry McDowell, Beech Creek.
Watson, Robert B.; Lock Haven.
Welliver, William E., Lock Haven.
CLINTON COUNTY SOCIETY
(Organized 1866. Reorganized 1883.)
President. . .Edwin C. Blackburn, Lock Haven.
V. Pres Marsden D. Campbell, Logantown.
Sec.-Treas. . . Robert B. Watson, Lock Haven.
Censors Perry McDowell Tibbins, Beech Creek.
Say lor J. Mc(ihee, Lock Haven.
Allen B. Painter, Mill Hall.
Committee on Public Policy and Legislation:
John B. Critchfield, Lock Haven.
Itobert B. Watson, Lock Haven.
Stated meetings in Lock Haven Hospital the fourth
Friday of each month at 8 p. m. Election of officers
in January.
MEMBERS (25)
Blackburn, Mwin C, Lock Haven.
Campbell, Marsden D., Logantown.
Corson, Joseph M., Hughesville (Lycoming Co.).
Critchfield, John B., Lock Haven.
Dwyer, Francis P., Renovo.
Fulmer, Charles L., Renovo.
Green, George D., Lock Haven.
Harshberger, Joseph W., Lamar.
Holloway, Luther M., Salona.
Kirk, Clair B., Mill Hall.
Liken, Loyal L., Smithmill (Qearfield Co.).
Lubrecht, James Louis, Lock Haven.
McGhee, Saylor J., 214 W. Main St., Ix)ck Haven.
Mervine, Graydon D., 204 W. Main St., Lock Haven.
Painter, Allen B., Mill Hall.
Roach, Thomas E., Renovo.
Rosser, Orrin H., Renovo.
Rothrock, Donald M., Bitumen.
Shoemaker, William J., Lock Haven.
Teah, Theodore E., 103 W. Main St., Lock Haven.
Thomas, David W., Lock Haven.
Tibbins, Joseph E., Beech Creek.
COLUMBIA COUNTY SOCIETY
(Organized June 31, 1858.)
President... Charles B. Yost, Bloomsburg.
1st V. Pres.. Martin W. Freas, Berwick.
2d V. Pres... Clark S. Long, Benton.
Sec.-Treas... Luther B. Kline, Catawissa.
Librarian... John W. Bruner, Bloomsburg.
Censors James R. Montgomery, Bloomsburg.
Edward L. Davis, Berwick.
Frank R. Clark, Berwick.
Committee on Public Policy and Legislation :
John W. Bruner, Bloomsburg.
J. Marion Vastine, Catawissa.
Harry S. Buckingham, Berwick.
Sci. Prog.... William C. Hensyl, Berwick.
Heister V. Hower, Berwick.
Edwin A. Glen, Berwick.
Official Publication: The Roster.
Issued Monthly.
Editor: Luther B. Kline, Catawissa.
Stated meetings second Thursday of each month, at
Bloomsburg, in March, Jinie, September and Decem-
ber; at Berwick in February, May, August and No-
vember; at Catawissa in January, April and October;
at Benton in July. Election of officers in December.
MEMBERS (47)
Albertson, Charles K., Benton.
Alleman, Emanuel A., Berwick.
Altmiller, Charles F., Bloomsburg.
Arinent, Samuel B., Bloomsburg.
Bierman, Henry, 38 W. Fourth St., Bloomsburg.
Brobst, Jacob R., Bloomsburg.
Brown, J. Jordan, Bloomsburg.
Bruner, John W., Bloomsburg.
Buckingham, Harry S., Berwick.
Carl, Allen Vincent, Numidia.
Christian, Howard S., Millville.
Clark, Frank R., Berwick.
Cohen, Joseph, Berwick.
Davis, Edward L., Berwick.
Davis, Reuben O., Berwick.
Drum, George F., Mifflinville.
FoUmer, George Elmer, Bloomsburg.
Freas, Martin W., Berwick.
Gemmill, James R., Millville.
Gemmill, John Michael, Belle Vernon (Fayette Co.).
Glenn, Edwin A., Berwick.
Gordner, Jesse W., Jerseytown.
Harter, Theodore C., Bloomsburg.
Hensyl, William C, Berwick.
Hower, Heister V., Berwick.
Hughes, Willet P., Bloomsburg.
John, J. Stacey, Bloomsburg.
Kline, Luther B., Catawissa.
Long, Qark S., Benton.
Macdonald, John T., Bloomsburg.
McHenry, Donald B., Orangeville.
Miller, Ralph E., Bloomsburg.
Montgomery, James R., Jr., Bloomsburg.
Montgomery, James R., Sr., Bloomsburg.
Patterson, Isaac E., Benton.
Pfahler, j. Fred., Berwick.
Robbins, Qifton Z., Bloomsburg.
Sharpless, Benjamin F., Catawissa.
Shuman, Ambrose, Catawissa.
Shuman, J. Elmer, Bloomsburg.
Steck, Charles T., Berwick.
Vastine, J. Marion, Catawissa.
Warntz, Ralph E., Nescopeck (Luzerne Co.).
Wear, Roland F., Berwick.
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Winterstecn, John C, Bloomsburg.
Wolf, Isaac R., Espy.
Yost, Charles B., Bloomsburg.
CRAWFORD COUNTY SOCIETY
(Organized 1867.)
President. . .R. Bruce Gamble, Meadville.
1st V.Pres.. William W. Shaffer, Meadville.
2d V. Pres...John L. Axtell, Cochranton.
Sec., Treas.
&Rept.... Cornelius C. Lafler, Meadville.
Censors Margaret B. Best, Meadville.
William H. Quay, jr., Townville.
J. Charles McFate, Meadville.
Committee on Public Policy and Legislation:
Oliver H. Jackson, Meadville.
J. Russell Mosier, R. D. 2, Meadville.
William G. Johnston, Titusville.
Walter H. Cowan, Saegerstown, R. D. 3.
Sylvester F. Hazen, Hartstown.
Official Publication: The Bulletin.
Issued Monthly.
Editor: Cornelius C. Laffer, Meadville.
Stated meetings the first Wednesday of each month,
except July, at 1:30 p. m., in the Chamber of Com-
merce, Meadville. Election of officers in January.
MEMBERS (54)
Axtell, John L., Cochranton.
Brophy, Edwin E., Meadville.
Brush, Harry I.,, Conneaut Lake,
Campbell, Mary M., Meadville.
Clark, Robert W., Venango.
Qawson, Frank A., Meadville.
Clouse, Ame Wilbur, Geneva.
Cowan, Walter H., Harmonsburg.
Daniels, Henry M., R. F. D. 1, Venango.
Dickey, Samuel J., Conneautville.
Eiler, V. Burton, Titusville.
Ferer, Charles K., Meadville.
Gamble, R. Bruce, Meadville.
Gamble, William M., Little Cooley.
Greenfield, Robert N., Penn Line.
Hamaker, Winters D., Hollywood Blvd., Los Angeles,
California.
Hayward, George Ernest, Meadville.
Hazen, Carl M., Titusville.
Hazen, Sylvester F., Hartstown.
Hildred, Herbert Howard, Titusville.
Hill, Clarence- C, Meadville.
Humphrey, Glennis E., Cambridge Springs.
Hyskell, William E., Meadville.
Jackson, Oliver H., Meadville.
Jameson, Hugh, Titusville.
Johnston, William G., Titusville.
LaflFer, Cornelius C, Meadville.
Lewis, Frank L., Atlantic.
Little, Theodore A., 259 E. Fifth St., Erie (Erie Co.).
Logan, James A., (Cambridge Springs.
Ix)gan, James Clark, Titusville.
Lowry, James A., Cochranton.
McFate, J. Charles, Meadville.
Mock, David C, 215 Cajon St., Redlands, California.
Mosier, J. Russell, R. D. 2, Meadville.
Nisbet, Frederick L., Meadville.
Pond, Ralph E., Meadville.
Quay, William H., Jr., Townville.
Rastatter, Paul, Meadville. ,
Roberts, John K., Meadville.
Rumsey, Frank M., Conneautville.
Shaffer, William Walter, Meadville.
Skelton, William B., Meadville.
Smith, Rodney S., Saegerstown.
Snodgrass, David G., Meadville.
Snicer, Clarence E., Titusville.
Thomas, George D., 742 North Park Ave., Meadville.
Thompson, Charles Wesley, Meadville.
Walker, Herman H., Linesville.
Walker, James N., Linesville.
Werle, Edgar J., Meadville.
Williams, Clyde L., Linesville.
Wilson, Joseph C, Titusville.
Winslow, Harry C, 883 Water St., Meadville.
CUMBERLAND COUNTY SOCIETY
(Organized July 17, 1866.)
President. . .Newton W. Hershner, Mechanicsburg.
1st. V. Pres. .Seth I. Cadwallader, West Fairview.
2d V. Pres. . . George L. Zimmerman, Carlisle.
Rec. Sec.
and Rept.. Calvin R. Rickenbaugh, Carlisle.
Cor. Sec Harry A. Spangler, Carlisle.
Treasurer. . .Ambrose Peffer, (Carlisle.
Censors Philip R. Koons, Mechanicsburg.
Henry C. Lawton, Camp Hill.
David W. Van Camp, Plainfield.
Committee on Public Policy and Legislation:
Edward R. Plank, Carlisle.
Philip R. Koons, Mechanicsburg.
Seth I. Cadwallader, West Fairview.
Official Publication : Bi-monthly Announcement of the
Medical Society of Cumberland County.
Issued every two months.
Editor: (^Ivin R. Rickenbaugh, Carlisle.
Stated meetings second Tuesday of January, March,
May, July, September and November; the January
meeting at Carlisle; the place of the other meetings to
be determined by vote of the society or on invitation.
Election of officers in January.
MEMBERS (41)
Bashore, Harvey B., West Fairview.
Beale, John E., Lemoyne.
Bowman, John W., Lemoyne.
Cadwallader, Seth I., West Fairview.
Cowell, Selden Sylvester, Huntsdale.
Dougherty, Milton M., Mechanicsburg.
Etter, Harry B., Shippensburg.
Galbraith, Anna M., Carlisle.
Good, John F., New Cumberland.
Hershner, Newton W., Mechanicsburg.
Irwin, George G., Mount Holly Springs.
Koons, Philip R., Mechanicsburg.
Lanshe, Harold F., New Cumberland.
Lawton, Henry C, Camp Hill.
Lee, Hildegard Longsdorf, Carlisle.
Lefever, Enos K., 630 S. Hanover St., Carlisle.
Le Van, J. Kimberly, Carlisle.
Longsdorf, Harold H., Dickinson.
McBride, Thomas S., Shippensburg.
McCreary, J. Bruce, Shippensburg.
Meily, Harry S., Carlisle.
Mowery, Samuel E., Mechanicsburg.
Peffer, Ambrose, Carlisle.
Peters, Milton R., Boiling Springs.
Peters, William E., Carlisle.
Phillipy, William Tell, Carlisle.
Plank, Exiward R., Carlisle.
Preston, Thomas Walbank, Carlisle, R. D. 1,
Rickenbaugh, Calvin R., Carlisle.
Ruch, William S., Carlisle.
Shepler, R. McMurran, Carlisle.
Shoemaker, Ferdinand, U. S. P. H. S. Hospital, No
67, 11th and Harrison Sts., Kansas City, Mo.
Spangler, Harry A., Carlisle.
Spangler, Jacob B., Mechanicsburg.
Stewart, Alexander, Shippensburg.
Stoey, Oliver P., Newville.
Sutliff, S. Dana, Shit)pensburg.
Taylor, Walter S., Carlisle.
Van Camp, David W., Plainfield.
Wagoner, Parker W., Carlisle.
Zimmerman, George L., Carlisle.
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THE PENNSYLVANIA MEDICAL JOURNAL
July, 1921
DAUPHIN COUNTY SOCIETY
(Organized 1866.)
(Harrisburg is the post office when street address only
is given.)
President... Clarence R. Phillips, 1646 N. Third St.
1st V.Pres.. Edward M. Green, Pennsylvania State
Lunatic Hospital.
2d V.Pres... Claude W. Batdorf, 1600 N. Third St.
Sec.-Treas... Andrew J. Griest, Steelton.
Trustee Hewett C. Myers, Steelton.
Censors Charles S. Rebuck, 412 N. Third St.
W. Tyler Douglas, 1643 Derry St.
John W. Macmullen, 1732 Market St.
Reporter. . . .Frank F. D. Reckord, 220 Kelker St.
Committee on Public Policy and Legislation:
J. Edward Dickinson, 228 N. Second St.
John B. McAlistcr, 234 N. Third St.
William J. Middleton, 101 N. Second St.,
Steelton.
George H. Widder, 1244 Derry St.
Charles S. Rebuck, 412 N. Third St.
Official Publication: The Dauphin Medical Acade-
mician.
Issued Monthly.
Editor: Andrew J. Griest, Steelton.
Regular meetings are held at 8:30 p. m., on the first
Tuesday of every month, except July and August, at
the Harrisburg Academy of Medicine Building, 319 N.
Second St. Library and Reading Room same place.
Board of Governors meets last Tuesday of each month
at 8:30 p. m. Election of officers in January.
MEMBERS (150)
Akers, Andrew T., 1941 Green St.
Arnold, John Loy, 1509 Market St.
Baker, William C., Hummelstown.
Batdorf, Claude Wellington, 1600 N. Third St.
Batt, Wilmer R., R. D. 2.
Bauder, George W., 1225 N. Second St.
Blair, Thomas, S., 403 N. Second St.
Bowman, Thomas E., 1541 State St.
Brown, George L., Fort Hunter.
Bryner, John H., Quentin (Lebanon Co.).
Beuhler, William S., Elizabethville.
Byrod, Frederick W., 223 Pine St., Steelton.
Coble, Aaron S., Dauphin.
Cocklin, Charles C, 126 Walnut St.
Coover, Carson, 223 Pine St.
Coover, Frederick W., 223 Pine St.
Corbus, Howard L., Penna. State Hospital.
Crampton, Charles H., 600 Forster St.
Gulp, John F., 410 N. Third St.
Dailey, Cornelius M., 1727 N. Sixth St.
Dailey, Gilbert L., 713 N. Third St.
Dailey, William P., Steelton.
Dapp, Gustave A., 1818 N. Third St.
Darlington, Emerson E., 2025 N. Sixth St.
Deckard, Park A., 709 N. Third St.
Deckard, Percy E., 13 Trinity Place, Williamsport
(Lycoming Co.).
DeVenney, John C, HIS N. Second St.
Dickinson, Bayard T., 343 N. Front St., Steelton.
Dickinson, J. Edward, 228 N. Second St.
Douglas, Henry Rea, 1800 Market St.
Douglass, William T., 1634 Derry St.
Ellenberger, Jchn Wesley, 922 N. Third St.
Emrich. Marion W., 1426 Market St.
Evans, William P., 109 W. Emaus St., Middletown.
Everhart, Edgar S., Lemoyne (Cumberland Co.).
Exley, Maude C, 112 State St.
Eager, John H., Jr., 120 Walnut St.
Fager, V. Hummel, 410 N. Second St.
Faller, Constantine P., 2.36 State St.
Famsler, H. Hershey, 1438 Market St.
Frasier, Lester W., Bowman Ave. and Market St.,
Camp Hill (Cumberland Co.).
Funk, David S., 300 N. Second St.
Garfinkle, B. Milton, 1219 N. Second St.
George, Henry William, Middletown.
Goldman, Louis C, 710 N. Sixth St.
Good, John L., Fourth and Bridge Sts., New Cumber-
land (Cumberland Co.).
Goodman, Charlotte E., State Hospital.
Graber, Leon K., 901 N. Second St.
Gracey, George F., 219 N. Second St.
Green, Edward M., Penna. State Lunatic Hospital.
Griest, Andrew Jackson, Steelton.
Gross, Herbert F., 1501 N. Second St.
Hamilton, Hugh, 315 Walnut St.
Hassler, Samuel F., 500 N. Second St.
Hazen, Merl V., 410 N. Third St.
Hershey, Martin L., Hershey.
Hetrick, David Joseph, 54 N. Thirteenth St.
Hileman, Joseph B., 413 Market St.
Holmes, Robert E., Eighteenth and State Sts.
Home, John W., jr., Hummelstown.
Hottenstein, D. Edgar, 403 Union St., Millersburg.
Houck, William S., 1517 N. Second St.
Isenberg, Alfred P., 141 W. Greenwich St., Reading
(Berks Co.).
James, William T., 1900 N. Sixth St.
Jauss, Christian E., 1323 N. Sixth St.
Jeffers, Benjamin B., 36 N. Front St., Steelton.
Kcene, Charles E. L., 1849 Berryhill St.
Kilgore, Frank D., 2011 N. Sixth St.
Kirby, Harry J., 255 Cumberland St.
Kirkpatrick, Samuel A., 200 Third St., New Cumber-
land (Cumberland Co.).
Klase, Harry E., 1706 Market St.
Kocevar, Martin F., 403 S. Second St., Steelton.
Kreider, John H., 1410 Derry St.
Kunkel, George B., 118 Locust St.
Lakin, Harry A., 10 S. Twentieth St.
Laverty, (jeorge L., 404 N. Third St.
Lawson, Edward Kirby, Penbrook.
Layton, Morris H., Jr., 930 W. Sixth St.
Lenker, Jesse L., 232 State St.
McAlister, John B., 234 N. Third St.
McGowan, Hiram, Penn Harris Hotel.
MacMullen, John W., 1732 Market St.
Manning, Charles J., 1519 N. Sixth St.
Marshall, A. Leslie, 631 Boas St.
Marshall, L. Samuel, Halifax.
Middleton, William J., 101 N. Second St., Steelton
Miller, David I., 1839 N. Sixth St.
Miller, J. Harvey, 19 N. Fourth St.
Miller, Richard J., 124 State St.
Moffitt, George R., 200 Pine St.
Mulligan, Peter B., 621 N. Second St.
Myers, Hewett C, 232 S. Second St., Steelton.
Newman, Oscar A., 617 Race St.
Nicodemus, EMwin A., 1439 Derry St.
Nissley, Martin L., Hummelstown.
Oenslager, John, Jr., 711 N. Third St.
Oxley, James E. T., 8 S. Sixteenth St.
Page, Arthur L., 1315 Derry St.
Park, J. Walter, 32 N. Second St.
Perkins, Roscoe L., 2001 N. Second St.
Peters, Jacob M., R. D. 1, Camp Hill (Cumberland
Co.).
Phillips, Clarence R., 1646 N. Third St.
Plank, John R., 106 N. Front St., Steelton.
Putt, Maurice O., Oberlin.
Rahter, J. Howard, 324 N. Second St.
Raunick, John M. J., 1,410 N. Second St.
Rebuck, Charles S., 412 N. Third St.
Reckord, Frank F. D., 220 Kelker St.
Reed, Josiah F., 131 State St.
Rhoads, Joseph E., 402 N. Second St.
Rickert, Charles M., 232 Maclay St.
Ridgway, Richard Frederick L., Pouch A, Penna. Sate
Hospital.
Ritzman, Allen Z., 812 N. Sixth St.
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Jui<Y, 1921
MEMBERSHIP LIST
739
Roberts, Sylvia J., 1837 N. Second St.
Russell, W. Stewart, 260 S. Second St., Steelton.
Sayo, Ernest B., Penna. State Lunatic HospiUl.
Schaffner, Daniel W., Enhaut.
Shaffer, Harry A., Williamstown.
Shaffer, Joseph Wright, 2329 N. Sixth St.
Shearer, Alfred L., 804 N. Sixth St.
Shenk, Frank L., Linglestown.
Shepler. Norman Bruce, 711 N. Third St.
Sherger, John A., 1809 N. Sixth St.
Shope, Jacob W., 32 S. Thirteenth St.
Smith, B. Frank, 1601 Market St.
Smith, Charles H., Linglestown.
Smith, Harvey F., 130 State St.
Snyder, Charles R., Marysville (Perry Co.).
Stauffer, Charles C, 1516 N. Second St.
Stevens, John C, 240 S. Thirteenth St.
Stine, Harvey A., Sixteenth and Berrvhill Sts.
Stull, George B., 217 Woodbine St.
Swiler, Robert D., 1331 Derry St.
Taylor, Louise H., 1800 N. Third St.
Traver, David B., Steelton.
Traver, Samuel N., 128 Locust St.
Trullinger, Charles I., 2022 N. Sixth St.
Ulrich, Marion, 139 Center St., Millersburg.
Wagenseller, James L., 36 S. Thirteenth St.
Walter, Harry B., 1317 N. Third St.
Weirick, Ernest Charles, Enola (Cumberland Co.).
West, William H., 1801 Green St.
Whipple, Earle Rogers, 210 S. Second St., Steelton.
Widder, George H., 1244 Derry St.
Wintersteen, Grace, State Hospital.
Wright, Louis W.. 227 Pine St.
Wright, William E., 206 State St.
Zeigler, John B., Pcnbrook.
Zimmerman, (Jeorge A., 213 N. Second St.
Zimmerman, J. Landis, Hershcy.
DELAWARE COUNTY SOCIETY
(Organized May 30, 1850)
(Chester is the post office when street address only is
given.)
President. . .George H. Cross, 525 Welsh St.
1st V.Pres.. John B. Roxby, 110 Cornell Ave., Swarlh-
■ more.
2d V.Pres... J. Clinton Storbuck, Media.
Sec.-Treas.. .Walter E. Egbert, 601 E. Thirteenth St.
Reporter.... George B. Sickle, 516 E. Ninth St.
Censors J. Harvey Fronfield, Media.
Katherine Ulrich, 413 E. Ninth St.
Harry C. Donahoo, 511 Karl in St.
Committee on Public Policy and Legislation:
Adam J. Simpson, 401 E. Twelfth St.
Daniel J. Monihan, Ninth St. and Morton
Ave.
J. Harvey Fronfield, Media.
Exec. Com. .John B. Roxby, 110 Cornell Ave., Swarth-
more.
J. Clinton Starbuck, Media.
Walter E. Egbert, 601 E. Thirteenth St.
Official Publication: The Bulletin.
Issued Monthly.
Editors: C. Irvin Stiteler, Fifth and Welsh Sts.
Tohn S. Eynon, Eighth and Kerlin Sts.
Walter E. Egbert, 601 E. Thirteenth St.
Stated meetings the third Thursday of each month at
3:30 p. m., at Chester Hospital unless otherwise di-
rected. Election of officers in January.
MEMBEItS (86)
Armitage, George L., Jr., Chester.
Armitage, Harry M.. 401 E. Thirteenth St.
Bartleson. Henrv C, Lansdowne.
Pin", Edward W.. Second and Norris Sts.
Rlair. Walter A., Unland.
Boudarl, Jane R., 817 Edgmont Ave.
Brown, Ellen, 714 Madison St.
Bryant, F. Otis, 500 E. Broad St.
Campbell, Ethan A., Ridley Park.
Chartock, Samuel, 526 North Fourth St., Phila., Pa.
Crist, John O., 209 E. Ninth St.
Cross, George H., 525 Welsh St.
Crothers, George F., Marcus Hook.
Darlington, Horace H^ Concordville.
Devereux, Robert T., 210 Yale Ave., Swarthmore.
Dick, H. Lenox H., Darby.
Dickeson, Morton P., Media.
Donahoo, Harry C, 511 Kerlin St .
Dunn, Joseph F., Third and Lloyd Sts.
Dunn, Louis S., 522 W. Ninth St.
Easby, Alice Rogers, 23 E. Second St., Media.
Egbert, Walter E., 601 E. Thirteenth St.
Emery, Walter V., 1135 Edgmont Ave.
Evans, Fred H., 216 W. Fourth St.
Evans, William B., (Chester.
Eynon, John Schofield, Eighth and Kerlin Sts.
Feddeman, Charles E., 405 E. Thirteenth St.
Forwood, Jonathan Larkin, Fifteenth St. and Edgmont
Ave.
Fronfield, J. Harvey, Media.
Gallager, Harry, Seventh St. and Concord Ave.
Gottschalk, Leon, Marcus Hook.
Gray, Joseph R. T., Jr., City Hall.
Gray, Stoddard P., 1925 W. Third St.
Hammond, William, Glenolden.
Hiller, Hiram M., Swarthmore.
Hoskins, John, 2414 Edgmont Ave.
Howell, Elizabeth W., 26th and Chestnut Sts.
Hughes, George M., 421 E. Ninth St.
Hunlock, Fred S., 514 Parker Ave., Coliingdale.
Janvier, George Victor, 30 Runnymede Ave., Lans-
downe.
Johnston, Frank E., Moores.
Kinne, Howard S., 826 E. Sixteenth St.
Lambichi, Marika E., 319 E. Broad St.
Landry, Walter A., 809 Madison St.
LaShelle, Charles L., Lenni Mills.
Uhman, William F., 2124 W. Third St.
Lithgow, William D., Seventh and Barclay St.
Longhead, Raymond B., 2216 W. Third St.
Lyons, J. Chalmers, Marcus Hook.
McCutcheon, Thomas O., Upper Darby.
Maison, Robert S., 521 W. Seventh St.
Monihan, Daniel J., Ninth St. and Morton Ave.
Morton, Alexander R., Morton.
Mullison, G. Bigelow, 212 E. Ninth St.
Neufield, Maurice A., 407 E. Ninth St.
Nothnagle, Frank R., 408 E. Thirteenth St.
Omdoff, Hersey E., Glen Riddle.
Orr, Adrian V. B., 408-9 Crozer BIdg.
Owen, Richard, 1011 Chester Ave., Moores.
Parson, Isaac I., Media.
Pike, Perry Covington, 25 W. State St., Media.
Poulson, William W., 932 Market St., Marcus Hook.
Pyle, Jerome L., Glen Mills.
Raiman, William A., Swarthmore.
Reynolds, Victor M., 120 Main St., Darby.
Roberts, James E., Lansdowne.
Roxby, John Byers, 110 Cornell Ave., Swarthmore.
Rozploch, Albin R., 415 Highland Ave.
Schoff, Charles H., Media.
Sharpe, A. Maxwell, 708 Sproul St.
Sherman, Jeannette H., Ridley Park.
Shortlidge, Charles B., Lima.
Sickle, George B., S16 E. Ninth St.
Simpson, Adam J., 401 E. Twelfth. St.
Smith, Norman D., Swarthmore.
Stanton, Herbert C, Clifton Heights.
Starbuck, J. Qinton. Media.
Stiteler, C. Irwin, Fifth and Welsh Sts.
Stull, Clark Deakyne, 111 Swarthmore Ave., Ridlev
Park.
Ulrich, Katharine, 413 E. Ninth St.
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740
THE PENNSYLVANIA MEDICAL JOURNAL
Ji'LV, 1921
Usset, Albert L., 712 W. Third St.
Webster, George C, Jr., 311 W. Seventh St.
West, Harman, 60 Winona Ave., Norwood.
White, Amy E., 807 Madison St.
Wolfe, A. Chester, Ridley Park.
Wood, J. William, 219 E. Fifth St.
ELK COUNTY SOCIETY
(Organized 1881.)
President. . .James G. Flynn, Ridgway.
V. Pres James E. Rutherford, Ridgway.
Secretary. ..Andrew L. Benson, Ridgway.
Treasurer. ..Michael M. Rankin, Ridgway.
Reporter — Samuel G. Logan, Ridgway.
Committee on Public Policy and Legislation:
John C. McAllister, Ridgway.
Samuel T. McCabe, Johnsonburg.
Joseph E. Madara, St. Marys.
Stated meetings at 1 p. m. the second Thursday of
each month at Ridgway. Election of officers in Janu-
ary.
MEMBERS (27)
Atkinson, Walter M., Brockwayville (Jefferson Co.).
Barratt, Stanley, Wilcox.
Beale, Bertram A., Dubois (Clearfield Co.).
Benson, Andrew L., Ridgway.
Black, Walter M., St. Marys.
Bush, Walter H., Emporium (Cameron Co.).
Dye, Adelbert D., Elbon.
Earley, Francis G., Ridgrway.
Falk, Harry S., Emporium (Cameron Co.).
Flynn, James G., Ridgway.
Heilman, Russell P., Emporium ((Cameron Co.).
Hutchison, George M., Dagus Mines.
Leary, Maurice T., Ridgway.
Logan, Samuel G., Ridgway.
Luhr, Augusttis C, St. Marys.
McAllister, John Craig, Ridgway.
McCabe, Samuel T., Johnsonburg.
Madara, Joseph E., St. Marys.
Mansuy, Edward A., Driftwood (Cameron Co.).
Rankin, Michael M., Ridgway.
Russ, Eben J., St. Marys.
Rutherford, James E., Ridgway.
Shannon, Albert C, St. Marys.
Shaw, Walter C. Ridgway.
Smith, Henry H., Johnsonburg.
Wamick, John W., Johnsonburg.
Wilson, Oarence G., St. Marjs.
ERIE COUNTY SOCIETY
(Reorganized June 25, 1895.)
(Erie is the post office when street address only is
given.)
President... John A. Darrow, 106 W. Ninth St.
1st V. Pres.. Charles Kemble, 146 W. Ninth St.
2d V. Pres.. .William H. Rouche, 226 W. Eighth St.
Secretary... Roy S. Minerd, 128 W. Eighth. St.
Treasurer... J. Elmer Croop, 557 E. Sixth St.
Reporter
& Librarian. Fred E. Ross, 132 W. Ninth St.
Censors Orel N. Chaffee, 820 Sassafras St.
Frank P. McCarthy, 147 E. Fourth St.
Thomas -P. Tredway, 233 W. Eighth St.
Committee on Public Policy and Legislation :
John W. Wright, 247 W. Eighth St.
George A. Reed, .122 W. Twenty-first St.
William W. Richardson, Commerce Bldg.
John A. Darrow, 106 W. Ninth St.
Roy S. Minerd. 128 W. Eighth St.
■ ' Stated meetings in the Library Building. Erie, the
first Tuesday of each month at 8 :30 p. m. Election of
officers in January.
MEMBERS (122)
Ackerman, John, 138 W. Seventh St.
Allen, William G., 101 E. Eighteenth St.
Andrews, William K., Waterford.
Barkey, Peter, 130 W. Ninth St.
Barrett, Martin C, 734 W. Eighth St.
Beck, Frank W., 408 E. Sixth St.
Bednarkiewicz, Ignatius A., 602 E. Twelfth St.
Bell, John J., 110 W. Ninth St.
Bodine, Francis S., 1019 East Ave.
Boughton, Guy C, 810 Peach St.
Bunshaw, Albert H., 1204 W. Tw^ty-first St.
Cameron, Alexander C., 11 W. Eighth St.
Chaffee, Orel N., 820 Sassafras St
Croop, J. Elmer, 557 E. Sixth St.
Darrow, John A., 106 W. Ninth St.
Dasher, J. Howard, 114 E. Sixth St.
Davis, Arthur G., 1019 East Ave.
Dennis, David N., 221 W. Ninth St.
Dennis, Edward P., 221 W. Ninth St.
Dickinson, George S., 140 W. Eighth St.
Douville, Jeffrey C, North East.
Drake, J. C. Merle, 720 Sassafras St.
Drozeski, Edward H., 117 E. Sixth St.
Dunn, Harrison A., 230 W. Eighth St.
Dunn, Ira J., 406 Masonic Temple.
Durbin, George S., Fairview.
Eastman, Ford, Masonic Temple.
Fisher", Fred, 343 E. Sixth St
Flynn, Theobald M. M., 238 W. Tenth St.
Foringer, Henry H., Penna. S. and S. Home.
Fust, John H. E., 138 W. Ninth St.
Galster, Herman C, 129 W. Twenty-fifth St.
Ghering, Harold A., Minboro.
Gibbons, Robert L., 420 E. Eleventh St.
Gillespie, Warren S., Edinboro.
Graham, Vem W., Corry.
Griswold, Homer E., 812 Peach St.
Hall, Friend L., 234 W. Eighteenth St.
Hammond, Charles C, 2530 Parade St.
Heard, Corydon F., 402 Masonic Temple.
Heard, James L., North East.
Hess, Elmer, 501 Commerce Bldg.
Hotchkiss, C. W., Weslej^ille.
Howe, J. Burkett, 932 Peach St
Howe, Lewellyn O., 606 Victory Rd.
Humphrey, William J., S South St., Union City.
Irwin, Jeremiah S., 125 W. Eighth St
Jackson, DeWitt 234 W. Eighth St.
Johnson, Philip T., 139 E. Sixth St.
Kemble, Charles C, 146 W. Ninth St.
Kendall, Eugene E., Waterford.
Kern, Rudolph A., 1015 W. Eighth St.
Kibler, John C, Corry.
Kramer, Daniel W., 920 E. Twenty-first St
Krimmel, Frank B., 361 E. Sixth St
Krum, Astley G., 163 W. Eighteenth St
Lasher, Lemuel A., 216 W. Twenty-fourth St
Law-Wright, Katherine H., 247 W. Eighth St
Lefever, Oarence H., 507 W. Eleventh St
Lick, Maxwell, 149 W. Eighth St.
Lininger, Carl B., Sixth St. and East Ave.
Luke, Ray H., 806 Rankin Ave., Lawrence Park.
Lyons, Harry E., 618 W. Twentv-sixth St.
McCallum, Chester H., 219 W. EighA St
McCallum, Malcolm J., 133 W. Ninth St
McCarthy. Frank P., 147 E. Fourth St.
McConnell. Whitman C, 156 W. Eighth St.
McCune, Charles E.. West Springfield.
McCune, Fred K., Girard.
McNeil, Charles A., 136 E. Eighteenth St.
Miller. Adolbert B., 147 W. Eighth St
Miller. Richard O., 838 E. Twenty-fourth St
Minerd. Rov S.. 128 W. Eighth St
Moorhead, Hugh M., 804 Peach St
Ms7anowski. Melchior M.. 611 E. Fourteenth St
O'Donnell, John J., 2420 Parade St.
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July, 1921
MEMBERSHIP LIST
741
Olds, Harry H., WesleyvUle.
Parsons, Percy P., 102^ W. Eighth St.
Peters, Charles O., Albion.
Peters, Joel M., Albion.
Pfadt, Jacob J., 715 W. Twenty-sixth St.
Purcell, Thomas, 716 Sassafras St.
Putts, B. Swayne, 117 W. Eighth St.
Ray, George S., 153 W. Eighth St.
Reed, George A., 122 W. Twenty-first St.
Reichard, Simon W., 813 French St.
Reinoehl, David V., 139 W. Tenth St.
Renz, Oscar W., 526 E. Twenty-first St.
Richardson, William W., Commerce Bldg.
Ross, Fred E., 132 W. Ninth St.
Roth, Augustus H., 110 W. Ninth St.
Rouche, William H., 226 W. Eighth St.
Russell, James A. M., 206 Masonic Bldg.
Rutherford, J. Frank, Hastings (Cambria Co.).
Schlindwein, George W., 138 W. Ninth St.
Schmelter, John W., 213 W. Eighth St.
Schrade, Anna M., 716 Sassafras St.
Schreve, Owen M., 162 W. Eighth St.
Schurgot, James A., Hillsview Sanitarium, Wasliit.-g-
ton.
Scibetto, Samuel L., 306 W. Eighteenth St.
Silliman, James E , 137 W. Eighth St.
Smith, James R., 730 W. Eighteenth St.
Stackhouse, Joseph A., 116 W. Eighth St.
Steadman, Henry R., 529 E. Sixth St.
Steinberg, Edward I., 134 W. Ninth St.
Stilley, Jesse C, Eisert Bldg., Sixth St. and East Ave.
Stoney, George F., 759 E. Sixth St.
Strickland, Charles G., 153 W. Seventh St.
Strimple, James T., 343 E. Twelfth St.
Stroble, Walter G., 359 E. Sixth St.
Studebaker, George M., 426 E. Tenth St.
Thompson, Ross W., Wesleyville.
Tredway, Thomas P., 233 W. Eighth St.
Trippe, Frank A., 220 W. 16th St..
Umburn, Leroy, Albwn.
Walsh, Frank A., 128 E. Seventh St.
Washabaugh, William B.. 253 W. Eighth St.
Weibel, Elmer G., St. Vincent's Hospital.
Wheeler, Arthur C, 538 W. Seventh St.
Wishart, Hagar M., North East.
Woodruff, Row O., Waterford.
Wright. John W., 247 W. Eighth St.
FAYETTE COUNTY SOCIETY
(Organized May 18, 1869.)
(Connellsville is the post office when street address
only is given.)
President... Elliott B. Edie, 308 First National Bank
Bldg.
1st V.Pres.. Robert H. Jeffrey, Box 1041, Uniontown.
2d V.Pres... Jesse H. Hazlett, Vanderbilt.
Secretary. . .Robert E. Heath, Fairchance.
Treasurer. . .James H. Nixon, Uledi.
Reporter George H. Hess, Uniontown.
Censor Owen R. Altman, Uniontown.
Exec. Com. .Elliott B. Edie, 308 First National Bank
Bldg.
Samuel A. Baltz, Uniontown.
Robert E. Heath, Fairchance.
Committee on Public Policy and Legislation :
Arthur E. Crow, Uniontown.
Wilbur M. Lilly, Brownsville.
George W. Gallagher, 117 N. Sixth St.
Official Publication: The Mirror.
Issued Monthly.
Editor: Robert E. Heath, Fairchance.
Regular meetings shall be held the first Thursday
nf each month in Rainey Club Room, second floor,
Adams Building, Morgantown St., Uniontown.
MEMBERS (115)
Adams, Charles W., Uniontown.
Altman, Owen R., Uniontown.
Bailey, William J., Box 817.
Baltz, Samuel A., Uniontown.
Baum, Simon H., Uniontown.
Bell, Harry J., Dawson.
Bierer, Charles D., Uniontown.
Brady, Harry, Masontown.
Brooks, Don D., Connellsville.
Brown, Henry Stanley, Takoma Park, WasninRton,
D. C.
Burchinal, Lowty N., Point Marion.
Carothers, J. Richard, Waltersburg.
Cjirroll, James Basil, (Connellsville.
(Cochran, James L., 132 S. Pittsburgh St.
(Dogan, Jesse F., Dawson.
Cblbom, Andrew J., 131 N. Pittsburgh St.
Coll, Hugh J., Box 635.
(Conn, Clyde W., Uniontown, R. D. 5.
(Coughenour, Albert T., Point Marion.
Crawford, William B., Union St., Brownsville.
Crosbie, (jeorge T., Belle Vernon.
Crow, Arthur E., Uniontowm.
Cunningham, Daken W., Fairchance.
Davidson, Carlton H., New Salem.
Dixon, John C, 118 W. Apple St.
Doran, Benjamin P., Uniontown.
Echard. Thomas B., 301 S. N. Bank Bldg.
Eddy, Alexander T.,., Greensboro (Greene Co.).
Edie, Elliott B., 308 First Natl. Bank Bldg.
Edmunds, (jeorge H., Connellsville.
Evans, George O., Uniontown.
Fosselman, Don C., Dunbar.
Fox, Gilbert G., Newell.
Frankenburger, W. Sturgis, (Carmichaels (Greene
Co.).
Gallagher, (korge W., 117 N. Sixth St. -
(jordon, John W., Belle. Vernon.
Graham, (Charles R., Brownsville.
Gribble, Russell T., Fairchance.
Griffin, Gtorgt H., Uniontown.
Guiher, Horace B., Smithfield.
Hackney, Jacob S., 36 W. Church St., Uniontown.
Hall, Herbert E., Natl. Bank of Fayette Co. Bldg.,
Uniontown.
Hansel, George B., Fayette City.
Hazlett, Jesse H., Vanderbilt.-
Heath, Robert E., Fairchance.
Heise, Herman A., Uniontown.
Herrington, Lee R., New Salem
Hess, (jeorge H.. Uniontown.
Hibbs, Samuel E., Uniontown.
Hoffman, Harry Clyde, Box 754.
Hoover, Freeman S., Brownsville.
Hopwood, (Jeorge B.. (Chestnut Ridge.
Hopwood, William Henry, Smock.
Hunger, Arthur D., Point Marion.
Ingr^am, Eben R., Masontown.
Jackson, James Marcus, New Salem.
Jackson, John D.. 210 E. Crawford Ave.
Jeffrey, Robert Harrison, Box 1041, Uniontown.
Johnson, Chester B., Mt. Braddock.
Johnson, L. Dale, S. N. Bank Bldg.
Junk, James L., 104 Meadow Lane.
Kerr, J. French, 115 E. Fairview Ave.
Kidd, Alexander R., 402 S. N. Bank Bldg.
Kimmel, William S., Republic.
LaBarre, J., Pollard, Uniontown.
I^Clair. Charles H.. 24 Church St.
Larkin. Martin T., Brier Hill.
Lilley, Wilbur M.. Brownsville.
lx)we, David E., Uniontown.
Luman, Oark M., Uniontown.
McAninch, John V.. Alicia.
MrCombs. Edgar A.. 34."; N. Pittsburgh St.
McCormick, Louis P., 201 S. N. Bank BldK.
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THE PENNSYLVANIA MEDICAL JOURNAL
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McCracken, Jesse L., Smithfield.
McDaniel, Robert A., Connellsville.
McHugh, William A., Uniontown.
McKee, Robert S., 414 S. Ninth St.
Marston, Albicm J., Belle Vernon.
Martin, Ralpfa S., Star Junction.
Meachem, John J., Masontown.
Means, William H., Percy.
Merrick, Frank X., Uniontown.
Messmore, Harry Benjamin, Brownsville.
Messmore, John Lindsey, Masontown.
Messmore, Walter T., Hillcoke.
Meyers, William T., Uniontown.
Neff, George W., Masontown.
Nixon, James Holbert, Uledi.
Noon, Milton A., Everson.
O'Neil, Andrew, Uniontown.
Opinslqr, Andrew G., New Kensington (Westmoreland
Co.).
Osbum, Wilkins William, Upper Middletown.
Parshall, James W., Uniontown.
Patterson, William P., Fairchance.
Peters, Stephen E., Masontown.
Pisula, Vincent Paul, Everson.
Rasley, Edwin R., Uniontown.
Rebok, Edward H., Waltersburg.
Robinson, George H., Uniontown.
Ryan, Charles C, Republic.
Sangston, D. Hibbs, McClellandtowii.
Sangston, James H., McClellandtown.
Sherrick, Earl C, 136 S. Pittsburgh St.
Smith, Alfred C, Brownsville.
Smith, Charles H., 93 Morgantown St., Uniontown.
Smith, Peter Franklin, Uniontown.
Steeves, Edward W., Republic.
Stollar, Bert Lee, Fayette City.
Sturgeon, John D., Uniontown.
Utts, Charles William, 2 Weihe BIdg.
Van Gilder, James E., Uniontown.
Wagoner, LeRoy C, Brownsville.
Wame, William. Dunbar.
Wilson, James H., Belle Vernon.
Zoeller, L. J., Allison.
FRANKLIN COUNTY SOCIETY
(Organized Jan. 4, 1S25. Reorganized 1866.)
President... W. Edgar Holland, Fayetteville.
1st V.Pres.. John W. Croft, Waynesboro.
2d V.Pres... Thomas H. Gilland, Greencastle.
Sec. Rept — John J. CofTman, Scotland.
Asst. Sec — Samuel D. Shull, Chambersburg.
Treasurer. . .Frank N. Emmert, Chambersburg.
Censors A. Barr Snively, Waynesboro.
John K. Gordon, Chambersburg
Lewis H. Seaton, Chambersburg.
Exec. Com. .W. Exlgar Holland, Fayettevill-;.
John J., Coffman, Scotland.
Frank N. Emmert, Chambersburg.
Committee on Public Policy and Legislation :
A. Barr Snively, Waynesboro.
Leslie M. Kauifman, R. D. 8, Chambers-
burg.
Lewis H. Seaton, Chambersburg.
Official Publication: Call and Roster.
Issued Bi-Monthly.
Editor: John J. CofFman, Scotland.
Stated meetings in Chambersburg the third Tuesday
of each month unless otherwise decided. Election of
officers in January.
MEUBERS (54)
Amberson, J. Burns, Waynesboro.
Asper, Guy P., S. Main St.. Chambersburg.
Brid^ers, Harvey C, Blue Ridge Summit.
Brosius, William H.. Mont Alto.
Brown, Robert B., Waynesboro.
Bushey, Franklin A., Greencastle.
&>ttman, John J., Scotland.
Coons, Samuel G., Dry Run.
Crott, John W., 152 West Main St., Waynesboro.
Emmert, t^'rank N., Chambersburg.
Ennis, Joseph, Waynesboro.
Gans, Charles C, (Tapt M. C, Camp A. A. Hnin-
phreys, Va.
Gelwix, John M., Chambersburg.
Gilland, John C, Greencastle.
Gilland, I'homas H., Greencastle.
Gordon, John K., Chambersburg.
Hartzell, Charles A., Fayetteville.
Holland, W. Edgar, Fayetteville.
Hoover, Percy D., Waynesboro.
Kauifman, Leslie M., Chambersburg, R. D. 8.
Keck, George O., State Sanatorium, Mont Alto.
Kempter, J. Elmond, 150 E. Queen St., Chambersburg.
Kinter, John H., (Chambersburg.
Laughlin, Rebecca P., 11 N. Thirty-fourth St., Phila-
delphia (Phila. Co.).
McClain, Harry C, Hustontown (Fulton Co.).
Maclay, Joseph P., 44 Lincoln Way W., (^mbersburg.
Mayer, John H., (3iambersburg.
Miley, Harry M., North Main St., Chambersburg.
Mosser, John W., McCx>nnellsburg (Fulton Co.).
Myers, Benjamin F., 55 S. Second St., C:hambersburg.
Ogle, Charles C, 219 S. Main St., (3uimbersburg.
Palmer, Charles F., 125 E. Queen St., Chamhersburg.
Palmer, J. Judson, Needmore (Fulton (3o.).
Peters, Theodore, 164 ,E. Queen St., Chambersburg.
Robinson, (jeorge M., McConnellsburg (Fulton C^.).
Russell, Ella M., Lurgan Bldg., Chambersburg.
Ryder, Anna L. B., Chambersburg.
Saxe, LeRoy H., Fannettsburg.
Schultz, William C, Waynesboro.
Seaton, Lewis H., (Chambersburg.
Seibert, William E., Greencastle.
Shoemaker, David M., Waynesboro.
Shull, Samuel D., Main and King Sts., Chambersburg.
Snively, A. Barr, Waynesboro.
Sollenberger, Aaron B., Potomac and Second Sts.,
Waynesboro.
Sowell, (jcorge A., Greencastle.
Stewart, Helen M., 688 Phila. Ave., C3iambersburg.
Swann, James H., St. Thomas.
Swartzwelder, James S., Mercersburg.
Thomas, Samuel B., Waynesboro.
Thrush, Ambrose W., (Ihambersburg.
Unger, David F., Mercersburg.
Weagley, Theodore H., Marion.
White, Thomas D., Orrstown.
Wright, Fairfax G., (Chambersburg.
GREENE COUNTY SOCIETY
(Organized June 26, 1883.)
President... Ruf us E. Brock, Waynesburg.
V.Pres Frank S. Ullom, Waynesburg.
Sec.-Treas... Harry C. Scott, Waynesburg.
(Cor. Sec (Charles W. Spragg, Waynesburg.
Reporter Thomas B. Hill, Waynesburg.
Censors Robert W. Norris, Waynesburg.
Thomas N. Millikin, Waynesburg.
Samuel T. Williams, Waynesburg.
(Committee on Public Policy and Legislation:
Thomas B. Hill, Waynesburg.
Thomas L. Blair, Waynesburg.
Exec. Com.. .Ruf us E. Brock, Wa)rnesburg.
Lindsey S. McNeely, Kirby.
Stated meetings at Waynesburg the second Tuesday
of each month. Election of officers in May.
MEMBERS (25)
Askey, John W., Nemacolin.
Blair, Thomas L., Waynesburg.
Brock, Rufus Edward, Waynesburg., j
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Cocn, John A., Bristoria.
Core, Amanda R., Whiteley.
Day, Qinton H., Clarksville.
Day, Jonathan R., Nineveh.
Hatfield, George W., Mt. Morris.
Hill, Thomas Benton, Waynesburg.
Hoge, Smith A., Rices Landing,
lams, Samuel H., Waynesburg.
Knox, James A., Waynesburg.
Laidley, Edmund W., Carmichaels.
Lutz, Carl L., Rices Landing.
McNeely, Lindsey S., Kirby.
Millikin, Thomas N., Waynesburg.
Murray, Arthur T., Nineveh.
Norris, Robert Walton, Waynesburg.
Rouse, William J., Rices Landing.
Scott, Harry Chinsworth, Waynesburg.
Spragg, Charles William, Waynesburg.
UUom, Frank Sellers, Waynesburg.
Wignet, Stephen E., Waynesburg.
Williams, Samuel T., Waynesburg.
Woods, Harold B., R. D., Harveys.
HUNTINGDON COUNTY SOCIETY
(Organized Aug. 14, 1849. Reorganized April 9, 1872.)
(Huntingdon is the post office when street address
only is given.)
President... Harry C. Wilson, Warriors Mark.
V. Pres Fred R. Hutchinson, Seventh and Wash-
ington Sts.
Reporter John M. Keichline, Jr., Petersburg.
Secretary... John M. Beck, Alexandria.
Treasurer... George G. Harman, 523 Penn St.
Censors James R. St. Qair, Alexandria.
Fred P. Simpson, Mapleton Depot.
Charles R. Reiners, Huntingdon.
Committee on Public Health L^islation :
Howard C. Frontz, Huntingdon.
George G. Harman, 523 Penn St.
Fred P. Simpson, Mapleton Depot.
Prog. Com.. William H. Sears, 514 Penn St.
Qoy G. Brumbaugh, 805 Mifflin St.
John M. Keichline, Jr., Petersburg.
Official Publication: The Bulletin.
Issiied Monthly.
Editor: John M. Keichline, Jr., Petersburg.
Asso. Editor : Cloy G. Brumbaugh, 805 Mifflin St.
Stated meetings at the Huntingdon Club Rooms,
Huntingdon, the second Thursday of each month at
2:30 p. m. Election of officers in December.
MEMBERS (35)
Banks, Clark W., Derry (Westmoreland Co.).
Beck, John M., Alexandria.
Bley, Henry, East Mauch Chunk (Carbon Co.).
Brumbaugh, Qoy G., 805 Mifflin St.
Campbell, Charles, Petersburg.
Campbell, Robert B., Box 363, Mount Union.
(uimpbell, William J., 100 E. Penn Ave., Mt. Union.
Chisolm, Henry Qay, 528 Penn St
Decker, Raymond R., 26 Chestnut St, Lewistown (Mif-
flin Co.).
Dovey, Howard L., 830 W. Main St., Norristown
(Montgomery Co.).
Duncan, Earl Spence, Tarentum (Allegheny Co.).
Evans, A. Hank, Saxton (Bedford Co.).
Frontz, Howard C, 500 Mifflin St.
Green, Edward H., Capt. M. C, U. S. A., Fort War-
ren, Mass.
Harman, George G., 523 Penn St.
Hart, Joseph, Dudley.
Herkness, John S., 21 E. Penn Ave., Mount Union.
Horton, Harold G., Saltillo.
Hutchison. Fred R., Seventh and Washington Sts.
Johnston, James M., 813 Mifflin St.
Keichline, John M., Jr., Petersburg.
Koshland, James G., 621 Washington St.
Locke, Howard V., Orbisonia.
McClain, Charles A. Roe, 117 West Shirley St., Mt.
Union.
Moore, Robert Hall, 86 Beechwood Ave., Trenton, N.J.
Morgan, Marshall B., Sixth and Penn Sts.
Newlin, Gladys Wright, 600 Washington St.
Reiners, Charles R., Huntingdon.
Richards, Frank L., 527 Penn St.
St. Qair, James Roy, Alexandria.
Schum, Frank L., 322 Penn St.
Sears, William Hardin, 514 Perm St.
Simpson, Fred P., Mapleton Depot.
Waite, Alvin R.. Sixth and Mifflin Sts.
Wilson, Harry C, Warriors Mark.
INDIANA COUNTY SOCIETY
(Organized July 21, 1858.)
President... Harry B. Neal, Indiana.
1st V. Pres.. Alexander H. Stewart, Indiana.
2dV.Pres...Wm. L. Shields, Kent.
Secretary. . .James M. Torrence, Indiana.
Treasurer... Medus M. Davis, Indiana.
Reporter. . ..Charles Paul Reed, Indiana.
Censors William E. Dodson, Indiana.
William C. Widdowson, Black Lick.
Charles E. Rink, Indiana.
Committee on Public Health Legislation:
Wm. A. Simpson, Itidiana.
Wm. B. Anslcy, Saltsburg.
Qark M. Smith, Plumville.
Meetings second Thursday of each month in F.Iks
Club Rooms, Indiana.
MEMBERS (63)
Ansley, William B., Saltsburg.
Bee, Charles H., Mark>n Center.
Boden, Todd R., R. D., Mclntire.
Bushnell, Emerson M., Black Lick.
Buterbaugh, Howard B., Indiana.
Carson, Jason W., Indiana.
Carson, John B., Blairsville.
Clagett, Luther S., Blairsville.
Clark, Albert W., Indiana.
(ioe, Benjamin F., 206 N. Sixth St., Indiana.
(3oolidge, Leroy E., Qyraer.
Davis, Medus M., Indiana.
Dodson, William E., Indiana.
Elkin, John A., Smicksburg.
Everwine, J. Merle, Leechburg (Armstrong Co.).
Fisher, James G., Plumville.
Gates, Dunn William, Indiana.
Glasser, James Clair, Dixonville.
Gourley, John C. Windber (Somerset Co.).
Griffith, Wilbert E., Iselin.
Haegle, Edward A., Commodore.
Heiser, William H., Alverda.
Hileman, Elmer E., Hillsdale.
Hotham, H. DeV., Saltsburg.
Johns, William, 1236 Franklin Ave., Wilkinsburg
(Allegheny Co.).
Kirk, Charles H., Homer City.
Lewis, Ray N., Apollo (Armstrong Co.).
Lewis E. Budd, Glen Campbell.
Lloyd, Harvey W., Starford.
Lyon, (Jeorge R., Heilwood.
Lytle, Ralph M., Saltsburg.
McCreight, William S., Blairsville.
McFarlane, Joseph P., Vintondale.
McNeils, Thomas J., Homer City.
Miller, John S., Qymer.
Moore, Frank Fisher, Homer City.
Mulligan, Augustine J., Creekside.
Neal, Harry B., Indiana.
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THE PENNSYLVANIA MEDICAL JOURNAL
July, 1921
Nix, William H., Unionville (Chester Co.).
Onstott, Elmer E., Saltsburg.
Peterman, James Harvey, Cherry Tree.
Peters, William F., Homer City.
Raymond, Malcolm L., Waterman.
Keed, Charles Paul, Indiana.
keilly, Francis, Claghome.
Kink, Charles £., Indiana.
Rutledge, Albert T., Blairsville.
St. Qair, John M., Indiana.
St. Clair, Frederick W, Indiana.
Salisbury, William John, Armagh.
Shields, William L., Kent.
Simpson, George E., Indiana.
Simpson, William A., Indiana.
Smith, Clark M., Plumville.
Smith, H. Boydston, Blairsville.
Smith, John Henry, 410 E. Main St., Bradford (Mc-
Kean Co.).
Stevenson, Frank B., Indiana.
Stewart, Alexander H., Box 85, Indiana.
Stewart, John M., Marion Center.
Sutton, M. Alva, Avonmore (Westmoreland Co.).
Torrence, James M., Indiana.
Weitzel, William F., Indiana.
Widdowson, William Qiarles, Black Lick.
JEFFERSON COUNTY SOCIETY
(Organized Sept. 11, 1877. Incorporated April 16, 1887.)
President... Samuel M. Davenport, Dubois (Clearfield
Co.).
1st V. Pres.. Irwin R. Mohney, Brookville.
2d V. Pres... Alverdi J. Simpson, Summerville.
Sec.-Treas. .. Norman C. Mills, Eleanor.
Reporter William A. Hill, Reynoldsville.
Censor Abraham F. Balmer, Brookville.
Exec. Com .. Samuel M. Davenport, Dubois (Clearfield
Co.).
Norman C. Mills, Eleanor.
Spencer M. Free, Dubois (Clearfield Co.).
Committee on Public Policy and Legislation:
Spencer M. Free, Dubois (Clearfield Co.).
William F. Beyer, Punxsutawney.
Harry P. Thompson, Brookville.
Alverdi J. Simpson, Summerville.
Harry B. McGarrah, Timblin.
Prog. Com. .Spencer M. Free, Dubois (Qearfield Co.),
John H. Murray, Punxsutawney.
Norman C. Mills, Eleanor.
Stated meetings the second Thursday of each month
at place determined by vote. Election of officers in
January.
MEMBERS (46)
Balmer, Abraham F., Brookville.
Benson, Joseph P., Punxsutawney.
Beyer, S. Meigs, Punxsutawney.
Beyer, William F., Punxsutawney.
Booher, Jay C, Falls Creek (Qearfield Co.).
Borland, James C, Falls Creek (Clearfield Co.).
Bowser, Ira D., Reynoldsville.
FBrown, John K., Brookville.
Davenport, Samuel M., Dubois (Clearfield Co.).
Free, Spencer M., Dubois (Clearfield Co.).
Fulton, Howard C„ Dubois (Qearfield Co.).
Gatti, William J. Punxsutawney.
Gourley, Russell C, Punxsutawney.
Cirube, John E., Punxsutawney.
Hayes, Leo Z., Force (Elk Co.).
Heid, Edward F., Brockwayville.
Hill. William A., Reynoldsville.
HufT. Samuel R.. Eldred (McKean Co.).
Jaquish, Elyin W., Punxsutawney.
lohnstone. Charles W., Dubois (Clearfield Co.).
Jordan, Ralph Ross, Dubois (Clearfield Co.).
Kearney, J. Gardner, Reynoldsville.
Lorenzo, Frank A., Punxsutawney.
McGarrah, Harry B., Timblin.
Maine, Charles L., Dubois (Clearfield Co.).
Matson, Walter W., Brookville.
Mills, Norman C, Eleanor.
Mohney, Irviri R., Brookville.
Murray, John H., Punxsutawney.
Musser, Guy M., Punxsutawney.
Neale, James B., Reynoldsville.
Newcome, John A., Vandergrift (Westmoreland Co.).
Newcome, William C, Big Run.
O'Neal, Harry A., Brookville.
Pringle, Francis D., Punxsutawney.
Raine, J. Franklin, Sykesville.
Schumacher, Forrest L, Dubois (Clearfield Co.).
Scott, Qinton H., Brookville.
Simpson, Alverdi J., Summerville.
Smathers, Francis C, Pimxsutavwiey.
Snyder, Wayne L., Brookville.
Stauflfer, John A., Rossiter (Indiana Co.).
Stevenson, Charles R., Delancey.
Thompson, Harry P., Brookville.
Vosburg, Harry A., Jr., Tyler (Clearfield Co.).
Walter, Jacob A., Punxsutawney.
JUNIATA COUNTY SOCIETY
(Organized Aug. 7, 1907)
President... John W. Deckard, Richfield.
1st V. Pres.. William H. Banks, Mifflintovim.
2d V. Pres... Isaac G. Headings, McAlisterville.
Secretary... Brady F. Long, Mifflin.
Treasurer... Isaac G. Headings, McAlisterville.
Reporter Benjamin H. Ritter, McOjysville.
Censors Amos W. Shelley, Port Royal.
William H. Haines, Thompsontown.
Committee on Public Policy and Legislation:
Amos W. Shelley, Port Royal.
Joseph G. Brown, Okeson.
Meetings held the first Wednesday of January, April,
July and October at 1 p. m., In the Tuscarora Club
Rooms, Miffltntown. Election of officers in January.
MEMBERS (13)
Banks, William H., Mifflintown.
Brown, Joseph Stewart, Okeson.
Crawford, Darwin M., Mifflintown.
Deckard, John W., Richfield.
Haines, William H., Thompsontown.
Headings, Isaac G., McAlisterville.
Long, Brady F., Mifflin.
Metz, Samuel F., Thompsontown.
Quig, Robert M., East Waterford.
Ritter, Benjamin H., McCoysville.
Shelley, Amos W., Port Royal.
Shelley, Penrose H., Port Royal.
Willard, Herman F., Mexico.
LACKAWANNA COUNTY SOCIETY
(Organized Nov. 20. 1878.)
(Scranton is the post office when street address only is
given.)
President. ..Daniel E. Bemey, Connell Bldg.
1 St V. Pres.. William H. Berge, Main St., Avoca (Lu-
zerne Co.).
2d V. Pres... U. Grant Anderson, Main St., Carbondale.
Sec.-Treas... James D. Lewis, 204 W. Market St.
Librarian Frederick P. Hollister, 508 Dime Bank
Bldg.
Censors Nelson E. Newberry, 1515 Capouse Ave.
Charles Falkowsky, 'Jr., 327 Spruce St.
Joseph C. Reifsnyder, Connell Bldg.
Trustees John B. Corser, 345 Wyoming Ave.
Daniel A. Capwell, Scranton Real Estate
Bldg.
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MEMBERSHIP LIST
745
Lowell M. Gates, 802 Mulberry St.
Morgan J. Williams, 302 S. Main St.
Addison W. Smith, 219 Jefferson Ave.
Committee on Public Policy and Legislation:
Joseph C. Reifsnyder, Connell Bldg.
William Lynch, Farview (Wayne Co.).
Nelson E. Newberry, 1515 Capouse Ave.
Leo P. Gibbons, Connell Bldg.
Frederick L. Van Sickle, 212 North Third
St., Harrisburg (Dauphin Co.).
Official Publication: The Medical Society Reporter.
Issued Monthly.
Editor: Martin T. O'Malley, 306 Washington
Ave.
Regular weekly meetings are held on Tuesday even-
ings at 8:45 in the society's room, Real Estate Building,
136 North Washington Ave., Scranton, except July and
August. Election of officers in January.
MEMBERS (204)
Albertson, Harry W., 2416 N. Main Ave.
Alexander, Thomas L., 325 Senice St.
Anderson, U. Grant, Carbondale.
Amdt, Franklin F., 711 Monroe Ave.
Barder, John J., 123 Hickory St.
Bendick, John J., Olyphant.
Berge, William Henry, Avoca (Luzerne Co.).
Berney, Daniel E., Connell Bldg.
Bishop, Frederick J., 220 Connell Bldg.
Brennan, John J., 230 South Main Ave.
Breskman, Louis, 820 Main St., Dickson City.
Brown, Carl G., 322 Mulberry St.
Bryant, Frank G., 1107 Lafayette St.
Burns, Reed, 802 Jefferson Ave.
Butzner, John Decker, 506 Dime Bank Bldg.
Cantor, Aaron S., Dickson City.
Capwell, Daniel A., Real Estate Bldg.
Carr, Joseph A., Olyphant.
Carroll, Frank, 301 West Market St.
Carroll, Michael A., Rookery Bldg.
Catalano, Gregorio, Dunmore.
Cavill, Francis T., Jessup.
Clark, George A., Connell Bldg.
Clarke, Anna C, 320 Jefferson Ave.
Colcord, Albert J., Port Allegany (McKean Co.).
Conarton, Joseph L., Mayfield.
Conway, William H., Olyphant.
Cornell, Harvey B., 117 N. Main Ave.
Corser, John B., Scranton Private Hospital.
Costella, Bernard E., Vandling.
Cross, Friend A., 310 Dime Bank Bldg.
Curtin, Eugene A., Connell Bldg.
Davies, Emlyn Thomas, Old Forge.
Davies, Philip J., 608 South Main Ave.
Davies, William Rowland, Traders Bank Bldg.
Davis, Arthur E., Hotel Holland.
Davis, Fred Whitney, 433 Wyoming Ave.
Davis, William J. L., Board of Trade Bldg.
Davis, William T., County Savings Bank Bldg.
Dean, C. Ed^ar, 327 N. Washinsrton Ave.
Deantonio, Emilio, Box 68, 346 Franklin Ave.
Dolan, Willam K., 316 N. Washington Ave.
Donahoe, John P., 310 Wyoming Ave.
Dougherty, James J., Avoca (Luzerne Co).
Douglas, J. Nelson, 612 Spruce St.
Downton, Ernest W., Starrucca (Wayne Co.).
Druffner, Lewis C. Avoca (Luzerne Co.).
Edwards, Edward E., Taylor.
Elsinger, Lucius M., Connell Bldg.
Evans, Daniel W., 157 S. Main Ave.
Falkowsky, Charles, Jr., 327 Spruce St.
Flynn. Robert J.. 551 Fourth Ave.
Frey, Clarence Leslie, Dime Bank Bldg.
Fulton, William G., 433 Wyoming Ave.
Gardner, Arthur P.. Dime Bank Bldg.
Gardner, Herbert D., Scranton Private Hospital.
Garvey, Fiank C, Connell Bldg.
Garvey, Raymond J., Minooka.
Gates, Lowell M., 802 Mulberry St.
Gibbons, Leo P., Connell Bldg.
Gibbons, Myles A., Dunmore.
Gibbs, Howard W., 620 N. Washington Ave.
Gibbs, Louis H., 217 S. Main St.
Ginley, Frank, Dunmore.
Good friend, Harry, 325 Adams Ave.
Goodman, Isaac, 312 N. Washington Ave.
Grant, John W., Dickson City.
Griffiths, John L., Taylor.
Griffiths, Llewellyn D., 722 S. Main St.
Gross, Samuel, 406 Wyoming Ave.
Grover, John B., Peckville.
Hager, Albert E., Taylor.
Halpert, Henry, Connell Bldg.
Heston, Patrick J., 325 Pittston Ave.
Hollister, Frederick P., 508 Dime Bank Bldg.
Horger, Ulrich P., Old Forge.
Houser, Helen, 306 Wyoming Ave.
Jackson, Byron, County Bank Bldg.
Jenkins, David J., 234 S. Main Ave.
Johnson, William S., Carbondale.
Jones, Harry, Dickson City.
Kay, Thomas W., 506 Dime Bank Bldg.
Kearney, John V., Archbald.
Kearney, Patrick H., 312 Wyoming Ave.
Keller, William E., 510 Qay Ave.
Kelley, John F., 643 Adams Ave.
Kennedy, Lucius Carter, 1030 Green Ridge St.
Kerstetter, Paul P., 1009 S. Main Ave.
Kiesel, Ernest L., 515 Lackawanna Ave.
Killeen, Thomas G., Connell Bldg.
Knedler, J. Warren, Moscow.
Kraemer, Harry M., State Hospital.
Kulczycki, John, 429 Pittston Ave.
Leopardi, Enrico Alfredo, Old Forge.
Lewis, James D., 204 W. Market St.
Lindsay, (Jeorge G., Scranton Life Bldg.
Lloyd, Rossiter J., Olyphant.
Loftus, John, Old Forge.
Loftus, Walter E., Carbondale.
Lonergan, Philip A., Dickson City.
Longstreet, Samuel P., 511 N. Washington Ave.
Lonsdorf, Jacob John, Jr., 230 Stephen Ave.
Lynch, William, Farview (Wayne Co.).
Lyons, John W., Jessup.
McDonnell, Patrick J., Connell Bldg.
McGinty, Edward F., Olyphant.
McGuire, J. P., Forest City (Susquehanna Co.).
McKeage, Robert B., Traders Bank Bldg.
McLaine, Edward A., 433 Wyoming Ave.
MacDougall, William L., Laceyville (Wyoming Co.).
Mackintosh, James A., Archbald.
Malaun, Mervington E., Carbondale.
Manley, Peter C, 1326 Pittston Ave.
Milkman, Louis A., 1917 N. Main Ave.
Mittleman, Harry M., 504 Main St., Duryea.
Monie, Thomas, Archbald.
Moyer, Jacob C, 419 Connell Bldg.
Moylan, Francis P., 216 S. Main Ave.
Murray, Gilbert D., County Savings Bank Bldg.
Murrin, Connell Edward, 732 Pittston Ave.
Murrin, Joseph S., Carbondale.
Murphy, Frank L., Dunmore.
Myer, William W., Old Forge.
Nealon, Leo A., 425 Prospect Ave.
Newbury, Nelson E., 1515 Capouse Ave.
Newhart, Hariy S., 1206 Mulberry St.
Newman, William H., Clarks Summit.
Newton, James R., 311 Spruce St.
Niles, Frank L., Carbondale.
Niles, John S., Carbondale.
Noecker, Charles B., 216 Connell Bldg.
Noone, Michael J., 2060 N. Main Ave.
Novak, Albert A., Throop.
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746
THE PENNSYLVANIA MEDICAL JOURNAL
July, 1921
Nowicki, Zygmunt, 1101 Pittston Ave.
O'Brien, J. Emmett, Miller BIdg.
O'Connor, James J., Olyphant.
ODca, Nellie G , S. Main Ave.
O'Dea, P. John, S. Main Ave.
O'Malley, Martin F., 306 N. Washington Ave.
O'Malley, William J., 1230 Providence Rd.
O'Toole, James E., 124 S. Seventh St.
Peck, Welland A., 2604 N. Main Ave.
Peck, John L., 524 Vine St.
Peet, Ernest L., 102 W. Market St.
Pentecost, Milton L, 214-215 Traders Bank BIdg.
Price, John J., Olyjjiant.
Rea, James L., Jr., 1752 Sanderson Ave.
Rebhom, Earl H., 717 Quincey Ave.
Redding, Leonard G., Scranton Life BIdg.
Reedy, Walter M., 234 Connell BIdg.
Reifsnyder, Joseph C, Connell BIdg.
RiU, Reinhart J., 715 N. Main Ave.
Rivenburg, Sidney W., Kohima, Assam, India.
Robinson, Frederick G., Scranton Life BIdg.
Robison, John I., Union Bank BIdg.
Rodham, Thontas B., 1820 N. Main Ave.
Rosenberg, Milton M., 616 N. Washington Ave.
Ruddy, James P. H., Dime Bank BIdg.
Rutherford, Thomas A., Gark's Summit.
Salmon, William J. G., Old Forge.
Saltry, James F., Capouse Ave.
Sedlak, Frank J., 950 Prescott Ave.
Severson, Irwin W., 225 Jefferson Ave.
Shaul, Elmer B., 345 Wyoming Ave.
Shianta, Vladimir A., Olyphant.
Silverstein, Nathan, 540 Wyoming Avenue.
Simpson, Eugene R., Peckville.
Simrell, Herbert E., Qark's Summit.
Skeoch, James R., 1000 Webster Ave.
Smith, Addison W., 225 Jefferson Ave.
Stegner, Adam, Rendham.
Stevens, Floyd W., 135 S. Blakely St., Dunmore.
Sturge, Edgar, 1200 Providence Rd.
Sullivan, John J., Jr., Traders Bank BIdg.
Sullivan, John J., Sr., 2006 Wayne Ave
Sureth, Theodore, Traders Bank BIdg.
Swift, Frank L., Dunmore.
Shepherd, Richard C, 633 E. Market St.
Thomson, Charles E., Scranton Private Hospital.
Thompson, James J., Carbondale.
Timlin, John J., Old Forge.
Van Doren, William, Archbald.
Van Sickle, Frederick L., 212 North Third St., Har-
risburg (Dauphin Co.).
Van Vechten, George J, Olyphant •
Villone, Joseph, 206 Chestnut St
Von Poswik, Gisela, 211 Jefferson Ave.
Vorhees, Samuel H., Peckville.
Wagtner, Joseph A., Throop.
Wahl, John C, 328 Pittston Ave.
Wainwright, Jonathan M., Co. Savings Bank BIdg.
Walker, Patrick H., 509 Luzerne St.
Wall, Russell T., 516 Spruce St.
Walsh, Anthony T., 306 Pittston Ave.
Watson, Stephen S., Moosic.
Webb, Daniel A., 310 Wyoming Ave.
Wheelock, Frank R., 824 N. Main Ave.
White, J. Norman, 832 N. Main Ave.
White, Robert V., Brooks BIdg.
Williams, Morgan /., 302 S. Main Ave.
Wilson, John D., 225 Jefferson Ave.
Winter, Stanley, Avoca (Luzerne Co.).
Wormser, Bernard B., Board of Trade BIdg.
Zeller, Charles A., Dalton.
Zychowicz, John F., 314 Pittston Ave.
LANCASTER COUNTY SOCIETY
(Organized Jan. 26, 1844. Incorporated April 15, 1844.)
(Lancaster is the post office when street address only
is given.)
President. . .Edgar J. Stein, 225 N. Duke St.
1st V.Pres.. Tobias C. Shookers, 14o N. Prince St
2d V. Pres... William W. Workman, Mount Joy.
Sec.-Trcas... Horace C. Kinzer, 128 N. Duke St
Reporter — Walter D. Blahkenship, 144 E. Chestnut
St.
Onsors Jacob R. Lehman, Mountville.
John J. Newpher, Mount Joy.
Henry Walter, Rothsville.
Trustees.... J. Paul Roebuck, 233 N. Duke St
Frank Alleman, 420 W. Chestnut St
Lewis M. Bryson, Paradise.
Committee on Legal Affairs :
John L. Atlee, 37 E. Orange St
Frank Alleman, 420 W. Chestnut St
Walter F. Blankenship, 144 E. Chestnut
St
Committee on Public Policy and Legislation:
Frank G. Hartman, 136 N. Duke St.
Theodore B. Appel, 305 N. Duke St.
Horace C. Kinzer, 128 N. Duke St
Official Publication: The Bulletin.
Issued Monthly.
Editor: Walter D. Blankenship, 144 E. Chestnut
St
Stated meetings at Medical Gub Rooms, 16 South
Prince St.. Lancaster, the first Wednesday of each
month, at 2 p. m. Election ot officers in January.
MEMBERS (128)
Achey, Frederick A., 42 S. Prince St.
Alexander, Guy Levis, Clayton, Del.
Alleman, Frank, 420 W. Chestnut St
Appel, Theodore B., 305 N. Duke St
Armstrong, James, 732 Walnut St., Columbia.
Atlee, John L., 37 E. Orange St.
Baer, Walter K., 223 N.. Duke St.
Barsumian, Hagop G., 205 E. King St.
Binkley, William G., Washington Boro.
Bitzer, Newton E., 236 W. Chestnut St.
Blankenship, Walter D., 144 E. Chestnut St
Blough, Henry K., Elizabethtown.
Bolenius, Robert M., 48 S. Queen St.
Bowman, Abraham G., 318 N. Duke St.
Breneman. Park P., 146 E. Walnut St.
Bricker, Elizabeth Bausman, Lititz.
Bryson, Howard R., 246 W. Orange St.
Bryson, Lewis M., Paradise.
Gary, Dale Emerson, 204 E. King St.
Davis, Henry B., 241 E. King St
Davis, Miles L., 114 N. Prince St
Day, George E., Strasburg.
Deck, Roy, 234 N. Duke St.
Denlinger, Maurice M., Rohrerstown.
Denney, John D., Columbia.
Dunlap, J. Francis, Manheim.
Farmer, Clarence R., 573 W. Lemon St.
Fox, William Garfield. 48 E. Orange St.
Frew, George W. H.. Paradise.
Garretson. William, East Petersburg.
Garvey, Thomas O., 443 W. Chestnut St.
Gerhart, Milton U., 43 S. Prince St.
Good, Benjamin F., Washington Boro. R. D. 1.
Hamaker. William B., 235 N. Duke St.
Harter, G. Alvin. Mavtown.
Hartman. Frank G., 1.% N. Duke St
Heller, Samuel H., 10 N. Mulberry St
Helm, Charles E.. Quarryville.
Helm, John D., New Pmvidence.
Herr. Ambrose T.. 4^1 College Ave.
Herr. Benianiin F.. Millersville.
Herr, John T.. Landisville.
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July, 1921
MEMBERSHIP LIST
747
Herr, William H., 226 N. Duke St.
Herr, William M., 224 W. Orange St.
Hershey, George Blair, Gap.
Hershey, Jacob D., Manheim.
Hertz, John L., Lkitz.
Hess, Ammon Gross, Mountville.
Hess, William G., c/o Water and Power Co., Holt-
wood.
Hostetter, Jacob E., Gap, R. D. 1.
Ilyus, Edmund B., 130 E. Walnut St
Ingram, Theodore E., Marietta.
Irwin, Thaddeus S., Christiana.
Kendig, Benjamin E., Salunga.
Kendig, Jerome S., Salunga.
Kennedy, Joseph P., Columbia.
Keylor, Walter N., Leacock.
Kinard, George W., Leacock.
Kinard, George C, Lincoln.
Kinzer, Horace Clemens, 128 N. Duke St.
Kohibraker, George H., 130 E. Main St., Ephrata.
Leaman, Walter J.t Leaman Place.
Lefever, Willis Hess, 220 N. Duke St.
Leh, Homer D., 222 N. Duke St.
Lehman, Jacob R., Mountville.
Leslie, Leroy K., Bareville.
Lightner, Isaac Newton, Ephrata.
Long, Howard A., Brickville.
Lowell. Francis Carroll, 113 E. Walnut St.
Markel, Chester F., Columbia.
Martin, Daniel Webster, Manheim.
Martin, Dwight C, Lhitz.
Martin John R. S., Jr., Christiana.
Mentzer, John F., Ephrata.
Miller, Samuel W., 217 E. King St.
Mowery, Harry A., Marietta.
Moorehouse, William G.. 23 S. West End Ave.
Musset, J. Henry, Lampeter.
Mylin, Walter F., Intercourse.
Netcher, Charles E., 609 W. Orange St.
Newpher, John J., Mount Joy.
Noble, Edward I., 145 N. Duke St.
Pickel, J. Harry, Millersville.
Pomerantz, Harry, 26 E. Walnut St.
Posey, Silas Robert, Lititz.
Price, John B., 134 N. Duke St.
Reemsnyder, Byron J., Ephrata, R. D. 3.
Reemsnyder, Henry G., Ephrata.
Reeser, Norman B., Lititz.
Reeser, Richard, Columbia.
Ressler, Jacob L., Bird-in-Hand.
Rine, Sedic A., Lampeter.
Ringwalt, Martin, Rohrerstown.
Roebuck, J. Paul, 233 N. Duke St.
Rohrer, George R., 45 E. Orange St.
Roop, Harry B., Columbia.
Rothermel, Lewis R., Denver.
Royer, Jacob W., Terre Hill.
Russell,' Evans D., Reamstown.
Shaeffer, Peter F., Christiana.
Shartle, J. Miller, 30 S. Prince St.
Shear, Lewis M., 601 Manor St.
Shockers, Tobias C, 146 N. Prince St.
Simons, Isaac Shirk, Elizabethtown.
Smith, Edward K., Millersville.
Snyder, Asher F., Mount Joy.
Stahr, Charles P., 139 E. Walnut St.
Stein, Edgar J., 225 N. Duke St.
Steele, Marshall K., Quarryville.
Stever, John C, Bainbridge.
Steward, William J., State Inst., Pennhurst (Chester
Co.).
Stubbs, Ambrose H., Peach Bottom.
Sultzbach, Henry Miller, 231 E. King St.
Swab, Robert D., 23 E. Walnut St.
Thome, Winfield M., Mount Joy.
Tinney, W'lliam Scott, Strasburg.
Treichler, Vere, Elizabethtown.
Trexler, Jacob F., 134 N. Prince St. .
Walter, Adam V., Brownstown.
Walter, Henry, Rothsville.
Wentz. Paul R., New Holland.
Winters, John L., Blue Ball.
Witmer, Charles Howard, 126 E. Chestnut St.
Witmer, Elias H., Neffsville.
Workman, William M., Mount Joy.
Yoder, Mahlon Harold, Lititz.
Yost, Jchn W., Bethesda.
Zeigler, James P., Mount Joy.
LAWRENCE COUNTY SOCIETY
(Organized Oct. 7, 1897.)
President... Charles M. Iseman, EUwood City.
1st V.Pres.. James C. B. Douthett, New Castle.
2dV. Pres...Hollis G. Dean, New Castle.
Secretary... William A. Womer, New Castle.
Treasurer... William C. Burchfield, New Castle.
Censors Henry E. Helling, Ellwood City.
John Foster, New Castle.
Walter L. Campbell, New Castle.
Committee on Public Policy and Legislation:
C. Fenwick McDowell, New Castle.
Harry W. McKee, New Castle.
Colin M. Dumm, Ellwood City.
Entertainment Committee:
Jesse O. Brown, Ellwood City.
John Foster, New Castle.
Jesse R. Cooper, New Castle.
Official Publication: The Bulletin of the Lawrence
Coimty Medical Society.
Issued Monthly.
Editor: William A. Womer, New Castle.
Society meetings in society room in Greer Block,
New (^stle, on the first Thursday of every month at
8:30 p. m. Election of officers in January.
MEMBERS (59)
Blackwood, James M., New Castle.
Boak, Robert G., New Castle.
Brice, Patrick J., New Castle.
Brown, Jesse O., Ellwood City.
Burchfield, William Qinton, New Castle.
Campbell, Frank D., Hillsville.
Campbell, Walter L., 615 Croton Ave., New Castle.
Clark, William A., Jr., New Wilmington.
Geland, William D., New Castle.
Cook, Katharine M., New Wilmington.
Cooper, Jesse R., New Castle.
Davis, (jharles W., New Castle.
Dean, Holtis G., New Castle.
Douthett, James C. B., New Castle.
Duff, Thomas, Wampum.
Dumm, Cx)lin M., Ellwood City.
Eakin, F. Earle, New Castle.
Evans, William G., Ellwood City.
Flannery, Charles F., New Castle.
Foster, John, 36 Mercer St., New Castle.
Gageby, Lenore H., 1115 Ocean Front, Venice, (Cali-
fornia.
Grossman, I^uis W., New Castle.
Guy, Franklin W., 311 N. Liberty St., New Castle.
Harper, H. Cyrus, New Castle.
Helling, Henry E., Ellwood City.
Hunt, Charles B., 473 E. Washington St., New Castle.
Iseman, Charles M., Ellwood City.
Kaplan, Eliah, New Castle.
Lindley, Don C, New Castle.
McComb, Edwin C, Thayer BIdg., New Castle.
McCune, Samuel R. W., New Castle.
McDowell, C. Fenwick, New Castle.
McGiffin, Matthew N., New Bedford.
McKee, Harry W., New Castle.
McLaughry, Elizabeth M., New Castle.
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748
THE PENNSYLVANIA MEDICAL JOURNAL
July, 1921
Mitchell, Henry C, New Castle.
Perry, Samuel W., 225 E. Long Ave., New Castle.
Pollock, James K., New Castle.
Popp, James M., New Castle.
Ramsey, Wayne S., Pearson House, New Castle.
Reed, Charles A., 26 N. Mercer St., New Castle.
Sankey, Brant E., 118 N. Jefferson St., New Castle.
Shaffer, Thomas M., New Castle.
Shoaff, Paris, New Castle.
Smyser, Charles J., New Wilmington.
Snyder, Ernest Ulysses, Wallace Block, New Castle.
Steen, William L., N. Jefferson St., New Castle.
Trainor, Charles E., US E. North St., New Castle.
Tucker, John D., New Castle.
Urey, Frank F., E. Washington St., New Castle.
Urmson, Allan W., New Castle.
Wallace, Robert A., New Castle.
Warner, Samuel L., New Castle.
Williams, Thomas V., New Castle.
Wilson, Henry R., 373 Washington St., New Castle.
Wilson, Loyal W., New Castle.
Womer, William A., New Castle.
Worral, Emma Hodge, Pulaski.
Zerner, H. Elmore, New Castle.
Zimmerman, Curtis L., Lebanon.
Zimmerman, Frank D., Schaefferstown.
LEBANON COUNTY SOCIETY
(Organized March, 1847.)
President... Franklin B. Witmer, Lebanon.
1st V.Pres.. David M. Rank, Annville.
2dV. Pres...Abner W. Shultz, Lebanon.
Secretary. ..John E. Marshall, Lebanon.
Treasurer... J. DeWitt Kerr, Lebanon.
Reporter W. Horace Means, Lebanon.
Censors John C. Bucher, Lebanon.
Edwin B. Marshall, Annville.
Committee on Public Policy and Legislation:
John C. Bucher, Lebanon.
John Walter, Lebanon.
Albert S. Reiter, Myerstown.
Stated meetings the second Tuesday of each month at
2:30 p. m.. Court House, Lebanon. Election of officers
in January.
MEMBERS (33)
Bashore, Simeon D., Palmyra.
Beckley, Joseph R., Lebanon.
Boltz, Elias K., Lebanon.
Bordner, David Stanton, Palmyra.
Brubaker, Walter H., Lebanon.
Bucher, John C, Lebanon.
Fretz, Milton B., Palmyra.
Groh, John B., Lebanon.
Groh, John L., Lebanon,
Guilford, William M., Lebanon.
Kerr, J. DeWitt, Lebanon.
Light, John J., Liebanon.
Light, Lincoln R., Lebanon.
Light, Seth A., 604 Cumberland St., Lebanon.
Marshall, Edwin Bell, Annville.
Marshall, John E., Lebanon.
Maulfair, Harvey E., Lebanon.
Means, W. Horace. High St., Lebanon.
Rank, David M., Annville.
Reich, Paul D., Jonestown.
Reiter, Albert S., Myerstown.
Risscr, Ulysses G., (jampbelltown.
Roedel, William R., Lebanon.
Rutherford, Frank A., 518 Cumberland St., Lebanon.
Saylor, Qyde J., Lebanon.
Schultz, Abner W., Lebanon.
Shope, Samuel Z., 2018 Chestnut St., Philadelphia
(Phila. Co.).
Strickler, Charles M, Lebanon.
Walter, Tohn, Lebanon.
Weiss. Alfred S., 630 Chestnut St., Lebanon.
Witmer, Franklin B., Lebanon.
LEHIGH COUNTY SOCIETY
(Organized 1850.)
(Allentown is the post office when street address only
is given.)
President. . .R. Cx>melius Peters, 402 N. Eighth St.
1st V. Pres. .Hope T. M. Hitter, 101 N. Eleventh St
2d V. Pres. .. Howard B. Erdman, Macungie.
Secretary... J. Treichler Butz, Room 311, City Hall.
Treasurer... Willard D. Kline, 24 N. Eighth St.
Reporter.... Frederick R. Bausch, 109 N. Second St.
Librarian... Elmer H. Bausch, 252 N. Seventh St.
Censors Charles O. Henry, 102 N. Tenth St.
Edward W. Feldhoff, 1224 Turner St.
William B. Trexler, Fullerton.
Committee on Public Policy and Legislation:
Thomas H. Weaber, 211 N. Eighth St.
Martin J. Backenstoe, Emaus.
William B. Trexler, Fullerton.
Official Publication: Lehigh County Medical Bulletin.
Issued Monthly.
Editor: J. Treichler Butz, Room 311, City Hal!.
Stated meetings at the Chamber of Commerce
Rooms, Allentown, on the second Tuesday of eadi
month at 2:30 p. m. Election of officers in January.
MEMBERS (99)
Albright, Roderick E., 135 S. Fifth St.
Bachman, Rowland W., 301 N. Second St.
Backenstoe, Martin J., Emaus.
Backenstoe, William A., Emaus.
Baer, Harry A. D., 1146 Hamilton St.
Baker, Harry L., Catasauqua.
Bausch, Elmer H., 252 N. 7th St.
Bausch, Frederick R., 109 N. Second St.
Beck, Foster A., Allentown.
Boyer, Frank S., 16 N. Second St.
Boyer, George H., 528 N. Sixth St.
Brady, Walter C, Slatedale.
Bruch, Elmer C, 314 Hanover St., Bethlehem (North-
ampton Co.).
Biitz, J. Treichler, 304 N. Ninth St.
Butz, Warren H., 1338 Walnut St.
Cook, Thomas W., 631 St. John St.
Dickenshied, Eugene H., 14 N. Seventh St.
Diefenderfer, Alan L., Slatington.
Eckert, John T., 438 N. Sixth St.
Erdman, Howard B., Macungie.
Eshbach. William W., 520 Union St.
FeWhoff, Edward W., 1224 Turner St.
Fetherolf, Frederick A., 941 Hamilton St.
Fetherolf, William J., Steinsville.
Fogel, Solon C. B., 36 N. Twelfth St.
Gangewere, Victor J , Hanover BIdg.
Gearhart, Ethan A., 547 N. Eleventh St.
Gerberich, Arthur F., Limeport.
Guth, Henry E., Orefield.
Guth, Nathaniel C. E., 527 Liberty St.
Haas, Milton J., 1353 Chew St
Haff, Charles A., Northampton (Northampton Co.).
Harding, Frederick B., 959 Hamilton St.
Hartzell, William H., 22 N. Eifrhth St.
Hausman, William A.. Jr., 1116 Hamilton St.
Hendricks, Augustus W., 453 N. Sixth St.
Henry, Charles O., 102 N. Tenth St.
Herbst, Wflliam F., 28 N. Fifth St.
Hertz, William J., 125 N. Eighth St.
Holben, Franklin J., Schnecksville.
Hombeck, James L., Catasauqua.
Huebner. Irwin F., 802 Walnut St.
Jordan, Henry D., 544 N. Sixth St.
Keim, Harry J. S., Catasauqua.
Kemp, Maurice, 128 S. Madison St.
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JUI.Y, 1921
MEMBERSHIP LIST
749
Kern, Alvin J., Slatington.
Kern, Harrison B., Slatington.
King, Robert C, Hellertown (Northampton Co.).
Kistler, Jesse G., 1615 Oiew St
Kistler, Nelson F., 206 N. Ninth St
Kleckner, Martin S., 202 N. Eighth St
Kline, WUlard D., 24 N. Eighth St.
Klingaman, Harry E., Emaus.
Koch, Morris H., 1131 Linden St
Kress, Palmer J., 24 S. Seventh St
LaBarre, Louis C., 936 Hamilton St
Lawall, Griffith S., 534 N. Sixth St
Lear, John, 1038 Hamilton St
Lowright, Wallace J., Crater Valley.
McAvoy, Jeremiah F., Catasauqua.
Masonheimer, Willard C, 130 N. Seventh .St.
Matz, John D., 26 S. Seventh St
Mickley, Howard P., Neffs.
Miller, Albert N., East Texas.
Miller, Mahlon G., Siegfried (Northampton Co.).
Minner, J. Edwin S., Egypt.
Mohr, Eugene H., Alburtis.
Muschlitz, Charles H., Slatington.
Newhart, Carl J., Hokendauqua.
Noble, John W., 36 N. Jefferson St
Otto, Calvin J., 130 N. Seventh St
Parmet, David H., 436 Tilghman St
Peters, Nathaniel C, Cementon.
Peters, R. Cornelius, 402 N. Eighth St.
Peters, Warren J., 214 N. Thirteenth St.
Quinn, Sydney A., 753 N. Sixth St
Reitz, Charles B., Palmerton (Carbon Co.).
Riegel, William A., Catasauqua.
Ritter, Hope M., 101 N. Eleventh St
Rogers, Garence C, 322 £. Hamilton St
Schaeffer, Charles D., 28 N. Eighth St
Schaeffer, Forrest G., 143 N. Eighth St
Schaeffer, Robert L., 28 N. Eighth St.
SchaU, William J., 1022 Walnut St
Scheirer, Franklin B., 402 N. Sixth St
Schlesman, Charles H., 216 N. Seventh St.
Schneller, John, Catasauqua.
Seiberling, George F., 956 Hamilton St.
Shoemaker, Paul C, 45 N. Ninth St.
Smyth, Thomas L., 430 N. Second St
Sowden, Edgar L., Slatedale.
Trexlcr, William B., FuUerton.-
Troxell, William C, 502 N. Second St.
Weaber, Thomas H., 211 N. Eighth St.
Weaver, Aaron D., Macimgie.
Weaver, Joseph M., 48 S. Tenth St
Weida, Tsadore J., Emaus.
Wentz, Frank R., 610 N. Sixth St
Young, Mark, 728 N. Seventh St.
LUZERNE COUNTY SOCIETY
(Organized March 4, 1861.)
(Wilkes-Barre is the post office when street address
only is given.)
President. . .Lewis Edwards, 790 Market St., Kingston.
V. Pres Walter Davis, 24 S. Washington St
Secretary. . .Elmer L. Meyers, 239 S. Franklin St
Fin. Sec Marshall C. Rumbaugh, 618 Wyoming
Ave., Dorranceton (Kingston P. O.).
Treasurer.. .Ernest U. Buckman. 70 S. Franklin St.
Librarian Lewis H. Taylor, 83 S. Franklin St
Censors Lawrence A. Sheridan, 247 N. Main St
Charles L. Ashley, 118 Main St
Nathaniel Ross, 434 S. Franklin St.
Directors . . . Lewis Edwards, 790 Market St, Kingston.
Walter Davis, 24 S. Washington St
Samuel P. Mengel, 181 S. Franklin St.
Samuel M. Wolfe, 218 S. Franklin St.
Daniel G. Robinbold, 1170 Wyoming. Ave.
Forty Fort (Kingston P. O.).
Committee on Public Health Legislation:
Malcolm C. Guthrie, 109 S. Franklin St.
Daniel F. Dail^, 214 Chestnut St., Kings-
ton.
Chester H. Philips, Miners' Bank BIdg.
Official Publication: Transactions of the Luzerne
County Medical Society.
Issued Annually.
Editor: Lewis H. Taylor, 83 S. Franklin St.
Stated scientific meetings in the Society's Building,
South Franklin St., Wilkes-Barre, first and third
Wednesdays of each month, except July and August,
at 8:30 p. m. Election of officers last meeting in De-
cember. Business meetings second Wednesday of each
month.
MEMBERS (227)
Adams, Erick A., 259 Dana St.
Ahlbom, Maurice B., 99 N. Franklin St.
Andreas, (ieorge R., 204 E. South St.
Ashley, Charles L., 118 W. Main St, Plymouth.
Baker, Albert J., 811 N. Main St., Duryea.
Baker, Gordon E., 1659 Wyoming Ave., Forty Fort.
Barney, Delbert, 55 N. Washington St.
Barton, A. Arthur, 20 Main St., Plains.
Beaver, James R., 40 Luzerne Ave., West Pittston.
.Becker, Conrad J., 679 Hazel St.
Bennett, Oarence E., 14 Green St., Nanticoke.
Biehl, Jefferson P., 34 Center Ave., Plymouth.
Bixby, Edward W., 61 W. Ross St.
Blair, Lovisa Ida, 342 S. River St.
Blazejewski, Stanley W., 46 S. Washington St.
Briggs, Miron L., Shick^inny.
Brooks, Allan C, 84 N. Franklin St
Brooks, James, Main St, Plains.
Brosius, Peter F., 639 W. Diamond Ave., Hazleton.
Brown, Harry A., Lehman.
Buckley, Ralph Emerson, 143 N. Church St., Hazleton.
Buckman, Ernest U., 70 S. Franklin St.
Burke, Richard J., 15 S. Hudson St, Miners Mills.
Burkhardt, George F., 109 S. C^edar St., Hazleton.
Bums, John R., 246 Scott St.
Caffrey, Anthony J., 311 S. Washington St.
Carr, (korge W., 54 S. Franklin St
Carter, William S., 15 W. Broad St., Hazleton.
Qark, (leorge A., 326 S. Main St.
(3ollmann, Xavier K., 93 E. Main St.
Cook, Benjamin B., Wapwallopen.
(Zonnole, John F., 108 Church St, Plymouth.
Connole, Joseph V., Miners' Bank Bldg.
Corrigan, James A., 336 W. Broad St., Hazleton.
Corrigan, John J., 336 W. Broad St., Hazleton.
Corrigan, William H., 141 S. Washington St.
Costello, Edmund A., 72 Park Ave.-
Creasy, Raymond C, 195 S. Franklin St.
(Tressler, John Webster, 152 Hanover St.
Croop, Harry W., 234 Rutter Ave., Kingston.
Cuozzo, James A., 530 Carson St., Hazleton.
Dailey, Thomas J., 15^2 W. Main St., Plymouth.
Daley, Daniel F., 214 Chestnut St., Kingston.
Danzer, William F., 226 W. Broad St., Hazleton.
Dattner, Abram, 289 N. Main St.
Davis, Walter, 24 S. Washington St.
Davis, William J., 225 S. Barney St.
Davison, William F., 31 Union St., Dorranceton
(Kingston P. O.).
Deibel, Henry W., 531 S. River St.
Dessen, Louis A., 26 W. Diamond Ave., Hazleton.
Dickinson, (Tharles S., Freeland.
Dinkelspiel, Max R.. 20 N. Franklin St.
Dixon, James S., 30 Broad St., Pittston.
Dodson, Boyd. 186 Dana St.
Dodson, Daniel W., 130 Prospect St., Nanticoke.
Dolphin, Joseph F., Miners' Bank Bldg.
Donnelly, Francis E., 78 Lee Park Ave.
Dougherty, Joseph P., 41 N. Main St., Ashley.
Doyle, William J., 558 Hazel Ave.
Digitized by
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THE PENNSYLVANIA MEDICAL JOURNAL
July. 1921
Drake, George R., 135 W. Main St, Plymouth.
Dyson, John R., '^^ N. Church St., Hazleton.
Edwards, Lewis, /'QO Market St., Kingston.
I£d wards, Vivian P., 535 Main St., Edwardsville.
(Kingston P. O.).
Ellsworth, Elijah M., 80 N. Dorrance St., Dorranceton
(Kingston P. O.).
Ernst, Qiarles H., XI Academy St.
Everett, Shem A., Freeland.
Fabian, Andrew A., 137 Wilson St., Larksville (Ply-
mouth P. O.).
Pagan, Patrick E., 626 Alter St., Hazleton.
Farrar, John K., Audenried (Carbon Co.).
Fischer, Herman A., 316 S. Washington St.
hlanagan, Edward J., 205 Blackman St.
Fleming, James C, Dallas.
Fleming, xhomas F., 1210 Wyoming Ave., E.xetcr Boro.
Foss, Walter B., 36 N. Main St., Ashley.
Foster, Alfred E., 271 Barney St.
Foster, Wilbur A., Mountain Top.
Freeman, Stanley L., 132 S. Franklin St.
French, Samuel, Miners' Bank Bldg.
Gaughan, Martin C, 127 Broad St., Pittston.
Gaughan, Robert A., 180 N. Laurel St., Hazleton.
Geist, James W., 529 S. Franklin St.
Genung, Benjamin W., 203 Wilkes-Barre St., White
Haven.
Gibby, Herbert B., 96 S. Franklin St.
Gildea, John J., 480 N. Penna. Ave.
Gilligan, James P., 359 Scott St.
Griffith, Morgan E., 17 W. Ross St.
Groblewski, Casimir C, 20 Elm St., Plymouth.
Grover, Alfred Woodward, 256 Maple St., Kingston.
Gryczka, Stephen W., 207 Slocum St., Kingston.
Guthrie, Malcolm C, 109 S. Franklin St.
Hanlon, Edward F., 158 N. Wyoming St., Hazleton.
Harrington, George W., 544 N. Vine St., Hazleton.
Harrison, William F., 14 W. Carey St., Plains.
Hartman, William L., 806 Susquehanna Ave., West
Pittston.
Hauslohner, Austin L., 32 N. Washington St.
Hazlett, Almon C, 8 W. Eighth St., Wyoming.
Helman, William S., 621^ S. Main St., Avoca.
Hcyer, EMward G., State Hospital, Nanticoke.
Heyer, Frederick W., State Hospital, Nanticoke.
Higgs, Charles J., 57 Carey Ave.
Hilbert, John A., 6 N. Main St., Pittston.
Hinrichs, August G., 22 N. Main St., Pittston.
Hoffman, George L., 1110 Wyoming Ave., Kingston.
Howell, Gideon L., Trucksville.
Howell, John T., 84 N. Main St.
Howorth, John, 64 N. Franklin St.
Hubler, Philip F., 230 Parke St., West Pittston.
Huebner, Dewees A., Fern Glen.
Hughes, Willet E., 59 N. Main St., Ashley.
Hugo, John A., 127 Espy St., Nanticoke.
Jacobosky, Cyrus, 20 N. Franklin St.
James, Uriah A., 18 N. Main St., Pittston.
Jamison, Peter H., Nescopeck.
Judge, (diaries A., 405 Chestnut St., Kingston.
Kaufman, Albert, 51 N. Washington St.
Keller, Harry M., 215 W. Broad St., Hazleton.
Kerr, Percival M., 204 S. Franklin St.
Kingsbury, Dana W., 137 State St., Nanticoke.
Kirschner, John W., 63 Main St., Luzerne.
Kistler, Oliver F., 43 N. Franklin St.
Kleintob, Freas B., 270 Wyoming Ave., Wyoming.
Kocyan, Joseph J., 60 Hudson Rd.,- Plains.
Kochcznyski, Joseph C, Beishline Bldg., Hazleton.
Koons, Robert O., Conyngham.
Kosek, Frank J., 447 N. Main St.
Krajewski, Frank J., 61 N. Washington St.
Krych, Felix J., 285 Main St., Kingston.
Kudlich, Manfred H.. 29 W. Maple St., Hazleton.
I^ing, Henry M., Dallas.
Uke. David H., 137 Maple St.. Kingston.
Lance, Ruth Mitchell, 44 Reynolds St., Kingston.
Lathrop, Walter, State Hospital, Hazleton.
Lavin, John L., 36 Perrin St., Swoyersville (Kingston
P. O.).
Lenahan^ Hugh J., 10 Charles St., Pittston.
Long, Charles, 33 S. Washington St.
Long, (Charles A., Muhlenberg.
Lynn, Walter L., 398 N. Main St.
McClintock, Andrew T., 73 W. Northampton St.
McConnon, (Jeorge H., Savoy Bldg.
McGuire, William J., 357 E. South St.
McHugh, John J., 124 George Ave., Parsons.
McHugh, Patrick F., 211 Parrish St.
McLaughlin, Patrick A., 71 S. Washington St.
McLaughlin, Thomas V., 68 S. Washington St.
McNelis, Joseph, City Hospital.
Mahon, John B., 32 N. Main St., Pittston.
Marvin, Merton E., 19 Main St., Luzerne.
Matlack, Granville T., 33 W. Northampton St
Mayock, Peter P., 68 S. Main St.
Meixell, Edwin W., 25 W. Ross St
Mengel, Samuel P., 181 S. Franklin St.
Merritt, T. Gray, 215 Wyoming Ave., West Pittston.
Meyers, Elmer L., 239 S. Franklin St.
Miner, CJiarles H., 115 S. Franklin St.
Molinelli, John H., 106 N. Main St, PitUton.
Moore, (Charles E., Alden Station.
Morgan, Ashton H., 361 E. Market St
Mulligan, James A., 15 N. Main S*-. Plains.
Mundy, Leo C, 400 Scott St.
Murray, Michael A., 243 S. Washington St.
Myers, N. Ray, Wanamie.
Neale, Henry M., Upper Lehigh.
Nealon, James M., 76 Churdi St., Plymouth.
NeUel, Charles F., E. State St., Plynwuth.
Newth, John H.. 237 S. Main St., Pittston.
Nicholson, Charles E., Post Office Building, Pittston.
Nurse, Charles T. C, 107 Hickory St.
O'Britis, Constance A., 216 Slocum St., Kingston.
Owens, Harry J., 348 W. Broad St., Hazleton.
Parfitt, Oliver A., 203 Prospect Ave., Nanticoke.
Person, William C, 152 N. Laurel St., Hazleton.
Phillips, Chester H., Miners' Bank Bldg.
Prevost Clarence W., 222 Wyoming Ave., West Pitts-
ton.
Redelin, Albert Augustus, Freeland.
Reiche, Otto C, 328 W. Broad St., Hazleton.
Richards, Emrys, 173yi N. Main St
Robinhold, Daniel G., 1170 Wyoming Ave., Forty Fort
(Kingston P. O.).
Roe, J. Irving, 317 S. River St
Rogers, Lewis Leonidas, 268 Wyoming Ave., Kingston.
Rogers, Lewis Leonidas, Jr., 73 W. Northampton St
Ross, Nathaniel, 434 S. Franklin St.
Rubinstein, Harry, 51 N. Main St., Pittston.
Ruffner, Samuel A., 169 S. Maple St., Kingston.
Rumbaugh, Marshall Qoyd, 618 Wyoming Ave., Dor-
ranceton (Kingston P. O.).
Rummage, Leiand C, Nanticoke.
Rynkiewicz, Stanley H., 445 Main St., Edwardsville
.(Kingston P. O.).
Schappert, N. Louis, 57 S. Washington St.
Scheifly, John E., 284 Wyoming Ave., Kingston.
Shaflfer, Charles Layton, 219 (Dollege Ave., Kingston,
Sheridan, Lawrence A., 247 N. Main St.
Shuman, George A., 545 Main St., Edwardsville
(Kingston P. O.).
Smith, A. Burton, 394 Wyoming Ave.. Wyoming.
Smith, H. Alexander, 31 W. Union St.
Smith, Lawrence H., 189 N. (3iurch St., Hazleton.
Smith, W. Clive, 132 S. Franklin St.
Smith, Ziba L., West Nanticoke.
Stewart, Walter S.. 98 S. Franklin St
Stiff. William Clifton. 118 E. Main St., Plymouth.
Stoeckel, Louise M., 53 W Union St
Storz, John C. 551 Charles St., Luzerne.
Straub, Peter, 2.% Bowman St.
Taylor, Lewis H., 83 S. Franklin St.
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MEMBERSHIP LIST
751
Taylor, Richard P., 34 N. Washington St.
Teitsworth, Ira R., 25 Main St., Luzerne.
Templeton, Harry G., 101 Center Ave., Plymouth.
Thomas, Albert M., Glen Lyon.
Thomas, Frank D., Ill Wyoming Ave., Dorraiiceton
(Kingston P. O.).
Tischler, Max, 66 S. Washington St.
Tobias, John B., 305 E. Northampton St
Trapold, August, 239 S. Washington St.
Trapold, Augustine C, 239 S. Washington St.
Tressler, Charles W., Shickshinny.
Underwood, Sanford L., SJ4 Water St., Pittston.
Van Horn, Morris J., Townhill.
Wadhams, Raymond L., 72 N. Franklin St.
Wagner, Earl E., 205 Parrish SL
Wagner, gdward C. O., 125 S. Washington St.
Waters, William W., 101 S. Market St., Nanticoke.
Wenner, Thomas J., 150 S. Washington St.
Wetherby, Delia P., 69 W. Union St.
Whitney, Harry LeRoy, 153 W. Main St., Plymouth.
Wilcox, Homer B., 165 S. Maple St., Kingston
Williams, James T., 63 S. Washington St.
Woehrle, Robert S., 403 George Ave., Parsons.
Wolfe, John B., 203 W. River St.
Wolfe, Samuel M., 218 S. Franklin St.
Wycoff, Sarah Delia, 68 W. South St.
LYCOMING COUNTY SOCIETY
(Organized 1849.)
(Williamsport is the post office when street address
only is given.)
President... Robert K. Rewalt, First Natl. Bank Bldg.
1st V. Pres. .John B. Nutt, 430 Pine St.
2d V.Pres... Lloyd E. Wurster, 416 Pine St.
Secretary... Walter S. Brenholtz, 151 E. Third St.
Treasurer... Charles J. Cummings, 755 W. Fourth St.
Rep. Lib. . . .Wesley F. Kunkle, 519 Seventh Ave.
Trustees.... Victor P. Chaapel, 2017 W. Fourth St.
Charles A. Lehman, 2105 W. Fourth St.
Walter S. Brenholtz, 151 E. Third St.
Charles J. Cummings, 755 W. Fourth St.
Censors Horace G. McCormick, 420 Pine St.
Charles W. Youngman, 601 Pine St.
Charles E. Heller, 221 E. Third St.
Robert K. Rewalt, First Natk>nal Bank
Bldg.
Edward Lyon, 24 West Fourth St.
Committee on Public Policy and Legislation:
John A. Campbell, 838 Funston Ave., New-
berry Station.
W. Bastian Konkle, Montoursville.
Lee R. Rank, Milton (Northumberland
Co.).
T. Kenneth Wood, Muncy.
Warren N. Shuman, Jersey Shore.
J. Gibson Logue, 410 Rural Avenue.
J. Louis Mansuy, Ralston.
Program.... John B. Nutt, 430 Pine St.
Randall R. Hayes, 1225 Allegheny St.,
Jersey Shore.
Charles M. Adams, 1025 W. Fourth St.
Official Publication: The Medical Bulletin.
Issued Monthly.
Editor: Walter S. BrenholU. 151 E. Third St.
Stated meetings at City Hospital, Williamsport, sec-
ond Friday of each month at 1 :30 p. m. Annual meet-
ing in January.
MEMBERS (105)
Adams, Charles* M., 1025 W. Fourth St.
Adams, F. Raymond, Watsontown (Northumberland
Co.).
Albright, Joseph W., Muncy.
Baker, Harold F.. Muncv.
Bastian, Charles B., 48 W. Fourth St.
Bay, Percy A., Jersey Shore.
Beach, James D., 223 Market St. .
Bennett, Amos W., 1063 E. Third St.
Bingaman, Charles S., Palmerton (Carbon Co.).
Bom, Reuben H., Montoursville.
Bower, Raymond J., 324 Court St.
Boyer, Walter E., 861 E. Third St.
Brenholtz, Walter S., 151 E. Third St.
Brown, Barton, Savannah Quarantine Station, Savan-
nah, Ga.
Brown, J. Carlton, 35 W. Fourth St.
Camche, Leon J., Hart Building.
Campbell, John A., 838 Funston Ave., Newberry Sta.
Castlebury, Galen D., 215 E. Third St.
Chaapel, Victor P., 2017 W. Fourth St., Newberry Sta.
Clinger, Joseph A., Milton (Northumberland Co.).
Cummings, Charles J., 755 W. Fourth St.
Davis, George C, Milton (Northumberland Co.).
Decker, P. Harold, 416 Pine St.
Delaney, William E., 854 W. Third St.
Derr, Fuller S., Watsontown (Northumberland Co.).
Derr, Joseph L., Lairdsville.
Donaldson, Harry J., 106 E. Fourth St.
Drick, George R., 23 W. Fourth St.
Etter, Omer R., Warrensville.
Everett, Edward, Masten.
Fleming, J. Frank, Trout Run. j
Follmer, William H., 345 Campbell St
Fulmer, Joseph Cleveland, 1116 E. Third St.
Gilmore, Irwin T., Picture Rocks.
Glosser, William E., 440 Market St.
Goodman, Lee M., Jersey Shore.
Gordner, J. Frank, Montgomery.
Hardt, Albert F., 414 Pine St.
Harley, John P., 27 W. Fourth St.
Haskin, Herbert P., 324 High St.
Hayes, Randall B., 1225 Allegheny St., Jersey Shore.
Heller, Charles E;, 221 E. Third St.
Hoffa, J. Sidney, 352 Howard St.
Hull, Alem P., Montgomery.
Hull, Waldo W., 242 Pine St.
Htmt, James E., Salladasburg.
Kiess, Daniel E., Hughesville.
King, William L., Muncy.
Klump, George B., 430 Pine St.
Klump, Jdm A., 331 Elmira St.
Knauber, Leo M., 821 Diamond St.
Konkle, W. Bastian, Montoursville.
Kunkle, Wesley F., 519 Seventh Ave.
Lamade, Albert C, 42 E. Fourth St.
Langley, Louis Elsworth, 3 W. Third St.
Lechner, Frederick C, Williamsport Hospital.
Lehman, Charles A., 2105 W. Fourth St.
Logue, J. Gibson, Larrivee Bldg.
Logue, William P., 240 Pine St.
Lyon, Edward, 24 W. Fourth St.
McCormick, Horace G., 420 Pine St.
Mansuy, J. Louis, Ralston.
Marsh, William G., Watsontown (Northumberland
Co.).
Metzger, George W., Hughesville.
Milnor, Mahlon T., Warrensville.
Mohn, Charles L., Jersey Shore.
Mosher, James S., 210 Pine St.
Muffiy, George W., Turbotville (Northumberland Co.).
Nevling, Ferdinand S., Clearfield (Clearfield Co.).
Niple, Dio M., Turbotville (Northumberland Co.).
Norris, Franklin J., Government Hospital, Waukesha,
Wisconsin.
Nutt, John B., 430 Pine St.
Poust, G. Alvin, Hughesville.
Raemore, Millard L.. 514 W. Fourth St.
Rank, Lee Russell, Milton (Northumberland Co.).
Rankin, James R., Muncv.
Raoer, Thomas W.. 602 Pine St.
Reilly, Peter C. 220 Market St.
Renn. Carl G., Lairdsville.
Rewalt, Robert K., First Natl. Bank Bldg.
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752
THE PENNSYLVANIA MEDICAL JOURNAL
July, 1921
Ritter, Ella N., 1211 W. Fourth St
Ritter, George T., First Natl. Bank Bldg.
Ritter, H. Murray, First Natl. Bank Bldg.
Ritter, James W., Jersey Shore.
Rouse, Frank E., 2029 W. Third St.
San ford, Frederick G., 1407 Walnut St., Jersey Shore.
Schaefer, J. Elmer, Cogan Station.
Schneider, Charles, 1501 South Ave., South Williams-
port.
Schneider, George L., 16 W. Third St.
Senn, Carl H., 433 Market St.
Senn, Walter W., 76 Brandon Place.
Shaw, Clarence E., 37 W. Fourth St.
Shuman, Warren N., Jersey Shore.
Spencer, Robert D., State Hospital, Ashland.
Steans, Ralph, Lewisburg (Unron Co.).
Strait, Barbara Kuntz, 817 Main St., Penn Yan, N. Y.
Trainer, Robert F., 340 W. Fourth St.
Tule, R. Bruce, Milton (Northumberland Co.).
Turner, Wilbur E., Montgomery.
VanHorn, John W., Montoursville.
Voorhees, Charles D., Hughesville.
Welker, Abraham T., Collomsville.
Wood, T. Kenneth, Muncy.
Wurster, Lloyd E., 416 Pine St.
Youngman, Charles W., 601 Pine St.
McKEAN COUNTY SOCIETY
(Organized June 18, 1880.)
President... Benjamin F. White, Jr., Bradford.
V. Pres Burg Chadwick, Smethport.
Sec.-Treas...F. Wade Paton, Bradford.
Censors James B. Stewart, Bradford.
Louis D. Joseph, Bradford.
Evan O'Neill Kane, Kane.
Committee on Public Policy and Legislation :
Earle M. McLean, Bradford.
William A. Ostrander, Smethport.
William J. McGraner, Port Allegany.
Stated meetings at place selected the first Wednes-
day of each month. Election of officers in January.
MEUBERS (43)
Ash, Garrett G., Bradford.
Beatty, Smith G., Kane.
BenninghofT, George E., Bradford.
Canfield, Harris A., Bradford.
Chadwick, Burg, Smethport.
Cleveland, Howard Martin, Mt. Jewett.
Cox, Milo W., Kane.
Cummings, George M., Betula.
Dana, Lawrence W., Kane.
DeCaria, Francis, Bradford.
Eaman, Howard K., Mt. Jewett.
Fredericks, William J., Bradford.
Glenn, Thomas O., Bradford.
Haines, Samuel H., Bradford.
Hall, Bret H., Bradford.
Hamilton, Robert, Smethport.
Hannum, Oscar S., Bradford.
Hays, Mary J., Kane.
Hcintl)ach. James M., Kane.
Hickman, KImest H., Kane.
Hogan, William C, Bradford.
Johnson, Frederick C, Bradford.
Johnston, James, Bradford.
Joseph, Lotiis Daniel, Bradford.
Kane, Evan O'Neill, Kane.
Kane, Thomas L., Kane.
McCoy, Henry L., Smethport.
McGraner, William J., Port Allegany.
McLean, Earle McCormack, Bradford.
Nichols, Henry James, Bradford.
Ostrander, William A., Smethport.
Otto, James V., Port Allegany.
Paton. Fred Wade, Bradford.
Russell, Reister K., Bradford.
Stewart, James B., Bradford.
Straight-Robbins, Persis, Bradford.
Van Slyke, Allen A., Mt Jewett.
Vogan, David E., Kane.
Vogan, Guy S., Marienville.
White, Benjamin Franklin, jr., Bradford.
White, Grace, Bradford.
Wilson, Homer A., Bradford.
Woodhead, H. Irvm, Bradford.
MERCER COUNTY SOCIETY
(Organized 1848.)
President... August M. O'Brien, State St, Sharon.
1st V. Pres.. John E. Ferringer, Stoneboro.
2dV. Pres...aarence W. McElhaney, Greenville.
Sec.-Reporter.M. Edith MacBride, 203 Hamory Bldg,
Sharon.
Treasurer. . . Carl J. Mehler, Hamory Bldg., Sharon.
Censors Frank M. Bleakeny, Grove City.
Beriah E. Mossman, Greenville.
M. George Yeager, Mercer.
Committee on Public Policy and Legislation:
John H. Martin, Greenville,
Edwin M. McConnell, Grove City.
M. George Yeager, Mercer.
Stated meetings second Thursday in January, Mardi,
May, July, September and November at such place u
society shall direct. Electwn of officers in January.
MEMBERS (74)
Armstrong, Henry, Sharon.
Bachop, John C, Sheakleyville.
Bailey, Carl, 233 E. State St, Sharon.
Bailey, Nelson J., Jamestown.
Bakewell, Frank S., Greenville.
Barnes, Matthew A., Pardoe.
Batteiger, Frederick O., Greenville.
Biggins, Patrick E., Sharpsville.
Bleakney, Frank M., Grove City.
Breene, Lawrence N., Farrell.
Brown, David A., Greenville.
Brown, Robert W., Greenville.
Campbell, Willard B., Grove City.
Campbell, Watson E., Hamory Bldg., Sharon.
Campman, Clarence C, West Middlesex.
Cattron, Adison E., Sharpsville.
Cheeseman, John C, Dewey St, Ingram (Alleg. Co.).
Cooley, Judson, Sandy Lake.
Doyle, Joseph A., Greenville.
Elliott John W., Hamory Bldg., Sharon.
Ferringer, John E., Stoneboro.
Fisher, Philip P., Sharon.
Frye, Benjamin A., Sharpsville.
Funderburgh, Joe, Toledo, Ohio.
Gilliland, Caroline J., Vine St., Sharon.
Hagin, Edward N., 233 E. State St., Sharon.
Hamborszky, Eugene J., Farrell.
Hanna, David B., Stoneboro.
Heilman, Ralph S., Sharon.
Heilman, Salem, Sharon.
HoflFman, James D., Grove City.
Hogue, Thomas F., Fredonia.
Hope, Paul T., Mercer.
Hope, Robert M., Mercer.
Hunter, John A., West Middlesex.
Hyde, Allan P., 233 E. State St, Sharon.
Jones, Orlando A., Sharon.
Kelly, Ross A., Farrell.
Kennedy, George W., Hamory Bldg., Sharon.
Kusmin, Harry, Farrell.
MacBride, Martha Edith, 203 Hamory Bldg., Sharon.
McClelland, James H., Grove City.
McConnell, Edwin M., Grove City.
McElhaney, Oarence W., Greeirville.
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MEMBERSHIP LIST
753
Mclilree, Frank E., Greenville.
Marshall, Clifford C, 233 E. State St., Sharon.
Martin, John H., Greenville.
Martin, John M., Grove City.
Massey, Harvey E., Hamory Bldg., Sharon.
Matta, Florence B., Brownsville (Fayette Co.).
Mehler, Carl J., Hamory Bldg., Sharon.
Mehler, Robert E., Farrell.
Mitchell, Andrew J., Hamory Bldg., Sharon.
.Millikin, Harry W., Hamory Bldg., Sharon.
Montgomery, Beriah A., Grove Ci^.
Mossman, Beriah E., Greenville.
Moses, Charles H., Hamory Bldg., Sharon.
Nicholls, Robert D., Farrell.
O'Brien, August M., State St, Sharon.
Phillips, William H., Greenville.
Phythyon, Dan, Hamory Bldg., Sharon.
Reed, Joseph H., Sharon.
Rickenbrode, Charles O., Farrell.
Simpson, Spencer P., Sharon.
Spearman, John Francis, 205 Hamory Bldg., Sharon.
Tidd, Ralph M., Clark.
Tinker, Burgoyne L., West Middlesex.
Twitmyer, John H., Sharpsville.
Walker, Charles I., Sharon.
White, Harry, Hamory Bldg., Sharon.
Whyte, Harry A., 206 Idaho St., Farrell.
Writt, William M., Farrell.
Wyant, William W., Farrell.
Yeager, M. George, Mercer.
MIFFLIN COUNTY SOCIETY
(Organized March 4, 1847.)
President... James W. Mitchell, Lewistown.
1st V.Pres.. William H. Kohler, Milroy.
2dV.Pres...Hugh S. Alexander, Belleville.
Sec.-Treas... James A. C. Qarkson, Lewistown.
Reporter — Oscar M. Weaver, Lewistown.
Librarian — James A. C. Clarkson, Lewistown.
Censors Frederick A. Rupp, Lewistown.
Walter S. Wilson, Lewistown.
Robert T. Harnett, Lewistown.
Committee on Public Health Legislation:
John P.. Getter, Belleville..
Hugh S. Alexsinder, Belleville.
Samuel H. Rothrock, Reedsville.
Henry W. Sweigart, Lewistown.
Benjamin R. Kohler, Reedsville.
James W. Mitchell, Lewistown.
Committee on Program:
Frederick A. Rupp, Lewistown.
Paul M. Allis, Lewistown.
Charles M. Johnson, McVeytown.
Stated meetings in Lewistown or elsewhere as may
be selected, on the first Thursday of each month. Elec-
tion of officers in December.
MEMBERS (25)
Alexander, Hugh S., Belleville.
Allis, Paul M., Lewistown.
Allison, Elizabedi, 600 Lexington Ave., New York,
N. Y.
Barnett, Robert T., Lewistown.
Beyer, Samuel J., Milroy.
Brisbin, Charles H., Lewistown.
Garkson, James A. C, Lewistown.
Getter, John P., Belleville.
Hazlett, Silas M., Allensville.
Johnson, Charles M., McVeytown.
Kohler, Benjamin R., Reedsville.
Kohler, William H., Milroy.
Krepps, Raymond M., Lewistown.
McKim, Vincent I., Lewistown.
Miller, Henry E., McAlevys Fort (Huntingdon Co.).
Mitchell, James W., Lewistown.
Rothrock, Samuel H., Reedsville.
• Rupp, Frederick A., Lewistown.
Smith, Thomas H., Bumham.
Stambaugh, Charles J., Reedsville.
Steele, Bruce P., McVeytovra.
Sweigart, Henry W., Lewistown.
Swigart, Samuel W., Lewistown.
Weaver, Oscar M., Lewistown.
Wilson, Walter S., Lewistown.
MONROE COUNTY SOCIETY
(Organized Nov. 24, 1902.)
President... Charles S. Logan, 401 Main St., Strouds-
burg.
V.Pres J. Anson Singer, Elast Stroudsburg.
Secretary... William R. Levering, 757 Main St.,
Stroudsburg.
Treasurer. . .Eugene H. Levering, 805 Main St.,
Stroudsburg.
Censors Walter L. Angle, 229 S. Courtlandt St.,
East Stroudsburg.
Charles S. Flagler, Stroudsburg.
Committee on Public Policy and Legislation :
Walter L. Angle, East Stroudsburg.
Charles S. Flagler, Stroudsburg.
John C. Henry, Stroudsburg.
Meetings held four times a year at call of president.
MEMBERS (13)
Angle, Walter L., 229 S. Courtlandt St., East Strouds-
burg.
Flagler, Charles S., Stroudsburg.
Henry, John C, 177 Crystal St., East Stroudsburg.
Levering, Eugene H., 805 Main St., Stroudsburg.
Levering, William R., 31 N. Seventh St.
Logan, Charles Shaw, 401 Main St., Stroudsburg.
Rosenkrans, Carl B., 55 Crystal St., East Stroudsburg.
Singer, J. Anson, 116 Washington St., East Strouds-
burg.
Smith, Louis B., Bushkill (Pike County).
Stolz, Joseph A., Easton (Northampton Co.).
Trach, David C, Kresgeville.
Travis, George S., East Stroudsburg.
Wertman, Alvin A., Tannersville.
MONTGOMERY COUNTY SOCIETY
(Organized January, 1847.)
President.. .Oiarles F. Doran, Phoenix ville.
1st V. Pres. .George T. Lukens, Conshohocken.
2d V. Pres.. .George W. Miller, Norristown.
Rec. &
Fin. Sec. Edgar S. Buyers, Norristown.
Cor. Sec.
& Rept Benjamin F. Hubley, Norristown.
Treasurer... William G. Miller, Norristown.
Censors George F. Hartman, Port Kennedy.
Percy H. Corson, Plymouth.
William G. Miller, Norristown.
Trustees William G. Miller, Norristown.
J. Newton Hunsberger, Norristown.
Edgar S. Buyers, Norristown.
George F. Hartman, Port Kennedy.
Herbert A. Bostock, Norristown.
Committee on Public Policy and Legislation :
Herbert A. Bostock, Norristown.
William G. Miller, Norristown.
Oliver C. HeflFner, Pottstown.
Lib. Com.. . .J. Lawrence Eisenberg, Norristown.
Howard W. Hassell, Bridgeport.
\yinfred J. Wright, Skippack.
Official Publication: Montgomery Coiuity Medical
Bulletin.
Issued Monthly.
Editor: Frank C. Parker, Norristown.
Stated meetings in Montgomery Hospital. Norris-
Digitized by
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754
THE PENNSYLVANIA MEDICAL JOURNAL
Jui.y. 1921
town, at 2:30 p. m., on the first and third Wednesdays
of every month excepting July and August. Election
of officers in January.
MEMBERS (130)
Allebach, Newton G., Souderton.
Allen, Frederick B., North Wales.
Allen, H. Croskey, Norristown.
Anders, Walter L., 412-413 Bliss Bldg., Tulsa, Okla.
Anders, Warren Z., Collegeville.
Arnold, Cliflord H., Ardniore.
Arnold, Herbert A., Ardmore.
Atkinson, Paul G., Norristown.
Bacon, Edythe A., State Hospital, Norristown.
Bauman, J. Warren, Lansdale.
Benner, Ervin F., Salfordville.
Biddle, Stanley E., 5825 Chester Ave., Philadelphia
(Phila. Co.).
Bigoney, Carl F., Lansdale.
Bigoney, Franklin G., Lansdale.
Bostock, Herbert A., Norristown.
Branson, Thomas F., Rosemont.
Brown, Joel U., 14 Powell Ave., Millboume (Phila,
Co.).
Brush, Franklin C, 204 S. Gay St., Phoenixville (Ches-
ter c:o.).
Bushong, Frederick, Pottstown.
Buyers, Edgar S., Norristown.
Carpenter, Chapin, Wayne (Delaware Co.).
Chrystic, Walter, Bryn Mawr.
Cloud, Joseph Howard, Box 484, Ardmore.
Cordonna, George, Norristown.
Corson, Edward Foulk, 325 Cynwyd Rd., Cynwyd.
Corson, Percy H., Plymouth Meeting.
(^uncill, Malcolm S., Bryn Mawr.
Cross, Sumner H., Jenkintown.
Crowe, James, Huntingdon Valley.
Dewees, A. Lovett, Haverford.
Dill, Wallace W., Norristown.
Donaldson, Albert Barnes, Bala.
Doran, (Diaries F., Phoenixville (Chester Cx).).
Drake, Howard H., Norristown.
Eisenberg, J. Lawrence D., Norristown.
Elmer, Robert P., Wayne (Delaware Co.).
Evans, Alexander Rae, Ardmore.
Fabbri, Remo, 354 E. Main St., Norristown.
Faries, Clarence T., Narberth.
Fordyce, DeLorme T., C^onshohocken.
Gamble, Robert G., Haverford.
Gamer, Albert R., Norristown.
(Jery, Alfred O., East Greenville.
Ciodfrey, Andrew, Ambler.
Gotwals, John Elmer, Phoenixville (Chester Co.).
Graber, Henry, Royersford.
Hall, Katherine S., Fort Washington.
Hanley, Paul D., Pottstown.
Harris, Richard H., Elkins Park.
Hartman, (Jeorge F., Port Kennedy.
Harvey, John, Bryn Mawr.
Hassell, Howard W., Bridgeport.
Heflfner, Oliver C, Pottstown.
Herman, Ambrose C, Lansdale.
Highley, (Jeorge N., Conshohocken.
Hough, Mary P. H., Ambler.
Hubley, Benjamin F., Norristown.
Hunsberger, J. Newton, Norristown.
Hunsberger, William H., Pennsburg.
Imhoff, William H. M., House of Correction, Holmes-
burg, Phila. (Phila Co.).
Irwin, George R., Bridgeport.
Jago, Arthur H., Ardmore.
Janjigian, Robert R., State Hospital, Norristown.
Keaton, James M.. Ardmore.
Keller, David H., Bangor.
Keeler, Russell R.. Harlevsville.
Keeler. Vincent Z., Harleysville.
Kelt. Elmer A., 607 W. Lincoln Highwav, Rawlings,
Wyo.
Kerling, (ieorge A., Pennsburg.
Kershner, Ammon G., Norristown.
Knipe, Reinoehl, Norristown.
Knipe, William H., Limerick.
Kriebel, Elmer G., Norristown.
Krusen, Edward A., Norristown.
Krusen, Francis T., Norristown.
Lakin, H. Pearce, Lansdale.
Landis, James C, Pennsburg.
Little, Frederick B., Norristown.
Luders, Charles Williamson, Cynwyd.
Lukens, George T., (^nshohocken.
Lukens, Philip J., Ambler.
McCracken, James A., Norristown.
McGinnis, (jeorge E., Norristown.
McKenzie, William, Conshohocken.
McLaughlin, Perry W., Norristown.
MacLeod, George I., Ardmore.
Markley, John Morris, Graterford.
Mauger, Lee F., Pottstown.
Miller, (Jeorge W., Norristown.
Miller, Joseph S., Collegeville.
Miller, S. Metz, State Hospital, Norristown.
Miller, William G., Norristown.
Moore, Ronald C, Schwenksville.
Nathan, David, Norristown.
Neiflfer, Milton K., Wyncote.
Neiman, Howard Y., Pottstown.
Nicholson, Percival, Ardmore.
O'Neal, Alexander H., St. Davids (Delaware Co.).
Parker, Frank C, Norristown.
Parkinson, William, Conshohocken.
Perkins, John D., Jr., (x)nshohocken.
Peterson, Jessie Marie, State Hospital, Norristown.
Podall, Harry C, 622 Swede St., Norristown.
Porter, J. Kmer, Pottstown.
Quinn, Elwood T., Jenkintown.
Rahn, Norman H., Souderton.
Ramsey, Frank M., Chestnut Hill.
Read, Alfred H., Norristown.
Reed, Henry D., Pottstown.
Roberts, Isaac B., Llanerch (Delaware Co.).
Roberts, Willis Read, Norristown.
Rose, Clarence Atwood, Ardmore.
Roth, John A., Red Hill.
Rouse, John, Ogontz.
Ruth, Aaron L. Conshohocken.
Scholl, Harvey F., Green Lane.
SchoU, Henry Nathaniel, Kulpsville.
Seiple, J. Howard, Center Square.
Shaner, Warren B., Pottstown.
Sharpe, John S., Haverford.
Sharpless, Frederick C, Rosemont.
Shearer, Herbert B., Worcester.
Sheehan, William CoTcmata, Bethlehem Pike, Clicstnut
HilK (Phila.).
Shelley, Isaac H., Norristown.
Shelley, James A., Ambler.
Sherbon, John B., Pottstown.
Simpson, John C, 524 Swede St., Norristown.
Sm)rth, Henry Field, Wayne (Delaware (3o.).
Stapp, H. Forsythe, Pottstown.
Stein, George W.. Norristown.
Stein, Walter Jacob, Ardmore.
■Sturgis, Margaret C, Ardmore.
Sturgis, Samuel B., Ardmore.
Taylor, Herbert W., Haverford.
Taylor, Marianna, St. Davids (Delaware Co.).
Thomas, J. Quincy, Conshohocken.
Tunnell, Monroe H., 23 Prospect Ave., Bryn Mawr.
Tyler, Benjamin A., Royersford.
Van Buskirk, Frederick W., Pottstown.
Vedder, Wentworth D., Pottstown.
Watson, W. Stuart, Norristown.
Watson, William John, Cheltenham.
Weaver, Joseph K., Norristown.
Whitman, Russell B., Schwenksville.
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MEMBERSHIP LIST
755
Wiley, S. Nelson, Vineland, N. J.
Wills, T. Edmund, Pottstown.
Wilson, John G., State Hospital, Norristown.
Wolfe, K. Vincent, Norristown.
Wright, Wiftfred J., Skippack.
Wylie, Charles R., 558 High St., Pottstown.
Yeakle, Walter A., Norristown.
MONTOUR COUNTY SOCIETY
(Organized June 15, 1874.)
President... Robert A. Keilty, Geisinger Hospital,
Danville.
1st V.Pres.. Horace V. Pike, State Hospital, Danville.
2d V.Pres... Philip C. Newbaker, Danville.
Sec. Rept.... John H. Sandel, 218 Mill St., Danville.
Treasurer... George B. M. Free, State Hospital, Dan-
ville.
Censors Robert S. Patten, Danville.
Harold L. Foss, Danville.
Ernest T. Williams, Danville.
Committee on Public Policy and Legislation:
George B. M. Free, State Hospital, Dan-
ville.
Ernest T. Williams, Danville.
Enoch A. Adams, Geisinger Hospital, Dan-
ville.
Stated meetings at Danville, the third Friday of each
calendar month except August, at 8 p. m. July meet-
ing to be an outing. Election of officers in January.
MEMBERS (21)
A.dams. Enoch H., Geisinger Hospital, Danville.
Ashenhurst, Ida M., State Hospital, Danville.
Bitler, Benjamin E., Pottsgrove (Northum. Co.).
Chamberlain, Leslie R., State Hospital, Danville.
Foss, Harold L., Geisinger Hospital, Danville.
Free, George B. M., State Hospital, Danville.
Glenn, Frank D., State Hospital, Danville.
Keilty, Robert A., Geisinger Hospital, Danville.
Mayberry, Charles B., Retreat (Luzerne Co.).
Meredith, Hugh B., 3305 Arch St., Philadelphia
(Philadelphia Co.).
Nebinger, Reid, Geisinger Hospital, Danville.
Newbaker, Pliilip C, Danville.
Patten, Robert Swift, Danville.
Pike, Horace V., State Hospital, Danville.
Robbins, James E., State Hospital, Wemersville.
Sandel, John H., Danville.
Shearer, Joseph P., Florence Infirmary, Florence, S. C.
Shellenberger, Edward B., State Hospital, Danville.
Shultz, Cameron, Danville.
Snyder, John Howard, Sunbury (Northumberland Co.).
Williams, Ernest T., Danville.
NORTHAMPTON COUNTY SOCIETY
President. .
1st V. Pres
2d V. Pres.
Rec. Sec.-
Treas. . . .
Cor. Sec. ..
Reporter. .
Censors. . .
(Organized July 10, 1849.)
.Milton W. Phillips, Chipman Quarries.
. .Edward D. Schnabel, Bethlehem.
. . Paul R. Correll, Easton.
.Paul H. Walter, Bethlehem.
• George L. deSchweinitz, Bethlehem.
.W. Gilbert Tillman, Easton.
.John C. Keller, Wind Cap.
Clayton E. Royce, Bethlehem.
William P. Walker, S. Bethlehem.
Exec. Com.. M ikon W. Phillips, Chapman Quarries.
Paul H. Walter, Bethlehem.
Francis J. Dever, Bethlehem.
Committee on Public Policy and Legislation:
William P. O. Thompson, Easton.
Thomas Zulick Easton.
William L. Estes, Sr., Bethldiem.
Meetings shall be held at 11 a. m., on the third Fri-
day of every month except July and August at such
places as the society may determine oy vote. Outing
meeting in Augast.
MEMBERS (128)
Anderson, (jeorge R., Easton.
Beck, Charles E., Portland.
Beck, Richard H., Hecktown.
Beck, Senn G., Nazareth.
Beidelman, Edgar R., 314 W. Market St., Bethlehem
betts, James A., 100 N. Seventh St., Easton.
Blank, Oscar F., 545 N. New St., Bethlehem.
Bioss, Raymond H., 405 N. Broad St., Bethlehem.
Burkhart, Herman A , 552 Main St., Bethlehem.
bush, Elmer E., Danielsville.
Butler, Thomas James, 8 E. Fourth St., S. BethlehenL
Cathrall, Walter J., 116 E. Fourth St., S. Bethlehem.
Carty, Harry B., Freemansburg.
Cumbers, Francis S., 520 Seventh St., S. W., Roches-
ter, Minn.
Chase, Walter D., 230 E. Broad St., Bethlehem.
Collmar, Charles Easton.
Condron, James J., 362 Berwick St., Easton.
Cope, William F., Easton.
Correll, Paul R., Easton.
Dech, Qarence E., 408 Wyandotte St., S. Bethlehem.
Dech, Elmer J., 5 N. Fourteenth St., Easton.
Dech, Schuyler H., 118 S. Third St., Easton.
Deibert, Edward J,. Hellertown.
Dever, Francis J., 60 E. Broad St., Bethlehem.
Dilliard, Benjamin F., East Bangor.
Edwards, H. Threlkeld, South Bethlehem.
Estes, William L., 805 Delaware Ave., South Bethle-
hem.
Estes, William L., Jr., South Bethlehem.
Evans, E. William, Elaston.
Farber. William Daniel, 16-18 W. Twenty-first St..
Nortiiampton.
Fetherolf, James Allen, Stockertown.
Field, Benjamin Rush, Easton.
Field, George B. Wood, Easton.
Finady, William Aaron, 29 E. Fourth St., South Beth-
lehem.
Fisher, Ralph A., 1306 Washington St., Easton.
Fisler, Harry Cattell, Easton. '
Fox, Ardiur S., 1418 Washington St., Easton.
Fraunfelder, Jacob A., Nazareth.
Freed, Isadore E., 861 E. Fourth St., South Bethlehem.
Fretz, John E., Elaston.
Gabor, Adolph S., 901 E. Fourth St., South Bethlehem.
Click, William H., 812 E. Fourth St., South Bethlehem.
Green, Edgar M., Easton.
Guth, Henry E., Orefield (Lehigh Co.).
Hahn, Frank J., Bath.
Hamilton, Arthur B., 30 W. Church St., Rethlehcm.
Hance, Burtis M., 19 S. Third St., Easton.
Harman, Clair G., 62 N. Third St., Easton.
Heller, Austin D., 70 E. Broad St., Bethlehem.
Heller, Henry D., Hellertown.
Hoey, RoUa H., 357 Bushkill St., Easton.
Hoffman, Edward L., 1148 Northampton St., Easton.
Hummel, Clarence D., 2329 Hay St., Easton.
Hunt, Joseph S., Easton.
James, James Edward, 253 E. Broad St., Bethlehem.
Jones, Byron C, 644 Broadway, South Bethlehem
Keller, John C, Wind Gap.
Kern, Thomas B., 740 Main St., Bethlehem.
Kessler, Frank J., 118 S. Sixth St., Easton.
Kleinhans, Paul Howard, 65 W. Broad St., Bethlehem.
Klock, Glenn G., Easton.
Koch, Victor J., Nazareth.
Kotz, Adam L., Easton.
Leibert, Harry F., 532 E. Fourth St., South Bethlehem.
Leigh, Herbert CIrozier, 120 N. Third St., Easton.
Longacre, Jacob B., Weaversville.
Love, J. King, Easton.
Ludlow, David Hunt, Easton.
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THE PENNSYLVANIA MEDICAL JOURNAL
July, 1921
McCormick, Cardinal Claude, Pen Argyl.
AicCorniicK, Henry Edward, 61 N. Third St., Easton.
Maysels, Alexander J., li^l E. tourth i>t., is. bethle-
hem.
Aiazza, John Josiah Joseph, 9 Broadway, Bangor.
Messinger, victor S., Easton.
Michler, nenry D., Easton.
Miesse, Kate OeWitt, Easton.
Miller, Elmer C, East Bangor.
Morganstern, James A., li/ b. Third St., Easton.
Petrulias, George A., 10/ W. tourtii St., bouth Beth-
lehem.
Phillips, Milton W., Chapman Quarries.
Pohl, Henry C, Nazareth.
Uuiney, James J., 309 Uushkill St., ICastoii.
Kaub, Keuben, Easton.
Kauch, Stewart E., 3U4 Spring St., Bethlehem
Keagan, Artnur D., Easton.
Keicnard, iNoah W., ctangor.
Kentzheimer, William H., Hellertown.
Kichards, Elierslie Wallace, South Boston.
Richards, Oscar M., Soudi Easton.
Roberts, Frederick C, Easton.
Rohrbach, Harvey O., 540 N. New St., Bethlehem.
Rosenberry, Edward S., Stone Church.
Royce, Clayton E., St. Luke's Hosp., South Bethlehem.
Ruch, Asher George, 413 W. Broad St., Bethlehem.
Santee, Delbert Kansas, South Betlilehem.
Schlier, Earl B., 534 Ave. D, Bethlehem.
Schmoyer, Herbert John, 20i3 E. Broad ."st., Bethlehem.
Schnabel, Edwin D., Bethldiem.
Schwab, Thomas W., Bath.
deSchweinitz, George L., 85 E. Broad St., Bethlehem.
Sheridan, Rose B , 422 Wyandotte St., S. Bethlehem.
hherrer, i-rederick A., Easton.
Shifter, Leigh B., Easton.
Shoudy, Loyal A., Bethlehem.
SmocK, Edwin L., Bath, R. D. 2.
Smythe, William A., 422 W. Broad St., Bethlehem.
btem, freston t., 433 Wyandotte St., South Bethlehem.
Sterner, Paul F., 102 W. Fourth St., S. Bethldiera.
Stottlet, Clinton F., Pen Argyl.
Struthers, Clayton P., 1823 Ferry St., Easton.
Swan, Tyrus E., Easton.
Thomason, William P. O., Easton.
Tillfnan, W. GUbert, 1803 Washington St., Easton.
Uhler, Stewart Mann, Pen Argyl.
Uhler, Sydenham P., Easton.
Uhler, Tobias M., 54 S. Whitfield St., Nazareth.
Updegrove, Harvey C, Easton.
Updegrove, Jacob D., Easton.
Walker, William P., South Bethlehem.
Walter, Mitchell, 102 W. Fourth St., South Bethlehem.
Walter, Paul H., 60 E. Broad St., Bethlehem.
Walter, Robley D., 903 Ferry St., Easton.
Ward, Frederick E., 1119 Ferry St., Elaston.
Weaver, Henry F., Easton.
Welden, Carl F., 546 N. New St., Bethlehem.
West, John H., Easton.
Yost, Robert J., Fourth and Vine Sts., West Bethlehem.
Zulick, Thomas C, Easton.
NORTHUMBERLAND COUNTY SOCIETY
(Reorganized Nov. 27, 1903.)
President. . .George A. Deitrick, 30 N. Third .St., Sun-
bury
1st V. Pres. .E. Roger Samuel, Third and Hickory
Sts., Mt. Carmel.
2d V. Pres... Lloyd M. Holt, 146 E. Sunbury St., Sha-
mokin.
Secretary. . .Charles H. Swenk, 235 Market St., Sun-
bury.
Asst. Sec.
& Treas Robert B. McKay, 34 S. Second St., Sun-
bury.
Censors Lester E. Schoch, 217 E. Sunbury St.,
Shamokin.
Harry T. Sinunonds, 48 N. Market St,
Shamokin.
Charles W. Rice, 63 Queen St, Northum-
berland.
Committee on Public Policy and Legislation:
George W. Reese, State Hospital, Sha-
mokin.
Charles W. Rice, 63 Queen St., Northum-
berland.
Clay H. Weimer, 200 E. Dewart St.. Sha-
mokin.
Committee on Public Health:
John B. Cressinger, 243 Market Sq., Sun-
bury.
Alfred H. Smink, 2 S. Market St., Sha-
mokin.
Amos B. Schnader, 33 W. Third St., Mi.
Carmel.
Prog. Com.. George W. Reese, State Hospital, Sha-
mokin.
John W. McDonnell, 16 N. Fourth St
Horatio W. Gass, 910 Market St., Sun-
bury.
Official Publication: The Northumberland County
Medical Society Notes.
Issued Monthly.
Editor: Charles H. Swenk, 235 Market St., Sun-
bury.
Stated meetings at 1 :15 p. m., in Simbury, the first
Wednesday of January, March, May, September and ,
November; and in Shamokin, at 1 p. m., the first
Wednesday of February, April, June, October and
December. Annual meeting in Janvary.
MEMBERS (59)
Allison, Charles Eldward, Elysburg.
Bealor, Benjamin A., 505 N. Sixth St, Shamokin.
Becker, Harvey M., 49 S. Fourth St., Sunbury.
Blosser, Julius A., Dalmatia.
Buczko, Andrew B., State Hospital, Shamokin.
Burg, Stoddard Somers, U. S Marine Hospital No.
21, Stapleton, N. Y.
Campbell, Charles F., 514 Market St., Sunbury.
Conway, Mark A., Locust Gap.
Cooner, Charles C, Kulpmont.
Cressinger, John Brice, 243 Market Sq., Sunbury.
Deitrick, George A., 30 N. Third St., Sunbury.
Dietz, Qiarles K., 223 W. Spruce St., Shamokin.
Drumheller, Francis E., 134 Chestnut St., Simlniry.
Eister, W. Howard, 1029 Line St., Sunbury.
Enterline, John H., 604 E. Sunbury St., Shamokin.
Fagley, Raymond C, U. S. Pub. Health Hospital.
5800 Arsenal, St Louis, Mo.
Flanagan, Michael J., 307 N. Shamokin St., Shamokin.
Gass, Horatio W., 910 Market St, Sunbury.
Geise, Samuel B., 239 Chestnut St , Sun'jury.
Graham, William T., 244 Market Sq., Sunbury.
Heilman, D. Franklin, Northumberland.
HoUenback, David S., 56 E. Independence St., Sha-
mokin.
Holt, Lloyd M., 146 E. Sunbury St., Shamokin.
Jones, Adna S., 415 Spurzheim St, Shamokin.
Kalloway, Sidney, c/o Bertha Coal Co., Burgettstown
(Wash. Co.).
Karterman, William D., Hepler (Schuylkill Co.).
Knights. Agnes Sholly, Selins Grove (Snyder Co.).
Lyons, Fowler, Turbotville.
McCay, Robert B.. 34 S. Second St, Sunbury.
McDonnell, John W., 16 N. Fourth St., Sunbury.
McWilliams. Kimber C, 219 E. Dewart St., Shamokin.
Malick, Clarence Hiram, Hemdon.
Maurer, James M., 319 E. Sunbury St., Shamokin.
Meek, Francis J., 25 N. Shamokin St, Shamokin.
Mohn, James O.. Shamokin, R. D. 1.
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MEMBERSHIP LIST
757
Nickel, J. Edward, 202 Fairmont Ave., Sunbury.
Peril, Hyman H., 408 W. Spruce St., Shamokin.
Raker, Frederick D., 42 E. Independence St., Shamokin.
Ranck, Lee Russell, Milton.
Ratajski, Joseph E., 510 Pittston Ave., Scranton
(Lackawanna G>.).
Reese, George W., State Hospital, Shamokin.
Rice, Charles W., 63 Queen St., Northumberland.
Rice, Fred, 256 Arch St., Sunbury.
Salters, Oscar E., 41 S. Market St., Shamokin.
Samuel, E. Roger, Third and Hickory Sts., Mt Carmel.
Schoch, Lester E^gar, 217 E. Sunbury St., Shamokin.
Schoffstall, Josepfa W., 248 Market St., Sunbury.
Simmonds, Henry Thomas, 48 N. Market St., Sha-
mokin.
Simmons, Richard H., 116 S. Sixth St., Shamokin.
Smink, Alfred H., 2 S. Market St., Shamokin.
Steck, Fred P., Malick Bldg., Shanx)kin.
Strickland, James G., 25 S. Shamokin St., Shamokin.
Swenk, Charles H., 235 Market St., Sunbury.
Thomas, Charles Meade, Masonic Temple, Sunbury.
Tiffany, Thomas J., Pillow (Dauphin Co.).
Vastine, John H., 78 E. Sunbury St., Shamokin.
Weimer, Clay H., 200 E. Dewart St., Shamokin.
Wcntzel, William S., 414 Market St., Sunbury.
Zimmerman, Lorenzo B., 23 N. Oak St., Mt. Carmel
PERRY COUNTY SOCIETY
(Organized Nov. 19, 1849.)
President.. .Harvey M. Woods, Blain.
1st V. Pres.. William G. Morris, Liverpool.
2d V. Pres...Lenus A. (!arl, Newport.
Sec.-Rept... Maurice I. Stein, New Bloomiield.
Treasurer... Charles E. Delancy, Newport.
Censors A. Russell Johnston, New Bloomfield, 3
yrs.
Lenus A. Carl, Newport, 2 yrs.
Edward E. Moore, New Bloomfield, 1 yr.
.Annual meeting at New Bloomfield second week in
January. Quarterly meetings at places and times se-
lected. -
MBMBESS (17)
Beale, Benjamin F., Duncannon.
Bogar, (jcorge H. M., Liverpool.
Carl, Lenus A., Newport.
Delancy, Charles E., Newport.
Gearhart, Montgomery, Millerstown.
Johnston, A. Russell, New Bloomfield.
Kinzer, George S., Ickesburg.
Moore, Edward E., New Bloomfield.
Morris, William G., Liverpool.
Morrow, William T., Loysville.
Orris, Henry O., Newport.
Patterson, Frank, Med. Exmr. P. R. R., Huntingdon
(Huntingdon Co.).
Reifsnyder, Elizabeth, Liverpool.
Sheibly, John A., Shermans Dale.
Stein. Maurice Isaac, New Bloomfield.
VanDyke. Arthur D., 106 Penna. Sta., New York, N.V.
Woods, Harvey M., Blain.
PHILADELPHIA COUNTY SOCIETY
(Instituted 1849. Incorporated September 27, 1877.)
(Philadelphia is the post office when street address only
is given.)
President... George Morris Piersol, 1913 Spruce St.
IstV. Pres..Wilmer Krusen, 127 North Twentieth St.
Associate Vice-Presidents:
North Branch— W. Hershey Thomas, 1445 N. Seven-
teenth St.
South Branch— R. Powers Wilkinson, 1613 S. Broad
St.
Kensington Branch — G. Harvey Severs, 3401 North
Front St
West Branch — F. Mortimer Cleveland, 5213 Walnut
St.
Northeast Branch— JosejJi P. Ball, 5001 Frankford
Ave.
Northwest Branch — Howard D. (jeisler, 132 West
Walnut Lane, (jermantown.
Southeast Branch — ^Abraham I. Rubenstone, 1208
Spruce St.
Secretary. . .J. Morton Boice, 4020 Spruce St.
Assistant Secretary and Clerk of the Board of Direc-
tors:
Chas. Scott Miller, 1218 West Wyoming
Avenue.
Treasurer. . .Edward A. Shumway, 2046 Chestnut St.
Censors Levi J. Hammond, 1222 Spruce St. (5
years).
L. Webster Fox, S E. (Dor. of Seventeenth
and Spruce Sts. (4 years) .
John Welsh Croskey, 1909 Chestnut St.
(3 years).
Henry D. Jump, 2019 Walnut St. (2 yrs.).
William E. Hughes, 3945 Chestnut St. (1
year).
Directors :
William E. Parke, 1739 N. Seventeenth St. (1924).
George A. Knowles, 4812 Baltimore Ave. (1924).
F. Hurst Maier, 2019 Walnut St. (1924).
Paul B. Cassidy, 2037 Pine St. (1923).
Arthur C. Morgan, 2028 Chestnut St. (1923).
J. Norman Henry, 1906 Spruce St. (1923).
Moses Behrend, 1427 N. Broad St. (1922).
Paul J. Pontius, 1831 Chestnut St. (1922).
John F. Roderer, 2426 N. Sixth St. (1922).
Delegates to the Chamber of Commerce:
Wilmer Krusen, 127 N. Twentieth St.
George A. Knowles, 4812 Baltimore Ave.
COM MirreES-AT-LARCE
Public Policy and Legislatk)n:
Arthur C. Morgan, Chairman, 2028 Chestnut St.
Frederick S. Baldi.
Joshua E. Sweet.
Maurice J. JCarpeles.
(jeorge C. Yeager.
Increase of Membership:
(korge Wilson, Chairman, 5000 Walnut St.
Marion Hague Rea.
Francis C. O'Neill.
A. Graeme Mitchell.
Clement R. Bowen.
John Davis Paul.
Edward J. G. Beardsley.
Public Health and Preventive Medicine:
Seneca Egbert, Chairman, 4814 Springfield Ave.
David H. Bergey.
Randle C. Rosenberger.
Martha Tracy.
John R. Minehart.
Archives :
John H. Musser, Jr., Chairman, 262 S. 21st St.
Christian B. Longenecker.
C. Howard Moore.
Robert G. Torrey.
William N. Bradley.
Tuberculosis :
Henry R. M. Landis, Chairman, 11 S. 21st St.
Frank A. Craig.
Elmer H. Funk.
Edward J. G. Beardsley.
Thomas Klein.
Co-operative Allied Agencies and Institutions:
Wm. Duffield Robinson, Oiairman, 2012 Mt. Vernon
St.
George P. Pilling, Jr.
Irving W. Hollingshead.
Digitized by
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758
THE PENNSYLVANIA MEDICAL JOURNAL
July, 1921
Home of the Society:
John W. West, Chairman, 1125 Wallace St.
Levi J. Hammond.
Barton C. Hirst.
Charles A. E. Codman.
Isidor P. Strittmatter.
Library :
James M. Anders, Chairman, 1605 Walnut St.
Edward E. Montgomery.
Samuel A. Loewenberg.
Maurice J. Karpeles.
Abraham L Rubenstone.
William L. C. Spaeth.
John J. Lynch.
Harry B. Wilmer.
Nervous and Mental Diseases:
Theodore H. Weisenburg, Chairman, 1909 Chestnut
St.
Earl D. Bond.
Charles W. Burr.
Francis X. Dercum.
Charles K. Mills.
Daniel J. McCarthy.
George Wilson.
Foods, Drugs and Beverages :
Russell S. Boles, Chairman, 53rd St. and Overbrook
Ave.
Harry B. Wilmer.
Joseirfi Mclver.
Jos^ih C. Doane.
Edward H. Goodman.
Medical Education:
Itavid Riesman, Chairman, 1715 Spruce St.
Thomas McCrae.
John H. Gibbon.
William Pepper.
M. Howard Fussell.
Narcotics :
Joseph C. Doane, Chairman, Philadelphia General
Hospital.
Joseph Mclver.
John H. W. Rhein. "
Thomas C. Kelly.
Edward J. G. Beardsley.
Prevention of Cancer:
John G. Clark, Chairman, 2017 Walnut St.
Edward A. Schumann.
George G. Ross.
Catharine Macfarlane.
Floyd E. Keene.
Industrial Medicine:
Mervyn Ross Taylor, Chairman, 1823 Spring Garden
St.
William S. Higbee.
Charles N. Sturtevant.
Drury Hinton.
Edwin H. Mcllvain.
Housing :
Samuel McC. Hamill, Chairman, 1822 Spruce St.
John W. West.
Edward H. Goodman.
Stated meeting for business the third Wednesday
of January, April, June and October, at 8:30 p.m.
Election of officers in January. Scientific meetinss
the second and fourth Wednesdays of each month,
except July and August and the fourth Wednesday
of Tune and the second Wednesday of September, at
, « :36 p. m., all at the College of Physicians' Building,
' Twenty-second above Chestnut Street.
This society publishes a program of the medical
meetings of the various societies for the week, from
September to July, inclusive, the editor of which is
C. B. Longenecker, 3416 Baring Street.
The society also has a Medical Defense Fund oi
its own, for which purpose 25 cents is laid aside for
each member, the membership being based on the
number of members in good standing on March 31
of each year. Ralph B. Evans, Esq., is attorney (or
this medical defense feature, with Honorable Hampton
L. Carson as Consultant
NORTH BRANCH
Chairman... Victor A. Leob, 1632 N. Fifteenth St
Clerk Irwin S. MeyerhoflF, 17^ N. Sixteenth St
SOUTH BRANCH
Chairman. ..Frederick S. Baldi, 2117 Porter St
Clerk Thomas W. Armstrong, 1429 Christian St.
KENSINGTON BRANCH
Chairman. . .Harry W. Goos, Ambler and Dauphin Sts.
Clerk Otto Christian Hirst, 90S W. Lehigh Ave.
WEST BRANCH
Chairman... Collin Foulkrod, 3910 Chestnut St
Clerk Ralph Getelman, 2011 Chestnut St
NORTHEAST BRANCH
Chairman. ..William L. C. Spaeth, 5000 Jackson St.,
Frankford.
Clerk Francis F. Borzell, 1119 Harrison St,
Frankford.
NORTHWEST BRANCH
Chairman. . .Maurice J. Karpeles, 146 W. Chelten Ave.,
German town.
Clerk Stanley Q. West, 138 W. Walnut Lane,
Germantown.
SOUTHEAST BRANCH
Chairman. . .Samuel A. Loewenberg, 1905 Spruce St
Clerk M. B. Cooperman, 1811 South Broad St
All branches meet at 9 p. m., monthly except July
and August.
HONORARY MEMBERS
Heckel, Edward B., Jenkins Arcade, Pittsburgh, Pa.
Jackson, Edward, Majestic Building, Denver, Colo.
Leaman, Henry, Leaman Place, Lancaster, Pa.
McAlister, John B., 234 N. Third St, Harrisburg, Pa.
Taylor, Lewis H., 83 S. Franklin St, Wilkes-Barre, Pa.
MEMBERS (2,037)
Aarons, Bernard B. H., 1854 N. Thirteenth St
Abbot, E. Stanley, The Lenox, 1301 Spruce St
Abbott, Alexander C, 4016 Pine St.
Abbott, Frank C, 6108 Carpenter St.
Abrahamson, Philip, 1341 S. Sixth St.
Abramovitz, Max, 165 W. Susquehanna Ave.
Adams, Charles T., 5701 Girard Ave.
Adier, Francis Heed, 5922 Greene St, Gtn.
Adier, Lewis H., Jr., 1610 Arch St
Aitken, Charles S., 140 N. Broad St.
Albrecht, Herman E., 217 S. Forty-sixA St.
Albright, Markley C, 2130 S. Broad St
Alexander, Emory G., 1701 Spruce St
Alexander, Ruth, 210 E. Sixty-fourth St, New York
City.
Allen, Francis O., Jr., 2216 Walnut St
Allen, Jesse Hall, 1327 Spruce St.
Allen, Leo Barton, 2423 Allegheny Ave.
Allen, Luther M., 3100 Wharton St
Allman, Alfred F., 1639 S. Twenty-second St
Allyn, Herman B., 501 S. Forty-second St
Alrich, William M., 6829 Chew St., Gtn.
Alston, Robert Swan, 5348 Wingohocking Terrace, Gtn.
Anders, Andrew. 1724 Diamond St.
Anders, James M., 1605 Walnut St.
Anders, J. Wesley, 1329 W. Somerset St.
Anderson. Joseph W., 1709 Green St.
Andrus, Walter H., 5913 Greene St., Gtn.
Ankeney, Clinton R., 803 N. Twenty-fourth St
Annesley, William H.. 3445 Frankford Ave.
Annon, Walter T., 4532 N. 11th St
Anspach, Brooke M., 1827 Soruce St.
Antrim, Harold T., 1947 N. thirteen* St
Digitized by
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July, 1921
MEMBERSHIP LIST
759
Antunovic, Nedjelko, Posta Restante, Glavna Posta,
Zagreb, Jugo-Slavia.
-Apeldorn, Ernest F., 2113 N. Howard St.
Apple, Oarence E., 1509 Sixth-eighth Ave., Oak Lane.
Applegate, John C, 3540 N. Broad St.
Appleman, Leighton F., 308 S. Sixteenth St.
Armao, Joseph, 1603 S. Twelfth St.
Armstrong, Thomas M., 1429 Qiristian St.
Arnett, James H., 2540 N. Eleventh St.
Amett, John Hancock, 2116 Pine St.
Arnold, J. O., 4149 N. Broad St.
Aronson, Joseph D., Phipps Institute.
Artelt, Henry, 1521 N. Eighth St.
Artman, E. Louis, 2131 Pine St.
Asher, Joseph M., 1335 N. Broad St.
Asnis, Eugene J., 1731 Vine St.
Aspel, Joseph, 5803 Spruce St.
Assante, Pasquale, 1335 S. Broad St.
Astley, G. Mason, 5317 Master St.
Atkins, George H., 1727 S. Broad St.
Atkinson, Thomas H., 620 Diamond St.
Atlee, Louis W., 2039 Pine St.
Attix, James C, 2355 N. Thirteenth St.
Auge, Emily Whitten, 2734 Wharton St.
Austin, J. Harold, The Latham Apartments.
Austin, J. Paul, 5915 Greene St., Gtn.
Averett, Leonard, 1016 N. Sixth St.
Axilbund, Samuel, 5802 Cedar Ave.
Babbitt, James A., 1901 Chestnut St.
Babcock, W. Wayne, 2033 Walnut St.
Bachman, Harry S., 1134 W. Lehigh Ave.
Bacon, Emily P., 107 S. Twenty-first St.
Bacon, H. Augustus, 1527 Girard Ave.
Bacon, William D., 409 N. Fifty-fourth St.
Baer, Benjamin F., Jr., 2039 Chestnut St.
Baer, Louis, 1233 S. Fourth St.
Bailey, Edwin C. 710 Flanders BIdg.
Bailey, Robert W., 102 E. Price St., Gtn.
Bainbridge, Empson H., 1425 Poplar St.
Baird, Frank B., 723 S. Fifty-second St.
Baker, F. Kline, 3019 Diamond St.
Baker, George F., 403 Lafayette BIdg.
Baker, Victor Louis, Foulkrod & Hawthorne Sts.
Baldi, Frederick S., 2117 Porter St.
Baldwin, James H., 1426 Pine St.
Baldwin, Kate W., 1117 Spruce St.
Baldy, J. Montgomery, 409 Lincoln BIdg.
Balentine, Percy L., 1524 Chestnut St.
Ball, Joseph P., 5001 Frankford Ave.
Balliet, Tilghman M., 3709 Powelton Ave.
Banks, Henry W., 66 W. Ross St., Wilkes-Barre (Lu-
zerne Co.).
Bardsley, G. Ashton, 129 W. Susquehanna Ave.
Bare, Horace C, 2104 Green St.
Barenbaum, Louis, 519 N. Fourth St.
Barlow, Aaron, 1431 N. Franklin St.
Barlow, Louis E., 3113 Richmond St.
Barnard, Everett P., 119 S. Nineteenth St.
Barnes, Charles S., 2035 Chestnut St.
Bamett, Charles H. J., 812 S. Fifteenth St.
Barnett, Rose Lillian, 1822 W. Erie Ave.
Baron, Abraham I., 2422 N. Twenty-ninth St.
Baron, Samuel, 2124 S. Broad St.
Barrett, Onie Ann, 312 S. Sixteenth St.
Barrett, Robert C, Smithfield, Isle of Wight Co., Va.
Barron, Charles A., 6327 Torresdale Ave.
Barry, William D., 140 N. Broad St.
Bartle, Henry J.. 2014 Walnut St.
Barton, Isaac, 2044 .Chestnut St.
Bateman, Sydney E., 5300 Spruce St.
Bates, Hervey L., 134 Manheim St., Gtn.
Batroff, Warren C, 2456 N. Seventeenth St.
Bauer, Charles, 1335 N. Thirteenth St.
Bauer, Edward L., 6112 Germantown Ave.
Bauer, L. Demme, 1713 W. Girard Ave.
Bauer, Marie L., 1613 Fairmount Ave.
Baum, Charles, 1828 Wallace St.
Baun, William D., 623 E. Allegheny Ave.
Baxter, Ada R., 1923 Chestnut St.
Baxter, Hart B., 4812 Springfield Ave.
Bayley, Weston D., 1524 Chestnut St.
Bayton, George L., 1840 Christian St.
Beach, Edward W., 5052 Walnut St.
Beardsley, Edward J. G., 258 S. Sixteenth St.
Beardwood, Matthew, Jr., 5504 Ridge Ave.
Beates, Henry, Jr., 260 S. Sixteenth St.
Beaver, Matilda, 2300 Pine St.
Beck, Albert F., 6331 Elmwood Ave.
Becker, Carl E., Lankenau Hospital, Corinthian and
Girard Aves.
Becker, John B., 5211 Chester Ave.
Beckley, Allen G., 1710 Diamond St.
Bedrossian, Edward H., 2044 Chestnut St.
Beebe, Charles H., 2117 E. Cumberland St.
Beecroft, Elizabeth McK., 5546 N. Fifth St.
Behney, Charles Augustus, 5726 Lansdowne Ave.
Behrend, Moses, 1427 N. Broad St.
Bell, Edward H., 739 Spruce St.
Beltran, Basil R., 1828 S. Rittenhouse Sq.
Bemis, Royal W., 2512 N. Fifth St.
Bender, Engelbert C, 5201 Pine St
Bender, Paul B., 3318 Germantown Ave.
Benedict, Franklin D., 2503- N. Eighteenth St.
Bennett, John, 5911 Girard Ave.
Bennett, William A., 8008 Frankford Ave., Holmes-
burg.
Berens, Bernard, 2041 Chestnut St.
Berens, Conrad, 2004 Chestnut. St
Berg, Albert P^711 N. Eighth St.
Bergey, David H., 206 S. Fifty-third St.
Bernard, Melamed, 1417 S. Fourth St.
Bemardy, Henry L., 321 S. Eleventh St.
Bernd, Leo H., 2106 Chestnut St.
Bernett, Raul (y Cordova), Lying-in Charity Hospital,
Eleventh and Cherry Sts.
Bernhardt, William H., 2209 S. Ninth St.
Bernheim, Albert, 1212 Spruce St.
Bernstein, Mitchell, 1437 S. Broad St.
Bertin, Elmer J., 1702 Oregon Ave.
Bertolet, John Allan, 313 S. Eighteenth St.
Besser, Joseph P., 3134 Diamond St.
Bethel, John P., 3513 Hamilton St.
Bevier, George, Thirty-fourth and Pine Sts.
Beyea, Henry D., Roanes, Gloucester Co., Va.
Biedert, Charles C, 1531 N. Seventeenth St.
Billings, Arthur E., 1703 Spruce St.
Binder, Israel, 833 S. Third St.
Bird, Gustavus C, 1415 Erie Ave.
Birdsall, Joseph C, 116 S. Nineteenth St.
Bimey, Herman H., 4016 Chestnut St.
Bishop, Aaron L., 5324 Vine St.
Blackburn, Albert E., 3813 Powelton Ave.
Blackwood, J. Douglas, Jr., c/o Bureau of Navigation
Navy Dept., Washington, D. C.
. Blair, Mortimer W., 369 Green Lane, Rxb.
Blakeslee, Walter H., 3328 N. Seventeenth St.
Bland, P. Brooke, 1621 Spruce St.
Blayney, Charles A., 5009 Walnut St.
Blechschmidt, Dott Case, 100 S. Fifty-first St.
Blechschmidt, Julius, 100 S. Fifty-first St.
Blieden, Maurice S., 1310 S. Fifth St.
Blitzstein, Rosalie M., 4122 Girard Ave.
Block, Frank Benton, 2035 Chestnut St.
Bloom, Homer C, 1421 Walnut St.
Bloom, Rudolph, 4104 Girard Ave.
Bloomfield, Maximilian D., 2008 N. Park Ave.
Blumberg, Nathan, 708 Pine St.
Bochroch, Max H., 1539 Pine St.
Boehringer, H. Winfield, 1811 S. Twenty-second St.
Bogart, Arthur E., 5046 Market St.
Boger, John A., 2213 N. Broad St.
Bogia, Reuben A., 760 Preston St.
Boice, J. Morton, 4020 Spruce St.
Boles, Russell S., Overbrook Ave & Fifty-third St.
Digitized by
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760
THE PENNSYLVANIA MEDICAL JOURNAL
July, 1921
Bolton, Samuel, 4701 Leiper St., Frankford.
Bond, Earl D., 4401 Market St.
Bonnaffon, Samuel A., 3439 Walnut St.
Bonney, Charles W., 1117 Spruce St.
Boon, David John, 1532 N. Fifteenth St.
Boon, W. Thomas, 215 Greerl Lane, Manayunk.
Booye, Mark Townsend, 1816 N. Thirteenth St.
Borrowes, George H., 160 N. Twentieth St.
Borzell, Francis F., 1119 Harrison St., Frankford.
Boston, Frank E., 813 N. Sixteenth St.
Boston, L. Napoleon, 2024 Chestnut St.
Boston, Samuel C, 2249 Catherine St.
Bottomley, Harold L., Samaritan Hospital.
Boulton, Eleanore F., P. O. Box 638.
Bove, Anthony D., 1407 S. Thirteenth St.
Bowen, Clement R., 752 S. Sixtieth St.
Bowen, David R., Pennsylvania Hospital, Eighth and
Spruce Sts.
Bower, Collier L., 255 S. Sixteenth St.
Bower, John O., 2033 Walnut St.
Bowman, Benjamin, 2600 S. Sixth St.
Bowman, Frank S., 1711 S. Thirteenth St.
Bowyer, Maud A., 254 S. Sixteenth St.
Boyce, Lee, Route 2, Box 317, Los Angeles, California.
Boyd, George M., 1909 Spruce St.
Boyer, D. Pellman, 4747 Richmond St.
Boyer, Henry P., 4602 Baltimore Ave.
Boyer, J. Clinton, 4032 Spruce St.
Boyer, Merle S., 108 S. Fourth St.
Boyer, Robert, 2448 N. Broad St.
Bradley, Thomas B., 2009 Chestnut St.
Bradley, William N., 1725 Pine St.
Brady, Charles P., 7130 Rising Sun Ave., Fox Chase.
Brady, Franklin, 1815 Frankford Ave.
Bram, Israel, 1427 Spruce St.
Bransfield, John W., 2025 Walnut St.
Brav, Aaron, 917 Spruce St.
Brav, Herman A., 1933 N. Broad St.
Bready, William R., Jr., 1857 N. Eleventh St.
Brecker, N. Francis, 2347 St. Alban's St.
Bremer, Paul F., 839 N. Broad St.
Brenner, Maxwell B., 2919 Richmond St.
Brewster, Joseph H., Broad St. Station.
Brick, J. Coles, 1327 Spruce St.
Bricker, Charles E., 2739 Girard Ave.
Bricker, Sacks, 1101 Wyoming Ave.
Bridgett, Charles R., 3332 Chestnut St.
Bridgett, Frank A., 1809 Chestnut St.
Brinkerhoff, Nelson M., 1831 Chestnut St.
Brinton, Ward, 1423 Spruce St.
Brister, Samuel, 1946 N. Thirty-second St.
Brittingham, James D., 4011 Chestnut St.
Britton, Harry A., 351 N. Fifth St., Reading (Berks
Co.).
Broadfield, John A., 3131 Frankford Ave.
Brooke, Emma W., 312 S. Sixteenth St.
Brooke, John A.. 264 S. Sixteenth St.
Broomall, Harold S., 7201 Cresheim Rd., Mt. Airy.
Brophy, John A.. 2024 Chestnut St.
Brown, Claude P., 904 Mattison Avenue, Ambler.
Brown, C. Sheble, 4304 Frankford Ave.
Brown, H. MacVeagh, 4603 Baltimore Ave.
Brown, Henry P., Jr., 1822 Pine St.
Brown, Maurice. 4905 N. Twelfth St.
Brown, Samuel Horton, 1901 Mt. Vernon St.
Brown, William R., Jr., 2345 E. Cumberland St.
Brubaker, Albert P., 3426 Powelton Ave.
Bruck, Samuel, 1918 N. Franklin St.
Brumbaugh, Simon S., 2923 N. Twelfth St.
Brumm, Seth A.. 818 Stock Exchange Bldg.
Bruner, Henry G., 542 N. Eleventh St.
Brunei, John E.. 2038 N. Broad St.
Bryan, J. Roberts, 4200 Chestnut St.
Buchanan, Marv. 2106 Chestnut St.
Buckenham, John Edgar Burnett, 8601 Germantown.
Ave.
Buckley, Albert C, Friends Hospital, Frankford.
Budin, David, 3125 Diamond St.
Bunting, Josiah T., 6410 Germantown Ave.
Burge, Frank Walton, 4226 Walnut St.
Burk, Charles M., 158 N. Twentieth St.
Burke, Joseph J., 5117 Baltimore Ave.
Burke, Richard D., 515 Green St.
Burns, Joseph P., 5233 Chester Ave.
Bums, Louis J., 1906 Chestnut St.
Bums, Michael A., 2010 Chestnut St.
Bums, Stillwell C, 1925 Spring Garden St.
Burr, Oiarles W., 1918 Spruce St.
Burriss, Walton S., 6645 Torresdale Ave.
Burwell, T. Spotuas, 2008 Fitrwater St
Busch, John William, 2500 S. Eighteenth St.
Butler, Margaret F., 2127 Green St.
Butler, Ralph, 1926 Chestnut St.
Butt, Miriam M., 1701 Chestnut St.
Butte, Harley J., 2047 Christian St.
Butz, Alfred S., 735 N. Forty-first St.
Buzby, B. Franklin, 4427 Walnut St.
Bynon, Margaret H., Darling (Delaware Co.).
Byrne, Thomas J., 2037 Chestnut St.
Cadwalader, Williams B., 1501 Spmce St.
Cahall, William C, 154 W. Chelten Ave., -Gtn.
Cahan, Jacob M., 930 N. Eleventh St.
Cairas, Andrew A., 613 E. Phil-Ellena St., Gtn.
Callahan, Andrew, 1829 S. Broad St.
Cameron, George A., Greene St. and Schoolhouse Lane,
(5tn.
Cameron, J. Lawson, 1500 Girard Ave.
Campbell, Raymond F., 1311 W. Allegheny Ave.
Cancelmo, J. James, 5112 Spmce St.
Carey, Harry K., 2035 Chestnut St.
Cariss, Walter L., 2043 Walnut St.
Carlucci, Carmine, 819 Christian St.
Carmany, Harry S., 366 Green Lane, Rxb.
Camett, John B., 123 S. Twentieth St.
Carp, Israel Jay, 1608 S. Tendi St.
Carpenter, Herbert B., 1805 Spruce St.
Carpenter, Howard Childs, 1805 Spmce St.
Carpenter, John T., 2030 Chestnut St.
Carpenter, Samuel A., 2265 N. Sixteenth St.
Carr, Charles D., 1917 Spruce St.
Carrell, James Fell, 330 S. Seventeenth St.
Carreras, Pedro J., 973 N. Fifth St.
Carrier, Frederic, 406 S. Sixteenth St.
Carroll, William, 617 S. Sixteenth St.
Carmthers, Georgina H., 3064 Frankford Ave.
Carson, John B., 1802 Pine St.
Carter, Andrew D., 753 N. Fortieth St.
Case, Eugene A., 63 LaCrosse Ave., Lansdowne.
Casey, Arthur E. S., 5924 Cedar Ave.
Cassidy, Paul B., 2037 Pine St.
Catford, Damley Wood, 2901 N. Twenty-fourth St
Chaiken, Jacob B., 1338 N. Franklin St.
Chance, Burton, 1305 Spmce St.
Chandlee, William H., 4930 Frankford Ave.
Chandler, Charles F., 1750 N. Park Ave.
Chandler, Irene P., 741 N. Forty-first St.
Chandler, Swithin T., 5904 Greene St., Gtn.
Chapin, Laura S., 1724 Diamond St.
Chapman, John P., Sixth and Walnut St.
Chesner, Frank M., 703 Wharton St.
Chestnut, James C, 1817 Frankford Ave.
Cheston, RadcliflFe, 102 W. Chestnut Ave., Chestn-rt
Hill.
Child, Dorothy, 5023 McKean Ave., Gtn.
Chirinos, Frederick C, 2626 E. Allegheny Ave.
C^hodoflF, Louis, 705 Pine St.
Christenson, Newell A., 6717 Elmwood Ave.
Christie, W. Edgar, 1805 Pine St.
Christine, Gordon M., 2043 N. Twelfth St.
Ciccone, G. Vico, 1409 S. Broad St.
Claggett. Augustus H.. 2615 N. Twenty-ninth St.
Clapp, Georee H., 5129 Baltimore Ave.
Clark, Bennington F. R., Palmerton (Carbon Co.).
Clark, Cunningham P., 2001 Chestnut St.
Digitized by
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July, 1921
MEMBERSHIP LIST
761
Clark, Edward V., 2001 Chestnut St.
Clark, Elizabeth E., 252 High St., Gtn.
Clark, Elizabeth F. C, 2201 DeLancey Place.
Clark, George G., 2221 N. Sixteenth St.
Clark, Jefferson H., 3343 N. Twentieth St.
Clark, John G., 2017 Walnut St.
Clark, William L., Medical Arts Bldg.
Cleveland, F. Mortimer, 5211 Walnut St.
Cloud, Charles H., 14 N. Sixtieth St
Clouting, E. Sherman, 2434 N. Broad St.
Coates, George M., 1736 Pine St.
Codman, Charles A. E., 4116 Spruce St.
Cogill, Lida Stewart, 1831 Chestnut St.
Cohen, Abraham J., 1630 Spruce St
Cohen, Herman B., 1301 Spruce St
Cohen, Samuel, 2523 S. Broad St.
Colcher, Abraham E., 1135 Spruce St.
Cole, Charles J., Elkins Park (Montgomery Co.).
Coles, Strieker, 2103 Walnut St.
Colgan, James F. E., 1022 N. Fifth St.
Colgan, John A., 1809 Chestnut St
Coll, Charles A., 149 Midvale Ave.
Collins, Arthur A., Oxford (Chester Co.).
Collins, Ebert Caleb, 6027 Germantotim Ave.
Collins, Edward W., 2031 E. All^heny Ave.
Comerford, Joseph F., Hardy, Ky.
Conard, Thomas E., 1855 N. Seventeenth St.
Conlen, Alexander J. P., 1113 S. Fifty-third St.
Cooke, Dudley T., 1536 S. Broad St
Cooke, Edwin S., 1831 Chestnut St.
Coombs, James Norman, 1319 N. Broad St.
Cooperman, Morris B., 1811 S. Broad St
Cope, Thomas A., 6504 Germantown Ave.
Coplin, William M. L., 606 S. Forty-eighth St
Copp, Owen, 4401 Market St
Coppin, M. E. Thompson, 1913 Bainbridge St.
Cornell, Walter S., 729 City Hall.
Comfeld, Morris, 1336 S. Fourth St.
Comfeld, Rebecca, 1336 S. Fpurth St.
Cortese, Ignazio, 1025 Christian St.
Cowan, Alfred, 2018 Chestnut St
Cowie, Helen J., 222 S. Forty-fifth St.
Coyne, Frank M., 516 W. Luzerne St
Craig, Alexander R., 535 N. Dearborn St., Chicago, III.
Craig, Clark R., 331 S. Twelfth St.
Craig, Frank A., 1818 S. Rittenhouse Square.
Cramp, Joseph A., 1902 Chestnut St.
Crampton, George S., 1700 Walnut St.
Crandall, T. Vaughan, 114 S. Eighteenth St.
Creighton, William J., 1905 Chestnut St.
Crosby, William Smith, 1503 Locust St
Croskey, John W., 1909 Chestnut St.
Crowe, F. Beresford, 728 S. Sixtieth St.
Crowley, William Henry, 2402 E. Allegheny Ave.
Crueger, Edward A., "1123 N. Forty-first St.
Cruice, John M., 1932 Spruce St
Cryer, Matthew H., 140 S. Lansdowne Ave., Lans-
downe (Delaware Co.).
Culbertson, Walter L., 2502 N. Twenty-ninth St.
Cunningham, James H., 1703 S. Twenty-second St.
Cunningham, Joseph F., 4356 Penn St., Frankford.
Cunningham, J. Metz, 2018 E. Chelten Ave., Gtn.
Currie, Charles A., 50 W. Walnut Lane, Gtn.
Currie, Thomas R., 512 W. Lehigh Ave.
Custer, David D., 137 Green Lane, Manayunk.
Custer, Ella B., 137 Green Lane, Manayunk.
Cutting, Charles Theodore, 112 North Broad St.
Czubak, Matthew, 2716 N. Twelfth St.
DaCosta, J. Chalmers, 2045 Walnut St.
Daland, Judson, 317 S. Eighteenth St.
Daniels, Clarence D., 1338 Spruce St.
Dannenherst, Arthur M., 256 S. Fifteenth St
d'Anery, Tello J., 767 N. Fortieth St.
Davidson, Arthur J., 200 S. Twelfth St.
Davies, John R.. Jr., 302 S. Nineteenth St.
Davis, Edward P.. 250 S. Twenty-first St.
Davis J. Leslie, 135 S. Eighteenth St.
Davis, Leon O., 4515 Paul St., Frankford.
Davis, Richard S., 302 School Lane, Gtn.
Davis, T. Carroll, 3128 N. Broad St.
Davis, Warren B., 135 S. Eighteenth St
Davisson, Alexander H., 4514 Springfield Ave.
Day, Elbert O., 2/ Carpenter Lane, Mt. Airy.
Deardorff, William H., 5049 Hazel Ave.
Deaver, Henry C, 1701 Spruce St
Deaver, John B., 1634 Walnut St.
Deaver, Richard W., 6105 Main St., Gtn.
DeCarlo, John, 1124 Ellsworth St.
Deehan, Sylvester James, 843 N. Twenty-fourth St.
DeFord, Moses, 1524 Chestnut St
Deichler, L. Waller, 2028 Chestnut St.
Deitz, George W., Jr., 1744 Orthodox St., Frankford.
DeLong, Perce, 1909 Chestnut St
Dempsey, William T., 2606 N. Fifth St.
Dengler, Robert H., 2324 N. Broad St
Denney, George H., Medical Arts Bldg.
Dercum, Francis X., 1719 Walnut St
Despard, Duncan L., 1806 Pine St.
Devitt, Benjamin F., 1503 N. Fifteenth St.
Devitt, William, R. F. D., Georgetown, Del.
Devlin, Albert J., 1615 N. Tenth St.
Dewees, Ernest J., 409 Chestnut St.
Dewey, Julian H., 78 N. Qinton Ave., Trenton, N. J.
DeYoung, A. Henriques, 1949 N. Broad St.
Diamond, Henry N., 2136 S. Fifth St.
Dick, John W., 1945 Christian St.
Dick, Walter, 79 Pickering St., Brookville.
Dickinson, Harrington S., 3124 N. Broad St.
Diez, M. Luise, 305 Blackstone Boulevard, Providence,
R. L
Dintenfass, Henry, 415 Pine St.-
Diseroad, Benjamin F., 901 W. Lehigh Ave.
Diven, John, 2038 Chestnut St.
Dix, Archibald L., 5140 Greene St., Gtn.
Doane, Joseph C, Philadelphia Gen. Hospital.
Doe, Qiarles H., 925 Rush Building, Tacoma, Wash-
ington.
Dolson, Frank E., 1524 Chestnut St.
Donahue, John Leo, 216 E. Price St., Gtn.
Donmoyer, Ida L., 2443 N. Seventeenth St.
Donnelly, Daniel J., 1500 W. Erie Ave.
Donnelly, Dorothy, 1822 Chestnut St
Donnelly, Edward J., 3000 W. Lehigh Ave.
Donnelly, James Francis, 1536 N. Fifteenth St
Donnelly, John Develin, 1828 Pine St.
Donnelly, Robert T. M., 1242 W. Lehigh Ave.
Donnelly, William F., 616 N. Fifty-third St.
Donoghue, Robert L., 2700 N. Broad St.
Dorland, William A. N., 7 W. Madison St., Chicago,
III.
Dorr, Henry I., 15 Edgehill Road, Winchester, Mass.
Dorrance, George M., 2025 Walnut St
Dorsett, Ernest M., 1531 N. Nineteenth St.
Dorsett, Rae S., 213 S. Forty-sixth St.
Dougherty-Trexler, Henrietta M., 923 W. Susquehanna
Ave.
Douglass, Malcolm, 1814 Tioga St.
Douredoure, Eveleen A., 4107 Baltimore Ave.
Downs, Robert N., Jr., 6008 Greene St., Gtn.
Downs, Thomas A., 409 N. Forty-first St.
Doyle, Alfred S., 5849 Chestnut St.
Drake, Ellwood L., 2762 Pratt St., Bridesburg.
Dripps, John H., 1812 N. Eleventh St.
Druce, Thomas W., 6339 Elmwood Ave.
Drumheller, Floyd D., 5128 Chester Ave.
Drummond, Winslow, 1824 N. Thirteenth St.
Dubbs, John H., 2722 N. Twelfth St
Dubbs, Robert L., 1622 S. Eighteenth St.
Dubin-AlexandroflF, Charies W., 706 N. Fifth St.
Dukes, John L., 344 N. Fifty-second St.
Dunbar, Arthur W., 2412 S. Twenty-first St.
Duncan, Harry A., 2615 W. Somerset St.
Dundore, Qaude A., The Wellington.
Dyson, Frank M., 222 St. Mark's Square.
Digitized by
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762
THE PENNSYLVANIA MEDICAL JOURNAL
July, 1921
Earnshaw, Henry C, Bryn Mawr (Montgomery Co.).
Eckfeldt, John W., 6312 Vine St.
Edeiken, Louis, 2412 S. Fifth St.
Edwards, Preston M., 3957 Warren St.
Edwards, Thomson, 5827 Willows Ave.
Eft, Frederick, 1340 N. Thirteenth St.
Egan, John H., 1930 Race St.
Egbert, Seneca, 4814 Springfield Ave.
Eglick, Samuel, 525 N. Fourth St.
Egly, H. Q>nrad, Quarryville (Lancaster Co.).
Eiman, John, 516 N. Thirty-ninth St.
Eisenhardt, William G.. 2102 N. Sixth St.
Elder, Frank H., 6038 Overbrook Ave.
Eldredge, Clarence S., 2330 N. Seventeenth St.
Eliason, Eldredge L., 320 S. Sixteenth St.
Ellis, Samuel, 6203 Elmwood Ave.
Ellis, William T., 1926 N. Nineteenth St.
Ellison, Richard T., Ill Rex Ave., Chestnut Hill.
Ellison, Thomas, 2324 Bridge St. (Brides.)
Klzey, James Murray, 106 Highland Ave., Chestnut
Hill.
Elmer, Macomb K., The Covington.
Elmer, Walter G., 1801 Pine St.
Ely, Thomas C, 2018 Chestnut St.
Ely, William C, 3912 Oiestnut St.
Embery, Frank, 4660 Frankford Ave.
Emich, John P., 3245 N. Front St.
Enders, William J., Home for Consumptives, Chestnut
Hill.
Endres, Joseph M., 1416 S. Fifteenth St.
Engelhardt, Carolina S. Ruth, Lansdale Hospital, Lans-
dale, Pa.
Engle, Ralph L., 827 S. Sixtieth St.
Englerth, Louis D., 4912 Frankford Ave.
Enoch, George F., 8037 Frankford Ave.
Epstein, Abraham, 4027 Girard Ave.
Erck, Theodore A., 251 S. Thirteenth St.
Erney, Erwin H., 1723 N. Fifty-fifth St.
Ersner, Matthew S., 1729 Pine St.
Eshleman, Robert H., 4625 Baltimore Ave.
Eshner, Augustus A., 1019 Spruce St.
Evans, William, 4007 Chestnut St.
Everitt, Ella B., 1807 Spruce St.
Eves, Curtis C, 247 S. Seventeenth St.
Ewing, Charles H., 1330 S. Seventeenth St.
Ezickson, William J., 2143 N. Howard St.
Fadil, Alexander, 140 N. Broad St.
Falls, Samuel C, 743 N. Sixty-third St.
Faries, Randolph, 2007 Walnut St.
Faris, (Jeorge T., 17 Roberts Ave., Glenside (Mont-
gomery Co.).
Farley, David L., 1906 Pine St.
Farr, William W., 20 W. Ashmead Place, Germantown.
Farrar, Joseph D., 7103 York Rd.
Farrell, Martin Joseph, 4657 Lancaster Ave.
Farrington, Charlotte S., 2130 W. Passayunk Ave.
Faught, Francis A., 5006 Spruce St.
Felderman, Leon, 4428 York Rd.
Feldman, Jacob B., 1339 N. Seventh St.
Feldstein. Sidnev L.. 2145 N. Fifteenth St.
Felt, Carle Lee, 2007 Chestnut St.
Fenerty, Vincent J., 2217 E. Cumberland St.
Fenton, Thomas H., 1319 Spruce St.
Ferguson, Albert D., 50 E. Johnson St., Gtn.
Ferguson, George Mclntyre, 706 S. Forty-ninth St
Ferguson, William N., 125 W. Susquehanna Ave.
Ferguson, William N., Jr., 2725 N. Fifth St.
Ferry, Alfred A.. 629 N. Sixty-third St.
Fetterman, Wilfred B., 7047 Germantown Ave.
Fetterolf, George, 2047 Chestnut St.
Fiet, Harvey J., 2152 N. Fourth St.
Fife, Charles A., 2038 Chestnut St.
Kinck, Edward B., 1518 Pine St.
Pineman, Harry E., 1324 S. Fifth St
Fingles, Albert A., 2229 Vine St.
Fischelis, Philipp, 828 N. Fifth St
Fischer, Charles. 2082 E. Cumberland St.
Fish, Harry C, 200 N. Fiftieth St.
Kisher, Frank, 1911 Arch St.
Fisher, Henry, 2345 E. Dauphin St.
Fisher, Henry M., 102/ Pine St.
Fisher, Herbert P., 5532 Wayne Ave., Gtn.
Fisher, John M., 222 S. Fifteenth St.
Fisher, John V., 6027 Larchwood Ave.
Fisher, Lewis, 1820 Spruce St.
Fisher, Mary, 1911 Arch St.
Fisher, Mulford K., 3110 Diamond St.
Fitzpatrick, Ignatius L. J., 1807 S. Eighteenth St.
Flannery, Leo G., S. W. Cor. Broad and York Sts.
Fleming, Thomas J., 2225 Green St
Flick, John B., 738 Pine St.
Flynn, J. Cajetan, 1225 N. Sixth St
Foehrenbach, Julius E., 3228 N. Fifteenth St
Ford, Walter A, 256 S. 15th St.
Formad, Marie K., 927 N. Broad St
Forman, Horace J., Jr., 136 E. Herman St., Gtn.
Forst, John R., 166 W. Colter St., Gtn.
Foulkrod, Collin, 3910 Chestnut St.
Fox, C. Calvin, 350 S. Sixteenth St.
Fox, Herbert, 3902 Locust St.
Fox, L. Webster, 303 S. Seventeenth St.
Fox, S. Watson, 6618 Ridge Ave., Roxboro.
Fraley, Frederick, 1804 Pine St.
Fralinger, John J., 1827 S. Second St
Francine, Albert P., 264 S. Twenty-first St
Francis-Self, Marian, 223 E. Meade St., Chestnut Hill.
Frank, Abraham, 1917 N. Thirty-second St.
Franklin, Clarence P., 1527 Spruce St.
Franklin, M. Burnett, 1423 Diamond St.
Franklin, Melvin M., 6124 Greene St., Gtn.
Eraser, Hugh D., 6618 Woodland Ave.
Frazier, Charles H., 1724 Spruce St.
Freas, Henry M., 1319 W. Allegheny Ave.
Freeman, Frank E., 721 N. Sixty-third St
Freeman, Walter J., Jr., 1832 SpnKe St
Freeman, Walter S., 909 W. Susquehanna Ave.
Fretz, Howard G., 1207 W. Erie Ave.
Freund, Henty H., 1443 S. Broad St.
Frick, J. Howard, 25 High St, Gtn.
Fridy, Cyrus W., S. E. Cor. Fitty-eif^th St. and
Thomas Ave.
Friedenbcrg, Samuel, 717 Pine St.
Friedmann, Adolph H., 161 N. Sixtieth St.
Friedmann, O. Fleisher, 2124 N. Twelfth St.
Fries, Charles J. V., Jr., 2044 Chestnut St
Fries, Irvin A., 1312 S. Broad St.
Fritch, J. Scott, 1318 Spruce St.
Fritts, William H., 535 N. Eleventh St
Fritz, Clarence H., 1822 S. Broad St
Fritz, W. Wallace, 1600 Summer St.
Frosch, Frank J., 2736 N. Twelfth St.
Fuller, Daniel H., Pennsylvania Tlospital for Insane,
Market and Forty-fourth St.
Fuller, Dwight B., 208 N. Thirty-fourth St.
Fulton, T. Chalmers, Schuyler BIdg., Sixth and Dia-
mond Sts.
Fulton, Z. M. Kempton, 1111 W. Lehigh St
Funk, Elmer H., 1318 Spruce St.
Furbush, C. Lincoln, 4300 Locust St.
Fussell, George D., 421 Lyceum St., Rxb.
Fussell. M. Howard. 2035 Walnut St.
Gabrio, Max R., 1736 Welsh Road, Bustleton, Pa.
Gadd, Samuel W., 2114 S. Sixteenth St.
Gaillard, A. Theodore, 1926 Shunk St
Galbraith, James L., 2239 N. Nineteenth St.
Gallagher, James S., 207 E. Sixth St., Lansdale.
Gallagher, John P., 4104 York Road.
Gans, S. Leon, State Dept. of Health, Harrisbnnt
(Dauphin Co.).
Gartman, Leo N., 523 Pine St
Garvey, Joseph P., 3639 Spring Garden St.
Gaskill, Henry K., N. E. Cor. Sixteenth and Spruce
Sts.
Gaston, Ida E., 2833 Diamond St.
Digitized by
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July, 1921
MEMBERSHIP LIST
763
Gates, Manley F., U. S. Naval Hospital, Key West,
Florida.
Geisler, Howard D., 132 W. Walnut Lane, Gtn.
Gerhard, Arthur H., 726 Richmond St
Gerhard, Samuel P., 639 N. Sixteenth St
Gerlach, Ella M., 3706 Brown St
Gerlach, Richard F., 1416 N. Seventeenth St
Gessler, Charles W., 1311 S. Broad St
Getelman, Ralph E., 2011 Chestnut St.
Getson, Philip, 1301 E. Moyamensing Ave.
Getty, Mary, 254 S. Sixteenth St.
Geyer, George W., 5705 Chester Ave.
Gibbon, John H., 1608 Spruce St
Gibson, Ann Tomkins, 6323 Lancaster Ave.
Gilbride, John J., 1934 Chestnut St.
Gildersleve, George H., 525 N. Sixth St
Gile, Benjamin C, 1627 Walnut St.
Gilhool, Edward W., 3818 N. Broad St
Gill, A. Bruce, The Lenox, Thirteenth and Spruce Sts
Gilliland, Samuel H., Ambler (Montgomery Co.).
Gilmour, William Roger, 237 S. Forty-fourth St
Gilpin, Sherman F., 1934 Chestnut St
Ginsberg, Hyman M., 1013 S. Sixtieth St
Ginsburg, Morris, 1511 S. Ninth St
Ginsburg, Samuel A., 1901 S. Broad St
Girvin, John H., 2120 Walnut St.
Gittelson, Samuel J., 1017 Spruce St
Gittings, J. Qaxton, 1828 Pine St
Given, Ellis E. W., 2714 Columbia Ave.
Gleason, E. Baldwin, 2033 Chestnut St.
Goddard, Herbert M., 1531 Spruce St.
Godfrey, Henry G., 2054 E. Cumberland St.
Goepp, R. Max, 124 S. Eighteenth St
Goldberg, Harold G., 1925 Chestnut St.
Goldberg, Joseph M., 855 N. Seventh St.
Goldberg, Maurice, 1724 S. Broad St.
Goldberg, Samuel, 4546 N. Broad St.
Goldburgh, Harold L., 517 Pine St.
Golden, Henry, 1722 S. Broad St.
Golden, Louis M., 5201 Chester Ave.
Goldring, Emil J., 1722 N. Eighth St.
Goldsmith, N. Ralph, 2035 Chestnut St.
Goldsmith, S. Byron, 1338 Spruce St.
Goldstein, A. Otto, 979 N. Fifth St.
Goldstein, Joseph, 2437 W. Lehigh Ave.
Good, William H., 5309 Rising Sun Lane.
Goodman, Edward H., 248 S. Twenty-first St.
Goodman. Robert. 221 Fitzwater St.
Goodwin, Warren C, 3740 Powelton Ave.
Goos, Harry W., N. E. Cor. Amber and Dauphin Sts.
Gordon, Alfred, 1812 Spruce St.
Gordon, Benjamin L., 1230 Spruce St
Gordon, Chester A. A., 4062 Haverford Ave.
Gordon, Samuel, 2003 S. Fourth St.
Gorman, John F., 2523 West Allegheny Ave.
Goss, Charles, 1316 W. Allegheny Ave.
Gottshall, Florence M., 1613 S. Thirteenth St
Gowen, Francis V., 904 E. Chelten Ave., Gtn.
Gowens, Henry L., Jr., 37 S. Sixteenth St.
Grady, William P., 1214 N. Seventh St.
Graf, Edmund L.. 927 S. Sixtieth St.
Graham, Edwin E., 1713 Spruce St.
Graham, John, 326 S. Fifteenth St.
Grahn, S. Norman, 1744 N. Tenth St.
Grala, William Leon, 1633 Spruce St.
Gray, Alfred P., 1818 Orthodox St.
Gray, George B., 6118 W. Oxford St.
Gray, Robert L., 3031 N. Broad St
Grayson, Charles P., 262 S. Fifteenth St
Greco, Tobv A., 1508 S. Broad St
Green, Max, 2007 S; Fourth St.
Greenbaum, Sigmund S., 1714 Pine St.
oreenewalt, Frank L., 1424 Master St.
Greenway, Samuel B., 2717 N. Twelfth St.
Griffith, J. P. Crozer, 1810 Spruce St.
Grim, Ella Williams, 32 N. Fiftieth St.
Grime, Robert T., 3830 Locust St.
Grimes, Charles Henry, 3546 N. Broad St.
Grimes, Robert B., 1147 S. Broad St.
Griscom, J. Milton, 1925 Chestnut St.
Groff, Charles A., 222 N. Thirteenth St.
Groff, Henry C, S. E. Cor. Broad and Venango St».
Groff, John W., 3500 N. Broad St.
Gross, Samuel, 645 Ritner St.
Gulezian, Lucy E., 5636 Catharine St.
Gummey, Frank B., 5418 Greene St., Gtn.
Gurin, Adolph A., 723 Pine St.
Guthrie, D. Clinton, 722 N. Fortieth St.
Haerer, Frederick J., 1241 Washington St., Cape May,
N. J.
Haig, Charles R., Jr., 1818 Diamond St
Haines, Fannie C, State Hospital, Taunton, Mass.
Haines, Wilbur H., Medical Arts Bldg., Sixteenth and
Walnut Sts.
Hale, George, Jr., 29 W. Main St., Haddonfield, N. J.
Hale, William H. L., 313 S. Seventeenth St
(lalperen, Abraham D., 2335 S. Eighth St.
Hall, William D. W., 801 S. Forty-ninth St
Hamill, Samuel McC, 1822 Spruce St.
Hamill, StejAen Aspinall, 2335 Oxford St.
Hamilton, William A., 602 E. Girard Ave.
Hamilton, William Z . 1221 W. Lehigh Ave.
Hammer, A. Wiese, . 8 S. Fifteenth St.
Hammond, Frank C i311 N. Broad St.
Hammond, Levi J., Iii2 Spruce St.
Hancock, Frank Bacon, 2065 N. Sixty-third St.
Hand, Alfred, Jr., 1724 Pine St
Hanna, George C, 4840 Frankford St.
Hanna, Hugh, 2843 Diamond St.
Hannum, William, 844 N. Twenty-third St.
Hansen, Howard F., N. E. Cor. Seventeenth and Wal-
nut Sts.
Harbaugh, Charles H., 1143 S. Broad St
Harbridge, D. Forest, Goodrich Block, Phoenix, Ariz.
Hardin, Julia H., 6323 Lancaster Ave. '•'
Hare, Hobart A., 1801 Spruce St.
Hargett, Walter S., 5617 Girard Ave.
Harris, Frank D., 2315 N. Seventeenth St
Harris, Joseph G., 72iJ Fitzwater St.
Harris, Raymond J., 1921 Chestnut St.
Harrison, Francis G., 116 S. Nineteenth St.
Harrison, Rose, 1836 S. Broad St.
Harrison, William J., 3452 Kensington Ave.
Harte, Richard H., 1503 Spruce St.
Hartley, Harriet L., 1534 N. Fifteenth St.
Hartley T. Ruth, 1534 N. Fiiteenth St.
Hartz, William, 5559 Spruce St.
Hartzell, Milton B., 3644 Chestnut St.
Harvey, E. Marshall, Media (Delaware Co.).
Hatfield, Charles J., 2008 Walnut St.
Hatfield-Richardson, Bertha S., 2021 N. Thirteenth St
Hawke, Wilfred W., Medical Arts Bldg.
Hawkins, (Hiarles L., Medical Arts Bldg.
Hawman, E. G., 4051 N. Broad St.
Hawthorne, Herbert Reid, 606 N. Thirteenth St.
Hayes, John Agnew, 1903 Arch St.
Hazzard, Henry Draper, 1243 S. Broad St.
Head, Joseph, southeast corner Fifteenth and Locust
Sts.
Heam, Marion, 4227 Chestnut St.
Heam, William P., 2119 Spruce St.
Heame, Charles S., 1632 Chestnut St.
Heath, Frances J., care Methodist Mission, Peking,
China.
Hebert, Arthur W., 119 E. Lehigh Ave.
Hebsacker, William F., 2151 E. Cumberland St.
Heck, John A., 958 N. Fifth St.
Heed, CHiaries R., 1205 Spruce St.
Heilman, Eugene A., 876 Wynnewood Rd.
Heiner, Louis B., 2404 N. Thirty-second St.
Heineberg, Alfred, Sixteenth and Spruce Sts.
Heinkel, Howard F., 10,' E. Lehigh Ave.
Heisler, Frank J., 3136 Diamond St.
Heisler, John C, 3829 Walnut St
Digitized by
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764
THE PENNSYLVANIA MEDICAL JOURNAL
July, 1921
Heller, Edwin A., 1911 N. Broad St.
Henuninger, Edward F., 10 Kirklyn Ave., Upper Darby.
Henry, J. Norman, 1906 Spruce St.
Henry, Melvin K., 5011 Tacony St.
Henry, Robert W., 768 S. Fifteenth St.
Herbert, J. Frederick, 1523 Locust St.
Herbert, J. Frederick, Jr., 1523 Locust St
Herchelroth, Jacob G., 4837 Baltimore Ave.
Herman, Leon, Medical Arts Bldg.
Herman, Marguerite Bailey, 325 Pine St.
Herman, Maxwell, 1103 Spruce St.
Hermance, William Oakley, 2040 Pine St.
Herrraan, Clinton S., 5101 N. Broad St.
Herrman, Max F., 1411 Erie Ave.
Hewish, Edgar M., 2131 Columbia Ave.
Hewson, Addinell, 2120 Spruce St.
Hewson, William, 6300 Overbrook Ave.
Hibshman, Henry Z., 1831 Chestnut St.
Higbee, William S., 1703 S. Broad St.
Higgate, Wilford O., 822 N. Forty-first St.
Higgins, Frank J., 2229 N. Broad St
Higgins, James C, 141 N. Nineteenth St.
Hildrup, Josephine Wheeler, 18 Wellington Rd., Bos-
ton, Mass.
Hilferty, Edward F., 2225 N. Twenty-first St.
Hill, Anthony J., 1609 W. Girard Ave.
Hill, G. Alvin, 1524 Chestnut St
Hilly, Josei* F., 724 N. Fortieth St.
Hinkle. William M., 1323 N. Thirteenth St.
Hmkson, DeHaven, 329 N. Fortieth St.
Hinman, Alma Mae, 208 Rochelle Ave., Wissahickon.
Hinson, Eugene T., 1333 S. Nineteenth St.
Hinton, Drury, 4214 Walnut St.
Hirsch, Charles S., S. W. Cor. Ninth and Pine Sts.
Hirschler, Rose, 126 S. Seventeenth St
Hirst, Barton C, 1821 Spruce St.
Hirst, John Cooke, 1823 Pine St
Hirst, Otto C, 905 W. Lehigh Ave.
Hitschler, William A., Medical Arts Bldg.
Hoban, Charles J., 1609 S. Broad St.
Hobensack, J. Rex, 1706 Columbia Ave.
Hockaday, Agnes, 316 Shadeland Ave., Drexel Hill.
Hodge, Edward B., 2019 Spruce St
Hofkin, Adolph F., 922 N. Fifth St.
Hollingshead, Irving W., 123 S. Eighteenth St
Hollopeter, William C, 1520 Spruce St.
Holloway, Thomas B., 1819 Chestnut St.
Holmes, E. Burvill, 714 Montgomery Ave., Wynrii-
wood.
Holmes, John W., 819 N. Sixty-third St.
Holtzhausser, George J., 160 W. Girard Ave.
Hooker, Richard S., 2147 N. Howard St
Hopkins, Arthur H., 1726 Pine St
Hopkins, Frederick M., 107 N. Fifty-seventh St.
Hopkinson, Oliver, 1101 Pine St.
Hopkinson, Richard Dale, 217 Summit Ave., Jenkin-
town (Montgomery Co.).
Horan, William F., 6327 Lancaster Ave.
Horgan, Edward. 2208 Walnut St.
Home. S. Hamill, 1610 Spruce St.
Hornstine, Harry H., 615 N. Seventh St
Hornstine, Nathan H., 530 Spruce St
Houser, Lewis J., 162 N. Eighth St
How, Harold W., P. O. Box 172, Bryn Mawr (Mont-
gomery Co.).
Howard, Marie Seixas, 68 Seaman Ave., New York
City.
Hoyt, Daniel M., The Tracy, Thirty-sixth St. above
Chestnut
Hudson, Harry, 1602 Erie Ave.
Hughes, Charles Ralston, 247 S. Seventeenth St.
Hughes, Elizabeth M., 1924 N. Sixty-third St.
Hughes. William E.. 3945 Chestnut St.
Hume. John E., 1829 Spruce St.
Huneker, Minnie Arnold, The Lennox, Thirteenth and
Spruce Sts.
Hungerbuehler, John C, 1530 N. Franklin St.
Hunsicker, Hannah M., 5200 Rising Sun Ave.
Hunt, Laura Emma, 213 S. Seventeentfj St
Hunter, Robert J., 928 N. Sixty-third St
Huntoon, Frank M., 224 Park Ave., Swarthmore.
Hurlock, Frank I., 2831 Diamond St
Husik, David N., 1303 Locust St
Hustead, Frank H., 5112 N. Broad St
Huston, David T., 1809 (3iestnut St
Hutchinson, James P., 133 S. Twenty-second St
Huttenlock, Robert E., 1122 E. Columbia Ave.
Hutton, Frederick C, Fifteenlh and Jefferson Sts.
Immerman, Samuel L., 809 S. Sixtieth St.
Ingle, Henry B., 1937 Fairmount Ave.
Ingraham, S. Cooke, 125 Sumac St, Wissahickon.
Inslee, James P., 1509 Arch St.
Irwin, James A., 2019 S. Broad St
Irwin, William, 634 Snyder Ave.
Ivy, Robert H., 1503 Medical Arts Bldg.
Jackson, Chevalier, 1830 Rittenhouse Sq.
Jackson, J. Allen, State Hospital for the Insane, Dan-
ville (Montour Co.).
Jackson, Sumner W., Medical Arts Bldg.
Jacob, Louis H., 141 W. Susquehanna Ave.
Jacob, Moses, 1316 S. Fifth St
Jacobs, Leopold M., 2035 Chestnut St.
Jaffe, Jacob K., 1434 Spruce St.
Jameson, Howard Leon, 2133 S. Sixteenth St.
Janvier, Florizel, 4754 Penn St., Frankf ord.
Jenks, Horace H., 918 Clinton St.
John, Rutherford Lewis, 248 S. Twenty-first St.
Johnson, Alice Elizabeth, 17 S. Twenty-first St.
Johnson, Elmer E., 256 S. Fifteenth St.
Johnson, George Ernest, 5441 Chester Ave.
Johnson, Russel H., E^st Bell's Mill Rd., (Chestnut
Hill.
Johnson, William N., 6460 (jermantown Ave.
Johnson, William T., 4729 Baltimore Ave.
Johnston, Warren Herbert, 1413 S. Fifty-eighth St.
JoUey, W. A., 140 N. Broad St.
Jonas, Leon, 2253 N. Seventeenth St.
Jones, A. Arthur, 1810 Jefferson St.
Jones, Charles J., Los Angeles Athletic Qub, Los
Angeles, California.
Jones, Clifford B., 5538 Wayne Ave., Gtn.
Jones, Elemor C, 1531 N. Fifteenth St.
Jones, John Bayley, 938 W. Lycoming St.
Jones, John F. X., 103 S. Twenty-first St.
Jopson, John H., 1824 Pine St.
Jordan, Thomas B. L., Room B, Broad St. Station.
Joyce, William M., 1919 S. Broad St.
Judd, Clarence Wrigley, 4413 Richmond St.
Judson, Charles F., 1005 Spruce St.
Jump, Henry D., 2019 Walnut St.
Jurist, Louis, 1308 N. Broad St.
Kahn, Bernard L., 2125 S. Fourth St.
Kalteyer, Frederick J., 2003 Chestnut St.
Kamerly, E. Forrest, Jr., 1130 Spruce St
Kane, Qinton A., c/o Trust Dept., 318 Chestnut St.
Kane, Leo A., 2658 E. Thompson St.
Kapeghian, Ervant, 1029 Shackamaxon St.
Kapp, David, 1901 N. Broad St.
Karpeles, Maurice J., 146 W. Chelten Ave.
Katar, Felix M., 127 S. Thirty-sixth St.
Katzenstein, George P., 1915 N. Broad St.
Kauders, H. Randle, 648 E. Chelten Ave.
Kaufman, A Spenser, Spruce and Sixteenth Sts.
Kaufman, Isadore, 312 Otis Bldg., N. W. Cor. Six-
teenth and Sansom Sts.
Kay, James, 600 W. Olney Ave.
Keating, F. Raymond, 2100 S. Seventeenth St.
Keating, Howard F., 1761 N. Sixty-first St.
Keegan, Arthur P., 1411 S. Twenty-ninth St.
Keeler, J. Qarence. Medical Arts Bldg.
Keelv. Rnhert N.. The Art Qub, 220 S. Broad St.
Keen, William W., 1729 Chestnut St
Keenan. Andrew Joseph, 1809 Chestnut St.
Keene, Floyd E., Medical Arts Bldg.
Digitized by
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July, 1921
MEMBERSHIP LIST
765
Kehler, B. Frank, 316 S. Sixteenth St.
Reiser, Elmer E., 6933 Tulip St.
Keller, Albert P., 136 Race St.
Keller, Augustus H., 2551 E. Oearfield St.
Keller, Frederick E., 2217 E. Huntingdon St.
Kellner, Henry C. F., 1337 E. Montgomery Ave.
Kelly, Francis J., 407 S. Forty-second St.
Kelly, George F. J., 2114 S. Fifteenth St.
Kelly, James A., 1510 N. Seventeenth St.
Kelly, Maude M., 1200 Spruce St.
Kelly, Samuel J. J., 3857 N. Broad St.
Kelly, Thomas C, 105 Schoolhouse Lane, Gtn.
Kelly, William F., 1200 Poplar St.
Kelsey, Ernest W., 1217 Spruce St.
Kempton, Augustus F., 2118 Pine St.
Kennedy, James W., 241 N. Eighteenth St.
Kennedy, William Morton, 2535 N. Sixth St.
Kercher, Delno E., 1534 Pine St.
Kern, Richard A., 2319 E. Dauphin St.
Kerns, Samuel P., 1432 Diamond St.
Kerwin, Charles M., 5211 N. Third St.
Kessler, William C, 1130 S. Fifty-sixth St.
Kevin, Robert Oliver, 803 S. Forty-ninth St.
Keyes, Baldwin Longstreth, 4401 Market St.
Killian, Frederick W., 3725 Spring Garden St.
Kimmelman, Louis, 2401 N. Fifth St.
' Kinunelmain, Simon, 1730 S. Broad St.
Kindbom, Hanna, 1507 Poplar St.
King, Merrill Jenks, Boston City Hospital, Boston,
Mass.
King, William Howard, 1108 S. Forty-seventh St.
Kinney, Willard H., 315 S. Seventeenth St
Kjrby, EUwood R., 1202 Spruce St.
Kiric, George W., 1427 Girard Ave.
Kirshbaum, Helen, 1303 Locust St.
Kirshner, Louis A., 1944 N. Thirty-second St.
Kitchen, Joseph S., 3846 N. Eighteenth St.
Kitchen, Philip Gordon, 8021 Westchester Pike, Upper
Darby.
Kitchin, Edwin Paul, 154 W. Tabor Rd., OIney.
Klapp, Wilbur P., 1716 Spruce St.
Klauder, Joseph V., 1922 Spruce St.
Klein, Alexander, 1223 Spruce St.
Klein, Henry L., 708 N. Fortieth St.
Klein, Thomas, 1717 Pine St.
Klemm, Adam, 1204 W. Lehigh Ave.
Klimas, Enoch G., 2538 E. Allegheny Ave.
Kline, Harvey W., 3636 N. Seventeenth St.
Klopp, Edward, 'Jonathan, 1611 Spruce St.
Kloop, Peter P., 6TS W. Lehigh Ave.
■ Knipe, Jay C, 2035 Chestnut St.
Knipe, Norman L-, 701 S. Fifty-second St.
Knorr, John K., Jr., 2235 N. Sixteenth St.
Knowles, Frank C, 2022 Spruce St.
Knowles, George A., 4812 Baltimore Ave.
Knox, Andrew, 501 E. Allegheny Ave.
Knox, Henry, 5000 Spruce St.
Kobler, Henry B., Sixty-third and Media Sts.
Koenig, Augustus, 1324 Pine St.
Koenig, Carl F., 1734 Harrison St., Frankford.
Kohlman, Samuel H., 4536 Old York Rd.
Kohn, Bernard, 1516 N. Fifteenth St.
Konzelman, Frank W., 3638 N. Twenty-first St.
Kolmer, John A., Cynwyd (Montgomery Co.).
Kownacki, Francis J., 2372 Orthodox St., Frankford
Kraker, Florence E., 1507 Medical Arts BIdg
Krall, John T., 1421 Chestnut St.
Kramer, David Warren, 2035 Chestnut St.
Kraus, Gabriel J., 3153 Richmond St.
Krauss, Frederick, 1701 Chestnut St.
Krauss, Walter R.. 1614 N. Sixteenth St.
Kremens, Maxwell B.. 2514 S. Broad St.
Kremer, David N., 5916 Spruce St.
•Crieg, Henry C, 655 E. Allegheny Ave.
Kropp, Robert Stroud. 5113 N. Broad St.
Krumbhaar, Edward B., Box 4310, Chestnut Hill.
Krusen, Wilmer, 127 N. Twentieth St.
Kuehner, Howard M., 2174 E. York St.
Kurtz, Arthur D., 2520 N. Twenty-second St.
Kyle, Christian B., 703 W. Erie Aye.
Kyle, E. Bryan, 565 East Main St., Moorestown, N. J.
Lacy, Henry A., 743 N. Seventeenth St
Laessle, Henry A., 5900 Market St.
Laferty, John M., 3656 Frankford Ave.
Lambert Harold W., 4862 Tacony St
Lammer, Francis J., 2266 N. Nineteenth St.
Lamparter, Eugene, Green Lane (Montgomery Co.).
Landis, Henry R. M., 11 S. Twenty-first St
Lane, Dudley W., 2237 N. Twenty-ninth St
Langbord, Joseph A., 1037 S. Fifth St
Langdon, H. Maxwell, 2014 (jhestnut St.
Langdon, Roy L., 529 E. Chelten Ave.
Laplace, Ernest, 1828 S. Rittenhouse Sq.
Larer, Richard W., 1407 E. C:x>lumbia Ave.
Large, Octavius P., Twenty-ninth and Somerset Sts.
Latchford, O. Luther, 1607 N. Fifteenth St.
Lathrop, Ruth Webster, 1415 N. Seventeenth St.
Latta, Samuel W., 3602 Powelton Ave.
Lau, Scott W., N. E. Cor. Fifteenth and Ritner Sts.
Lawrance, J. Stuart, 1332 Spruce St.
Lawrence, Granville A., Medical Arts Bldg.
Laws, George M., 2033 Locust St.
Leach, Wilmon W., 2118 Spruce St.
Leaman, Enos H., 3440 N. Second St
Leaman, William G., 3700 Baring St.
Leavitt Frederic H., 1527 Pine St
Lebo, D. Austin, 2317 W. Somerset St.
Le Boutillier, Theodore, 2008 Walnut St.
LeCates, Charles A., Mt. Pocono (Monroe Co.).
Le Conte, Robert G., 2000 Spruce St
Lee, Walter Estell, 905 Pine St.
Leebrqn, Jacob D., 247 S. Thirteenth St.
Leedom, John, 725 W. Allegheny Ave.
Lefcoe, C. Henry, 1420 N. Thirteenth St
LeFever, Charlas W., 1708 Pine St
LeflFraan, Henry, 1839 N. Seventeenth St.
Legg, Albert N., 1639 W. Dauphin St.
Lehman, Frederick C, 2501 Columbia Ave
Lehman, Joseph D., 4257 Main St, Myk.
Lehrfeld, Louis, 702 S. Sixtieth St.
Leidy, C. Fontaine Maury, 338 S. Sixteenth St.
Leidy, Joseph, 1319 Locust St.
Lenahan, Joseph P., 3306 N. Fifth St
Lennon, James Sumner, 1608 Christian St
Leof, Morris V., 1700 N. Franklin St
Leonard, Charles F., 2025 S. Tenth St.
Leonard, Edward A., Jr., 1214 S. Fifty-third St.
Leopold, Raymond S., Wayne Ave. and Coulter St.,
Gtn.
Leopold, Samuel, 1814 Spruce St
Leopold, Simon S., 1428 N. Broad St
Lermann, William W., N. E. Cor. Sixteenth and Spruce
Leevan, Georges F.. 733 N. Forty-first St
Levering, J. Walter, 1309 Oak Lane.
Levi, L Valentine, 1736 N. Sixteenth St.
Levm, Samuel Fillmore, 619 S. Tenth St
Levis, George E., 4523 Frankford Ave.
Levitt, Michael L., 733 Walnut St.
Levy, Abram, 906 N. Franklin St
Levy, David W., 1122 E. Palmer St.
Levy, Jacob, 1920 S. Fifth St
Lewis, Clarence J., 7004 Torresdale Ave.
Lewis, Daniel W., 2111 Hunting Park Ave
Lewis, Fielding O., 261 S. Seventeenth St
Lewis, John F.. 917 S. Forty-ninth St
Lewis, Mary R. Hadley, 32 N. Fiftieth St.
Lewis, Morns J., 1316 Locust St.
Lewis, Paul A., Henry Phipps Institute.
Lichtenwalner, Abbott B., 2435 N. Seventh St
Liggett, Samuel J., 1234 W. Lehigh Ave.
Lieht Arthur B., 3737 Locust St.
Lilly, John H., 1SS3 E. Berks St.
Lincoln, Oarence W., Wayne (Delaware Cx).).
Lindauer, Eugene, 2018 Chestnut St
Digitized by
Google
766
THE PENNSYLVANIA MEDICAL JOURNAL
July, 1921
Linton, Jay D., 130 Green Lane, Manayunk.
Lippert, Freda E., 1716 N. Eighteenth St.
Lipftutz, Benjamin, 1007 Spruce St.
Llewellyn, Thomas H., 739 N. Fortieth St.
Lloyd, James Hendrie, 4057 Spruce St.
Lockrey, Sarah H., 1701 Chestnut St.
Lodholz, Edward, 1106 S. Fifty-second St.
Loeb, Ludwig, 1421 N. Fifteenth St.
Loeb, Victor A., 1622 N. Fifteenth St.
Loewenberg, Samuel A., 1905 Spruce St.
Loftus, John Edward, 605-606 Medical Arts Bldg.
Long, Samuel C, 1716 N. Sixteenth St.
Long, William H., 116 S. Fortieth St.
Longaker, Daniel, i402 N. Sixteen* St.
Longaker, Edwin P., 1402 N. Sixteenth St.
Longdon, Mary M. C, Oak Lane.
Longenecker, Christian B., 3416 Baring St.
Longshore, Howard K., 1516 Locust St.
Longshore, J. Bartley, 3150 N. Broad St.
Losada, Camella A., 30 Vesey St., New York, N. Y.
Lott, Harry Hunter, 1927 Chestnut St.
Loughery, Thomas P., 5545 Morton St., Gtn.
Loughridge, Jonathan Edwards, 6225 Greene St., Gtn.
Loux, Hiram R., Medical Arts Bldg.
Love, Julius D., 315 Pine St.
Love, Louis F., 1305 Locust St.
Lowa, Walter, 653 N. Broad St.
Lowenburg, Harry, 2011 Chestnut St.
Lownes, John B., Medical Arts Bldg.
Luburg, Leon F., 1822 Girard Ave.
Lucas, Walter S., Wynnewood (Montg. Co.).
Lucke, Baldwin, Medical Laboratories, U. of P.
Ludlum, Seymore D. W., 1827 Pine St.
Ludy, John B., 2042 Chestnut St.
Lukens, Robert M., 1308 Hunting Park Ave.
Lull. Clifford, B., Sixty-ninth and Market Sts.
Lupin, Emanuel J.. 2221 N. Thirty-third St.
Lynch, Frank Bruce, Jr., 5413 Sanson^ St.
Lynch, John J., 4280 Paul St.
Lyon, B. B. Vincent, 2014 Walnut St.
Lytle, L Walter, 1434 N. Fifteenth St.
McAllister, Anna M., 3503 Baring St.
McCalmont, William S., 746 N. Sixty-third St.
McCarthy, Cornelius T., 12 S. Thirty-eighth St.
McCarthy^ Daniel J., 2025 Walnut St.
McCarthy, Francis X., 6008 Germantown Av«.
McCarthy, Patrick A., 229 E. Price St., Gtn.
McClary, Samuel III, Medical Arts Bldg.
McCloskey, Edward W., 8720 Germantown Ave.
McCloskey, John F., 8720 Germantown Ave.
McCollin, James G., 5472 Baltimore Ave.
McCombs, Robert S., 124 S. Eighteenth St.
McCombs, William, 1527 N. Thirteenth St.
McConihay, Clarence W., 227 S. Ninth St.
McConnell, James W., 1909 Chestnut St.
McCormick, John A., 1311 N. Nineteenth St.
McCrae, Thomas, 1627 Spruce St.
McCrea, Lourain E., St. Agnes Hospital.
McCreight, Robert, 1340 E. Monteomery Ave.
McCullough, Francis J., 1009 S. Forty-seventh St.
McDaniel, Earl L., 1325 Erie Ave.
\fcDevitt, Charles H., 4600 Wayne Ave., Gtn.
McDougald, John Q., 1336 Lombard St.
McDowell. J. Edward, 4233 Walnut St.
McDowell, Norris S., 1529 W. Columbia Ave.
McDowell. Samuel B., 925 N. Broad St.
McFarland. Joseph, 442 W. Stafford St., Gtn.
McGinnis, Arthur, N. E. Cor. Logan and Greene Sts.,
Gtn.
McGlinn, John A., 113 S. Twentieth St.
McGuigan, John L, 60l8 Drexel Rd.
Mcllvain, Edwin H.. 3801 N. Seventeenth St.
Mclntire, Benjamin Meredith, 4833 Baltimore Ave.
Mclvcr, Joseph, 4634 Chester Ave.
McKeage, William, 3131 N. Broad St.
McKee, James H., Medical Arts Bldg.
McKee. Jennie M., 1219 Locust St.
McKeldin, Robert A. W., 5342 Catherine St.
McKenna, John A., Lansdowne and Baltimore Aves.
McKenzie, R. Tait, 2014 Pine St.
McKinley, Archibald L., 3702 N. Broad St
McKinney, Walter Byron, 2100 Girard Ave.
McKnight, Howard A., 241 S. Thirteenth St.
McLean, John D., 901 N. Front St., Harrisburg (Dau-
phin Co.).
McLemon, John, 2636 Federal St.
McMillan, Thomas M., Jr., The Gunther, Forty-first
St. and Baltimore Ave.
McMonagle, James W., 2120 S. Broad St.
McNerney, Aloysius F., 1806 N. Twenty-third St.
McQuaide, Florence Quindaro, 1336 Pine St.
MacCarroll, D. Randall, 1906 Chestnut St.
MacCoy, Alexander W., 1503 Locust St.
MacCracken, George Y., 612 N. Thirteenth St.
MacElree, George A., 2813 N. Front St.
Macfarlan, Douglas, 1805 Chestnut St.
Macfarlane, Catharine, 5808 Greene St., Gtn.
Maciejewski, AnAony S., 212 Van Buren St., Newark,
N.J.
Macintosh, William, 511 Green St.
MacKay, William H. G., 306 W. Upsal St.
Mackel, Charles F., 728 E. Allegheny Ave.
Mackenzie, Alice V., 1831 Chestnut St.
Mackenzie, George W., 1831 Chestnut St.
Mackinney, Wilfiam Humphrey, 1701 Chestnut St.
MacMurtrie, William J., 912 S. Forty-ninth St.
Macneill, Norman M., 4401 Market St.
MacSorley, Harriet E., 5634 Thomas Ave.
Magaziner, William E., 908 N. Franklin St.
Maier, Ernest G., 1323 N. Fifteenth St.
Maier, F. Hurst, 2019 Walnut St.
Major, Charles P., Tenth St. and Oak Lane.
Makler, Jacob S. P., 438 S. Fifth-sixth St.
Mallas, Maurice Louis, 927 Spruce St.
Mallon, Edward A., 1606 N. Seventeenth St.
Manasses, Jacob L., 1414 N. Fifteenth St.
Manges, Willis F., S. E. Cor. Fifteenth and Locust
Sts.
Mann, Benjamin H., 2208 S. Broad St.
Mann, Bernard, 6033 Chestnut St.
Mann, James Packard, 1234 Spring Garden St.
Mann, Victor L., White Memorial Hospital, Los An-
geles, California.
Manning, Charles L., 1834 Tioga St.
Manship, Frances Petty, 3604 Chestnut St.
Mantz, Francis A., 227 N. Eighteenth St.
Markowitz, Morris, 1001 N. Sixth St.
Marks, Jacob K., 1902 N. Twenty-second St
Marks, Morris, 607 N. Sixth St
Marks, Saul, 4140 Girard Ave.
Marsden, Biddle R., 8811 Germantown Ave.
Marshall, Alfred Cookman, Twenty-second and Bain-
bridge Sts.
Marshall, Clara, 901 S- Forty-seventh St
Marshall, George M., 1819 Spruce St.
Marter, Linnaeus E., 1631 Race St.
Martin, Collier Ford, 1831 Chestnut St.
Martin, Edward, 135 S. Eighteenth St.
Martin, Joseph, 2009 Columbia Ave.
Martin, Niles, 246 S. Forty-fifth St.
Martin, Sergeant P., 494 Franklin St., Buffalo, N. Y.
Martin, William J. F., 6938 Tulip St.
Martin, William Orlando, 4268 Paul St
Marvel, Henry V., 4839 Baltimore Ave.
Masland, Harvey C, 2130 N. Nineteenth St.
Massey, G. Betton, 1823 Wallace St.
Mathews, Abel J., Spencer St., west of Old York Rd.
Mathews, Franklin, 1010 Rockland St.
Mathews, William, 728 W. Lehigh Ave.
Mayor, Charles A., 1006 Ritner St
Mazer, Charles, 2238 S. Broad St.
Mazor, Samuel, 451 Ritner St.
Mecluskey, John Franklin, 2622 N. Seventeenth St.
Megargee, George L., 1 Madison Ave., New York
City.
Meine, Berta M., 1714 Pme St.
Digitized by
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Jui,Y, 1921
MEMBERSHIP LIST
767
Meisle, Frederick Aaron, ISO Richmond St.
Mel lor, John, 2045 Margaret St.
Melman, Ralph J., 933 N. Sixth St.
Melnick, Theodore, N. E. Cor. Sixtieth and Thompson
Sts.
Menah, William M., 1831 Chestnut St.
Mencke, J. Bemhard, 1816 Spruce St.
Mendel, James H., 7238 Boyer St., Mt. Airy.
Menger, Albert C, 1502 N. Twenty-ninth St.
Merrill, William Jackson, Medical Arts Bldg.
Merscher, Harry L., 2217 N. Broad St.
Merscher, Washington, 554 E. Washington Lane, Gtn.
Mershon, Oliver F., 2305 Christian St.
Messing, Max, 1736 S. Fifth St.
Meyerhoff, Irwin S., 1727 N. Sixteenth St.
Meyers, Milton K., 1529 S. Broad St.
Michener, Evan W., 3708 N. Broad St.
Mieldazis, Delia E., 5822 Spruce St.
Miller, Aaron G., 6161 Haverford Ave.
Miller, Albert G., 2150 N. Twenty-first St.
Miller, Chas. Scott, 1218 Wyoming Ave.
Miller, Edwin B., 2351 E. Cumberland St.
Miller, George B,. 1942 N. Broad St.
Miller, Henry J., 536 S. Fifty-second St.
Miller, Hugh McC, 1932 Spruce St.
Miller, Mary T., 313 N. Thirty-third St.
Miller, Morris Booth, 409 S. Twenty-second St.
Miller, M. Valentine, 6612 Germantown Ave.
MUler, T. Grier, 110 South Twentieth St.
Miller, W. Edward, 122 Main St., Darby (Del. Co.).
Miller, Walter M., 5100 Spruce St.
Milligan, Alice H. B., 4620 Kingessing Ave.
Milliken, Fred H., 3716 Walnut St.
Mills, Charles K., 1909 Chestnut. St.
Mills, H. Brooker, 1734 Spruce St.
Minehart, John R., 4821 Germantown Ave.
Mintzer, George S., 2416 S. Broad St.
Missett, Joseph V., S. W. Cor. Sixtv-third and Race
Sts.
Mitchell, A. Graeme, 1717 Pine St.
Mitchell, Charles F., 332 S. Fifteenth St.
Mitchell, Edward K., 710 W. Lehigh Ave.
Mitterling, Stephen, 5731 Baltimore Ave.
Modell, Daniel A., 1217 Lindley Ave.
Mohler, Henry K., 319 S. Sixteenth St.
Monaghan, William F., 901 N. Forty-fourth St.
Mongel, Ernest B., 1429 Tioga St.
Montgomery, Edward E., 1426 Spruce St.
Mooney, Thomas H., 2808 Wharton St.
Moore, Cyrus C, 2118 N. Hancock St.
Moore, C. Howard, 2237 W. Lehigh Ave.
Moore, Edward J., 1619 Arch St.
Moore, Eugene A., 103 N. Fifty-fourth St.
Moore, John D., 1940 N. Broad St.
Moore, Joseph A., 1216 N. Sixth St.
Moore, Joseph G., 5842 Haverford Ave.
Moore, Philip H.. 1225 Spruce St.
Moore, William Frederick, 1331 Pine St.
Moorhead. Stirling W., 1523 Pine St.
Moorhead, W. W., 1523 Pine St.
Morell, Charles J., 5253 Spruce St.
Moford, William B., 1534 S. Broad St.
Morgan, Arthur C, 2028 Chestnut St.
Moriarty, Charles A., 1833 Mt. Vernon St.
Morris, Casper, Jr., 2050 Locust St.
Morris, Elliston J., 128 S. Eighteenth St.
Morris, J., Cheston, Birmingham Road, West Chester
(Chester Co.).
Morrison, William H., 8021 Frankford Ave., Holmes-
burg.
Morrow, Tames A., 2038 S. Fifth St.
Morton, Dudley J., 33 W. Twelfth St., New York City.
Morton, George D., Honeybrook (Chester Co.).
Morton, Samuel W., 1926 Chestnut St.
Moss, Morris I., 869 N. Seventh St.
Moss, Samuel, 321 Pine St.
Moxey, Albert F., 47 Carpenter Lane, Mt. Airy.
Moylan, David J., 3729 Spring Garden St.
Moylan, John J., 228 E Price St., Gtn.
Moylan, Peter F., 1005 N. Sixth St.
Mudgett, John H., 2022 N. Thirteenth St.
Muellerschoen, George J., 1727 N. Fifteenth St.
Muldawer, Isaac J., 2023 S. Fourth St.
Mutford, Leslie Frank, 6300 Sherwood Rd.
Mullen, Oscar J., 1750 N. Park Ave.
Muller, Andrew J., 1136 N. Third St.
MuUer, George P., 1930 Spruce St.
Muller, Rudolph E., 1522 S. Broad St.
Mikller, Wiliara K., 6004 Greene St., Gtn.
Mulrenan, John P., 1228 S. Broad St.
Munson, Henry G., 4935 Catharine St.
Muri^y, Douglas P., Woman's Hospital (110th St.),
New York City.
Murphy, Edward J., 1429 W. Erie Ave.
Murphy, Eugene C., 2201 Spring Garden St.
Murphy, Frank A., 3019 Ridimond St.
Murphy, Henry P., 1246 N. Fifty-second St.
Murphy, John A., 313 Dickinson Ave., Swarthmore
(Del. Co.).
Murray, Bernard J., 48 W. Johnson St., Gtn.
Musser, John H., Jr., 262 S. Twenty-first St.
Mutschler. Louis H., 1625 Spruce St.
Myers, Israel, 1525 N. Eighth St.
Myers, Mae Lichtenwalner, 34 W. Pomona St., Gtn.
Myers, Tallyrand D., Box 314, Pasadena, Calif.
Nassau, Charles F., 1710 Locust St.
Neal, Samuel H., 1202 Lindley Ave.
Neel, Harry A. P., 3602 Disston St.
Neff, Joseph S., Narberth (Montg. Co.).
Neilson, Thomas R., 1937 Chestnut St.
Nelson, Wilhelmina T., County Prison, Tenth and
Reed Sts.
Neubauer, Bernard B., Medical Arts Bldg.
Nevergole, John A., 132 S. Twenty-third St.
Newcomet, William S., 3501 Baring St.
Newlin, Arthur, 1804 Pine St.
Newmayer, S. Weir, 1507 N. Seventeenth St.
Newton, Robley D., 718 N. Sixty-third St.
Nichols, William, 2044 Chestnut St.
Nicholson, William R., 2023 Spruce St.
Noble, Charies P., Radnor (Pa.).
Nock, Thomas O., 821 N. Twenty-fourth St.
Nofer, George H., 1759 Frankford Ave.
Noll. Franklin, 1844 N. Seventeenth St.
Norris, Charles C, Chestnut and Twenty-second Sts.
Norris, George W., 1820 S. Rittenhouse Sq.
Norris, Richard C, 500 N. Twentieth St.
Nvlan, Josef B., 1916 Rittenhouse St. •
O'Boyle, Cyril P., 410 N. Fifty-second St.
O'Brien, John P., 1629 Chestnut St.
O'Brien, Matthew Gushing, 2017 (Jreen St.
O'Brien, Thomas A., 1725 Girard Ave.
O'Connell, John A., 2128 Pine St.
O'Daniel, Andrew A., 1700 Walnut St.
O'Drain, Thomas I., 101 E. Mt. Airy Ave.
Oestreich, Henry N., 903 W. Lehigh Ave.
O'Farrell, Gerald D., Jr., 1301 Allegheny Ave. "
OflF. Henry J., 115 S. Twentieth St.
O'Hara, Michael, Jr., 2018 Pine St.
O'Harrow, Marian, 215 W. Park Ave., Valley City, N.
Dak.
Old. Herbert, Provident Life and Trust Co., Fourth
and Chestnut Sts.
Oliensis, Abraham E., 726 Pine St.
Oliver, Benjamin O., 1528 Morris St.
Olsho, Sidney L., Fifteenth and Locust Sts.
O'Malley, Austin, 2228 S. Broad St.
O'Neill, Francis C, 1725 Ritner St.
O'Neill, Joseph F., 1800 Vine St.
O'Reilly. Charles A., 1829 Chestnut St.
Orloff, Henry S., 1429 S. Fourth St.
Ornsteen, Abraham M.. 1639 N. Franklin St.
Osmond, Anna R., 6952 Torresdale Ave., Tacony.
Osmond, Martha E., 6952 Torresdale Ave., Tacony.
Ostheimer, Alfred J., Medical Arts Bide.
Ostheimer, Maurice, 2204 De Lancey Place.
Digitized by
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768
THE PENNSYLVANIA MEDICAL JOURNAL
July, 1921
Ott, Lambert, 190S N. Broad St.
Ottinger, Samuel J., S. E. Cor. Master and Twelfth
Sts.
Outerbridge, George W., 2039 Chestnut St.
Owen, Hubley R., 319 S. Sixteenth St.
Owen, John J., 411 Pine St.
Packard, Francis R., 302 S. Nineteenth St
Padilla, Arturo, 6159 Elmwood Ave.
Page, Henry F., 315 S. Sixteenth St
Pancoast, Qiarles S., 300 Wellins Ave., Olney.
Pancoast, Henry K., Ardmore (Montg. Co.).
Pannell, M. Norvel, 1921 Dickinson St.
Parish, Benjamin D., Medical Arts Bldg.
Park, Frederick S., Montgomeryand Atlantic Aves., '
Atlantic City, N. J.
Parke, Joseph Richardson, 902 Spruce St
Parke, William E., 1739 N. Seventeenth St.
Parker, Edward A., 1921 Chestnut St.
Parker, J. Sparks, 6805 Woodland Ave.
Parrish, Robirt C, 5301 Chester Ave.
Patten, Clarence A., 319 S. Sixteenth St.
Patterson, Francis D., 2103 Locust St
Patterson, Ross Vemet, 2126 Spruce St.
Patton, Gideon Harmer, 61 E. Penn St., Gtn.
Paul, Effie M., 1530 N. Seventeenth St.
Paul, James H., 2222 S. Fifteenth St.
Paul, John Davis, 3112 N. Broad St
Pease, Theodore N., 5800 Spruce St.
Peck, Elizabeth L., 4113 Walnut St
Pelouze, Percy Starr, 1831 Chestnut St
Peltz, Alberta, 5802 Springfield Ave.
Pemberton, Ralph, 318 S. Twenty-first St
Penrose, Charles Bingham, 1720 Spruce St
Penza, John G., 921 Federal St.
Peoples, John, 871 N. Twentieth St
Peper, O. H. Perry, Medical Arts Bldg.
Penoer, William, 1811 Spruce St
Percival, M. Fraser, 2332 S. Broad St
Perkins, Francis M., 320 S. Fifteenth St.
Perlman, Horace D., 1932 N. Seventh St.
Pessolano, Joseph Anthony, 1058 Madison Ave., Al-
bany, N. Y.
Peter, Luther C, 1529 Spruce St
Petruska, Louis, 328 Federal St
Petty, Orlando H., 6215 Ridge Ave.
Pfahler, George E., 1321 Spruce St
Pfeiffer, Damon B., 2028 Pjne St.
Pfleuger, Henry F., 1511 N. Seventh St
Pfromm, George W., 1431 N. Fifteenth St
Phelps, George F., 6019 Lansdowne Ave.
Phillips, Arthur W., 3904 Walnut St
Phillips, Horace, 707 Lincoln Bldg.
Phillips, James R., 1205 Cottman St.
Phillips, Richard J., 123 S. Thirty-ninth St
Phillips, Thomas W., 144 N. Sixtieth St
Picard, Henry L., 207 Professional Bldg., 1831 Chest-
nut St.
Pickett Elizabeth Lovelace, Aldan (Del. Co.).
Piersol, George A., 4724 Chester Ave.
Piersol, George Morris, 1913 Spruce St.
Pike, Charles P., 7282 Woodland Ave.
Pilkington, Horatio, 4238 Paul St., Fkd.
Pilling, George P., Jr., 4044 Chestnut St
Piper, Edmund B., 1936 Spruce St
Plass, Charles F. W., Chew St. and Chelten Ave., Gtn.
Piatt, Michael, 5932 Spruce St.
Pleibel, Eugene Theodore, 3733 N. Marshall St
Podolski, Louis A., 1117 W. Lehigh Ave.
Pontius, Paul J., 1831 Chestnut St.
Posey, William Campbell, 2049 Chestnut St
Post, Joseph W., 1264 W. Erie Ave.
Potsdamer, Joseph B., 1818 N. Broad St.
Pottberg, Charles, 2338 N. Broad St.
Potter, Ellen C, 1720 Chestnut St
Potts, Charles S., 2018 Chestnut St.
Powell, Tamlin L., 2111 Master St
Powell. William E., 2357 E. Dauphin St.
Price, Charles E., 316 N. Fifty-second St
Pritchard, William C, 5616 Spruce St
Propper, Julius, 4502 Baker St., Manayimk.
Purdy, John, 722 W. Lehigh Ave.
Pumell, Caroline M., 132 S. Eighteenth St
Pyle, Walter L., 1931 Chestnut St
Quicksall, William E., 1819 Spruce St
Raby, Mahlon R., 5430 Wayne Ave.
RadcliflFe, McCluney, 1906 Chestnut St
Raftery, John G., Grant Ave., Torresdale.
Rainear, A. Rusling, 2024 Diamond St
Rainville, Joseph A., 1312 Porter St
Rakin, William E., 1225 Spruce St
Ramer, E. Blanche, care Dr. Frances M. Allen, Timken
Building, San Diego, California.
Ramer, T. Maude, 1600 Poplar St
Ramsey, William G., 1430 S. Broad St
Ramspacker, Theodore F., 1411 E. Moyamensing Ave.
Randall, Alexander, 1310 Medical Arts Bldg.
Randall, B. Alexander, 1717 Locust St.
Rankin, Charles Cooper, 2002 Chestnut St
Ransley, Alexander W., 309 S. Sixteenth St
Raudenbush, James S., 3633 N. Fifteenth St
Ravdin, L S., 1930 Spruce St.
Rea, Marion H., 119 Coulter Ave., Ardmore.
Real, Albert, 495 N. Fourth St
Reckefus, Charles H., Jr., 506 N. Sixth St
Reddie, Jacobina S., 774 State St., Springfield, Mass.
Reed, Howard, 1829 Diamond St.
Reed, Oliver K„ 4005 Chestnut St.
Rees, William Thomas, 3763 N. Eighteenth St.
Reese, Warren Snyder, 230 S. Twenty-first St.
Reeves, Joseph M., 1916 Spruce St
Reeves, Rufus S., 2026 Locust St.
ReRister, Robert P., 905 Pine St.
Rehfuss, Martin E., N. E. Cor. Sixteenth and Spruce
Sts.
Reiflf, E. Paul, 5051 Chestnut St.
Reilly, John J., 2406 S. Twenty-first St.
Reimann, Stanley P., 516 Arbutus St
Reimel, Clara, 723 W. Girard Ave.
Reisert, William, 1429 Morris St
Reiss, Abe, 918 N. Fifth St.
Reiter, David, 4025 Girard Ave.
Remig, J<An H., 805 S. Twelfth St
Renninger, Abner R., The Lenox, Thirteenth and
Spruce St.
Repp, John J., 926 S. Sixtieth St
Repplier, Sidnqr J., Roumfort Rd., Mt. Airy.
Reynolds, Charles B., 2003 Diamond St
Rhein, John H. W., 1732 Pine St.
Rhein, Robert D., Fifteenth and Pine Sts.
Rhoades, Edward G., 159 W. Coulter St, Gtn.
Rhoades, John Neely, 1635" S. Broad St
Ricciardi, Jcrfin, 1104 Ellsworth St
Richards, Florence H., 3708 Hamilton St
Richards, James L., 213 S. Fiftieth St
Richardson, Neafie, S. E. Cor. Broad and Norris Sts.
Richey, Gladys, 5443 Angora Terrace. ^
Richmond, Gorge Nelson, 4003 Chestnut St
Ridpath, Robert F., 1928 Chestnut St
Riegel, Walter S., 808 Cumberland St, Lebanon (Leba-
non Co.).
Rieger, Charles L. W., 1304 Rockland St, Logan.
Riesman, David, 1715 Spruce St
Righter, Harvey M., 5049 Spruce St
Ring, G. Oram, Northeast comer Seventeenth and
Walnut Sts.
Rishel, George P., 2035 Diamond St
Riskoff, Abraham D., 1433 S. Sixth St
Ritter, William J., 3315 N. Broad St.
Rivard, Ruth Miller, 5031 Woodland Ave.
Rivas, Damaso, Med. Dept, Univ. of Penna.
Roberts, John B., 313 ,S. Seventeenth St.
Roberts, Joseph W., 1426 N. Eighteenth St
Roberts, Mercedes A., 1142 S. Eleventh St
Roberts, Walter, 1732 Spruce St
Robertson, William E, 327 S. Seventeenth St
Robinson, William C, 7132 Boyer St
Digitized by
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July, 1921
MEMBERSHIP LIST
769
Robinson, William D., 2012 Mt. Vernon St.
Robrecht, John J., 3940 Chestnut St.
Rochelle, Mary J., 2423 N. Seventh St
Rodenheiser, Edwin W., 1809 Chestnut St.
Roderer, John F., 2426 N. Sixth St.
Rodgers, George R., 2018 N. Thirteenth St.
Rodman, J. Stewart, Medical Arts Bldg.
Rogers, Asa H„ 911 W. Indiana Ave.
Rommel, John C., 4601 N. Broad St.
Roper, William F., S439 N. F[fth St.
Rosenbaum, George, Flanders Bldg.
Rosenberger, Randle C, 2330 N. Thirteenth St.
Rosenblum, Philip S., 1624 Spruce St
Rosenfeld, David H., 801 S. Fifty-eighth St
Rosenfeld, Samuel, 1641 S. Fifth St
Rosenthal, Joseph Morris, 700 E. Chelten Ave., Gtn.
Ross, George G., 1721 Spruce St.
Ross, Josei* H., 106 W. Susquehanna Ave.
Ross, Thomas C, 1701 Harrison St.
Rostow, Leo J., 1222 N. Seventh St
Roth, David A., 3029 Diamond St
Rothberg, Israel, 2001 N. Thirty-second St.
Rothkugel, Paul B,, 2501 N. Thirty-second St.
Rothschild, Norman S., 1525 Wahiut St.
Roussel, Albert E., 2108 Pine St.
Rovno, Philip, 423 Pine St
Rowahd, Alexander H. C, 3704 Spring Garden St.
Royer, B. Franklin, 900 Spruce St
Rubenstone, Abraham I., 1208 Spruce St.
Rubin, Robert William, 2243 S. Ninth St.
Rubin, Rose S., 811 N. Seventh St.
Rubin, Samuel, 1735 S. Eighth St
Rudolpby, Jay Besson, 1931 Chestnut St.
Ruff, Adolph, 2555 N. Eleven* St
Ruffcll, Charles E., 244 E. Girard Ave.
Rugh, J. Torrance, Medical Arts Building.
Runkle, Stuart C, 238 S. Forty-fifth St.
Ruoff, William, 1301 N. Thirteenth St
Rupert, Mary P. S., Medical Arts Bldg.
Rush, Eugene, 5421 Baltimore Ave.
Russell, Carlton N., 130 S. Eighteenth St
Russell, Charles T., Jr., 2521 E. Nprris St.
Rutberg, Jacob James, 621 Spruce St.
Ryan, Maria Page, 2526 S. Lambert St.
Ryan, William C., 1229 N. Eighteenth St.
Ryan, William J., 701 S. Fifty-fifth St
Ryan, William J., 1535 Chestnut St.
Ryan, William John, 1941 Snyder Ave.
Saal frank, Charles W., Second St Pike and Levick,
Lawndale.
Sailer, Joseph, 1218 Spruce St.
Sajous, C. E. deM., 2043 Walnut St.
Sajous, Louis T. deM., 2043 Walnut St.
Sallom, Abdullah K., 1441 S. Broad St
Saltzman, Louis A., 1530 S. Fifth St.
Sampson Allen G., 2834 Columbia Ave.
Sands, M. Jane, 1905 Infirmary, Bryn Mawr College,
Bryn Mawr.
Sangree, Henry, 4031 Baltimore. Ave.
Sargent, A. Alonzo, 1308 Pine St
Sartain, Paul J., 2006 Walnut St.
Saunders, Griffin A., 2122 Fitzvirater St
Saunders, Robert Ritchie, 926 N. Fifteenth St.
Sautter, Albert C, 1421 Locust St.
Savidge, Edgar, 242 S. Twenty-first St
Savitz, Samuel A., 1825 Tasker St.
Sawyer, William Alfred, Landing and Penfield Rds.,
R. F. D. No. 3, Rochester, N. Y.
Saxon, Gordon J., 1411 Walnut St.
Saylor, Edwin S., 2005 Chestnut St
Saylor, Horace S., 6105 A Jefferson St
Scanlan, Leo F., 1915 Green St.
Scarlett, Hunter W., 230 S. Twenty-first St.
Schabinger, Charles, 4526 N. Broad St.
Schaeffer, J. Parsons, 4634 Spruce St.
Schafer, Charles S., 1745 N. Seventeenth St.
Schafflc, Karl, 3309 Macomb St., N. W., Washington,
D. C.
Schaller, Abraham Lincoln, 810 S. Fifth St.
Schamberg, Jay F., 1922 Spruce St.
Schantz, William S., 5100 Wamock St
Schatz, Harry A., 2035 Chestnut St.
Schaubel, Charles W., 2346 E. Norris St
Schaul, Otto D., 4920 Woodland Ave.
Scheehle, J. Evans, 312 Otis Bldg.
Schell, J. Thompson, 2102 Spruce St
Schenberg, JosejA, 451 S. Fifty-first St.
Schenker, Hyman S., 946 N. Franklin St.
Schetky^ Martha G. K., 911 S. Forty-eighth St
Schetlo', S. Elizabeth A., 18 Wellington Road, Brook-
Schisler, Belle A., 2039 N. Twenty-ninth St
Schlaff, Herman, 4404 Germantown Ave.
Schmidt, William H., 1532 Erie Ave.
Schnabel, Truman G., 1704 Pine St.
Schneideman, Florence M., 1831 Chestnut St.
Schneideman, Theodore B., 1831 Chestnut St.
Schneider, Charles J., 1930 N. Seventh St
Schneyer, Julius, 935 N. Eighth St.
Schoales, Charles B., 1428 N. Eleventh St.
Schock, Harvey E.. 2048 Pine St
SchoU, Alfred K., 1115 Pennsylvania Building.
Scholl, B. Frank, 1420 N. Seventeenth St.
Schoonmaker, Irving R., 5223 Chester Ave.
Schreiber, William L, N. E. Cor. Thirteenth and Chel-
ten Ave., Oak Lane.
Schumann, Edward A., 15 Pelham Road, Mt. Airy.
Schwartz, Bernard S., 1020 Snyder Ave.
Schwartz, George J., 1630 Walnut St
Schwartz, Max J., 1235 Snyder Ave.
Schwartz, Morris, 218 Rjtner St.
deSchweinitz, George E., 1705 Walnut St.
Schwenk, Peter N. K., 1417 N. Broad St
Schwerin, Justin G., 2113 N. Seventeenth St.
Scott, Egbert T., 5827 Haverford Ave.
Scull, William B., 3024 Richmond St.
Seabold, William F., 5617 Spruce St
Seabrook, Alice M., 3553 Hollywood Blvd., Los An-
geles, Calif.
Seelaus, Henry K., 3015 N. Broad St.
Segal, Bemhard, 1418 S. Broad St.
Segal, Louis, 704 S. Fifty-second St
Segal, Morris, 4759 N. Eleventh St
Seiberling, Joseph D., 339 S. Eighteenth St.
Seibert, William K., 1517 W. Erie Ave.
Seidel, Victor I., 2338 N. Twenty-ninth St.
Seifert, F. Robert, 2202 E. Cumberland St.
Seilikovitch, Solomon, 935 S. Third St.
Seipel, Russell C, 6000 Jefferson St.
Seiss, Ralph W., 255 S. Seventeenth St.
Seligman, Louis, 247 S. Thirteenth St.
Seltzer, Charles M., 2021 Spring Garden St.
Sender, Arthur C, 1311 W. Allegheny Ave.
Sener, Walter J., 1529 Spruce St.
Service, Charles A., City Ave., Bala (Montg. Co.).
Severs, G. Harvey, 3401 N. Front St.
Shaar, Camille M., 916 Spruce St.
Shaffer, George E., 3608 Richmond St.
Shaham, Simon, Snyder Ave. and Ninth St.
Shallow, Thomas A., 3942 Chestnut St.
Shammo, George C, 260 N. Fifty-second St.
Shaner, Samuel R., 209 N. Sixtieth St.
Shannon, Charles E. G., 1633 Spruce St.
Shapiro, Morris S., 516 Pine St.
Sharkev, John A., 5741 Baltimore Ave.
Shea, William K., 1705 N. Eighteenth St.
SheaflF, Philip A., 4006 Baring St
Sheraeley, William G., Jr., 1831 Chestnut St.
Shepherd, Mary E., 1908 Diamond St.
Shepherd, Samuel G.. 2333 Wharton St.
Shields, William G., 414 Schoolhouse Lane, Gtn.
Shmookler, Henry B., 1320 S. Fifth St.
Shoemaker, George Erety, 1906 Qiestnut St.
Shoemaker, Harvey, 2001 Chestnut St.
Shoemaker, William T., 109 S. Twentieth St.
Sholler, George W., 1224 W. Lehigh Ave.
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770
THE PENNSYLVANIA MEDICAL JOURNAL
July, 1921
Shope, Edward P. L., Episcopal Hospital.
Shuman, George H., IIOS Park BIdg., Pittsburgh
(Allegheny Co.).
Shumway, Edward A., 2046 Chestnut St.
Shurtleff, Henry C, 31 S. Fortieth St.
Shuster, Benjamin H., 436 Spruce St.
Shute, Harry A., 1408 N. Fifteenth St.
Siege], Alvin E., 313 S. Eighteenth St.
Siggins, John C, 1728 Spring Garden St..
Silverman, Abraham, 1511 W. Girard Ave.
Simcox, Lawrence, 2005 Chestnut St.
Simkins, James J., 2002 N. Twenty-first St.
Simmons, Clifford F., 1939 Hunting Park Ave.
Sinisohn, Joseph S., 1501 N. Seventeenth St.
Sinclair, John F., 4103 Walnut St.
Sinexon, Justus, 3903 Chestnut St.
Singer, Samuel, 4150 Girard Ave.
Sinkler, Francis W., 1606 Walnut St.
Sinnamon, George, 2204 E. York St.
Siter, E. Hollingsworth, 1520 Locust St.
Skillem, Penn-Gaskill, Sharon Hill (Delaware Co ).
Skillern, Penn-Gaskill, Jr., 1523 Locust St.
Skillem, Ross Hall, 1928 Chestnut St.
Skillem, Samuel R., Jr., Pembroke Rd. and Bentley
Ave., Cynwyd.
Skversky, Frank Benjamin, 918 Porter St.
Slade, Frederick G., 2332 N. Twenty-fifth St.
Slaughter, Charles H. P., 1630 S Broad St.
Slaymaker, John M., 3502 Spring Garden St.
Slifer, G. Baringer, 1707 Ritner St.
Sloane, Henry O., 1737 N. Franklin St.
Slonimsky, George, 730 W. Moyamensfng Ave.
Small, William B., 1321 Spruce St.
Smiley, Anne E., Northwest comer Fifty-first and
Chestnut Sts.
Smith, A. Depont, Pelhara Court, Gtn.
Smith, (proline E., Perry Bldg.
Smith, Clarence D., 741 Spruce St.
Smith, David E., 425 North Second West, Salt Lake
City, Utah.
Smith, Frederick C, 6247 Haverford Ave.
Smith, Henry A., N. E. Cor. Sixteenth and Oxford Sts.
Smith, James A., 233 S. Forty-fifth St.
Smith, J. Howard, 1020 S. Sixtieth St.
Smith, J. Melvin, Fifty-second and Jefferson Sts.
Smith, Joseph I., 1721 N. Seventeenth St.
Smith, Lynnley G., 1912 Diamond St.
Smith, R. Penn, Box 36, Station Hosp., Camp Dix,
N. J.
Smith, Rolla L., 2987 Richmond St.
Smith, Samuel Calvin, 323 S. Eighteenth St.
Smith, S. MacCuen, 1429 Spruce St.
Smith, William A., 2141 Howard St.
Smock, Ledru P., 3330 Chestnut St.
Smoczynski, M. Edward, 4650 Tacony St., Frankford.
Smukler, Max £., 1909 N. Broad St.
Smyth, Calvin M., Jr., 257 S. Twenty-first St.
Snively, Andrew F., 323 S. Fifty-first St.
Snively, Robley D., 1709 Tioga St.
Snodgrass, Oliver E., 2350 N. Nineteenth St.
Snyder, Elizabeth, 2035 Columbia Ave.
Snydcrman, Henry S., 1920 N. Seventh St.
Sohn, George W., 135 Green Lane, Myk.
Solis-Cohen, Jacob, 2113 Chestnut St.
Solis-Cohen, Leon, 1525 Walnut St.
Solis-Cohen, Myer, 2113 Chestnut St.
Solis-Cohen, Solomon, 1525 Walnut St.
Somers, Lewis S., 3554 N. Broad St.
Sommers, Raymond L., 2403 E. York St.
Sonneborn, George A., 1200 W. Erie Ave.
Sowden, Frederic D., 156 W. Allegheny Ave.
Spaeth, William L. C, 5000 Jackson St., Fkd.
Spangler, Ralph H., 2217 S. Broad St.
Spears, Mary M., 2121 N. College Ave.
Speer, Henry N., 727 S. Fifty-fifth St.
Speese, John, 2032 Locust St.
Speirs, George Campbell, 1419 Spruce St.
Spellissy, Joseph M., 317 S. Fifteenth St.
Spencer, George W., 1734 S. Fifty-eighth St.
Spencert Sylvia D., 1830 S. Rittenhouse Sq.
Spencer, William H., 1830 S. Rittenhouse Sq.
Spiegle, Grace E., 2115 N. Twelfth St.
Spiers, Israel, 3031 Diamond St
Spiller, William G., Twenty-first and Chestnut Sts.
Sprague, Frances R., Bryn Mawr (Montg. Co.).
Sprissler, Theodore, 1151 S. Broad St.
Spitz, Louis, 4112 W. Girard Ave.
Stahl, B. Franklin, 1727 Pine St.
Stamm, Camille J., 1412 Diamond St.
Stanton, John Joseph, 1404 N. Sixteenth St.
Starkey, Katharine, 2018 N. Twenty-second St.
Stauffer, Nathan P., 1819 Walnut St.
Steel, William A., 3300 N. Broad St.
Steinbock, Frederick W., 1339 N. Thirteenth St
Steiner, Samuel, 943 N. Fifth St.
Steinfield, Edward, 4641 N. Thirteenth St.
Steinmetz, Charles G., Jr., 4426 Chestnut St.
Stellwagon, Thomas C, Jr., 1912 Pine St.
Stembler, Harry A., 939 N. Eighth St.
Stengel, Alfred, 1728 Spruce St.
Stephen, (Jeorge L., Atglen (Chester Ck).).
Sterling, Alexander, 2044 Chestnut St.
Stevens, Arthur A., 314 S. Sixteenth St.
Stevens, William W., 5722 Chester Ave.
Stewart, Francis E., 11 W. Phil-Ellena St., Gtn.
Stewart, Thomas .S., S. E. Cor. Eighteenth and Spruce
Sts.
Stiles, Charles M., 1831 Chestnut St
Stiles, Francis A., 3801 Powelton Ave.
Stimson, Cheney M., N. E. Cor. Greene and Harvey
Sts., Gtn.
Stirk, James C, 734 Yale Ave., Swarthmore (Dela-
ware Co.).
Stirling, Samuel R., 1931 E. Cumberland St
Stone, Edward R., 1701 Master St.
Stoner. W. H., Medical Laboratories, University of
Pennsylvania.
Stout, George C, 1611 Walnut St.
Stout, Oliver, 3351 N. Fifth St.
Stout Philip S., 4701 Chester Ave.
Strauss, Abram, Medical Arts Bldg.
Strawbridge, I. Rendall, 1418 N. Fifteenth St
Strecker, Edward A., 4401 Market St.
Strecker, Henry A., 1318 Pine St.
Strickland, (jeorge G., 1437 Brown St
Strickler, Albert, 4037 Girard Ave.
Strittmatter, Isidor P., 999 N. Sixth St.
Stroup, A. Clarke, 1245 S. Twenty-third St
Strouse, Frederic M., 1301 Spruce St
Strousse, Jacob L., 1425 W. Erie Ave.
Stryker, Samuel S., Northeast comer Thirty-ninth and
Walnut Sts.
Stubbs, Charles P., 220 W. Cx)ulter St, Gtn.
Stuckert, Harry, 2116 N. Twenty-first St
Sturr, Robert P., 1823 Spruce St
Sturtevant, Charles N., 4321 Frankford Ave.
Suiter, David L., 218 E. Wyoming Ave.
Sulman, Louis D., 126 N. Sixtieth St
Sutliff, Fred A., 1901 Cayuga St.
Sutton, Howard A., 114 S. Nineteenth St.
Swalm, Charles J., York and Rockland Sts.
Swalm, M. C. Edna, 4901 N. Thirteenth St
Swalm, William Albert, 4901 N. Thirteenth St
Swartley, William B., 5919 Greene St, Gtn.
Swayne, Eugene, Hotel Victory, Harriman (Bock?
Co.).
Sweeney, Edmund B., 1721 N. Sixteenth St.
Sweeney, James J., 159 E. Lehigh Ave.
Sweet, Joshua E., 301 St. Mark's Sq.
Sweet, William M., 1205 Sproce St.
Swindalls, Walton C, 2049 Chestnut St.
Tait Thomas W., 320 S. Fifteenth St.
Tallant Alice W., 1200 Spmce St.
Talley, James E., 218 S. Twentieth St
Tannenbaum, Simon, Jewish Hospital.
Target, John D., 1112 Jackson St.
Targette, Archibald F., 5229 Haverford Ave.
Tarrant, A. Overton, Fifty-seventh and Wdwter Sts.
Digitized by
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July, 1921
MEMBERSHIP LIST
771
Tassman, Isaac S., 1823 W. Erie Ave.
Taukersley, Grace, 1831 Chestnut St.
Taylor J. Madison, 1504 Pine St.
Taylor, M. Ross, 1823 Spring Garden St.
Taylor, Norman H. 8016 Seminole St., Chestnut Hill.
Taylor, Robert F., 2064 E. Cumberland St.
Tavlor, William Johnson, 1825 Pine St.
Taylor, William L., 1340 N. Twelfth St.
Teller, William H., 1713 Green St.
Thissell, Henry N., 6043 Germantown Ave.
Thomas, Anne H., Medical Arts Bldg.
Thomas, Barton K., 324 High St., Pottstown (Montg.
Co.).
Thomas, Benjamin A., 116 W. Nineteenth St.
Thomas, Charles H., 3634 Chestnut St.
Thomas, Claude L., 2802 Columbia Ave.
Thomas, Eb W., 1833 Chestnut St.
Thomas, Frank W., 27 E. Mt. Airy Ave.
Thomas, George P., 2113 N. Seventh St.
Thomas, T. Turner, 1905 Chestnut St.
Thomas, W. Hersey, Medical Arts Building.
Thompson, Frank A., 5108 Springfield Ave.
Thompson, Ross Hall, 1415 N. Sixteenth St.
Thorington, James, 2031 Chestnut St.
Thornton, E. Quin, 1331 Pine St.
Thornton, Mary Bickings, 2703 W. Somerset St.
Thorp, John S., 5901 Chester Ave.
Thrush, M. Clayton, 3705 Spring Garden St.
Thudium, William J., 1630 Walnut St.
Tod, Alva F., 447 Diamond St.
Toland, J. Hart, 2526 S. Broad St.
Toland, Joseph J., Jr., 4605 Leiper St., Fkd.
Tomassene, Raymond A., 1708 Pine St.
Tomlin, Aimer N., 518 N. Fortieth St.
Torrey, Robert G., 1716 Locust St.
Toulmin, Harry, S. E. Cor. Sixth and Walnut Sts.
Town, Edwin C, Box 936, Narberth (Pa.).
Tracy, Martha, 170O, Chestnut St.
Tracy, Stephen E., 1527 Spruce St.
Traganza, Frederick, 2009 N. Twenty-second St.
Trager, Herman, 5903 Walnut St.
Trasoff, Abraham, 5907 Walnut St.
Trau, Philip A., 1520 Diamond St.
Treacy, Alfred J. M., 910 E. Chelten Ave.
Trcichler-Reedy, Elsie Rau, 328 W. Manheim St., Gtn.
Trinkle, Wilmer W.. 1438 S. Thirteenth St.
Trotman, James A., 1608 Wharton St.
Truitt. George W., 2425 E. Clearfield St.
Tucker, Gabriel F., 301 S. Twelfth St.
Tullidge, George B., 843 N. Sixty-third St.
Tunis, Joseph P., Churchville P. O. (Bucks Cx).).
Tunnell, Stephen Wilmer, 1831 (Thestnut St.
Turner, Creighton H., 2504 S. Twentieth St.
Turner, John B., 1831 Chestnut St.
Turner, John H., HI, 343 S. Chester Ave., Glenolden
(Del. Co.).
Turner, John P.. 1302 S. Eighteenth St.
Turner, Joseph, 1625 Butler St.
Turner, Linton, 450 Lyceum Ave.. Rxb.
Twaddell, Thomas P. H., 4203 Chester Ave.
Tyler, Everett A., 2104 Chestnut St.
Tyson, Ralph M., 6709 N. Eighth St.
Tyson, T. Mellor, 1506 Spruce St.
Udell, William, 1628 S. Ninth St.
Ulanski, Benjamin, 4410 Germantown Ave.
Ullom,. Josephus T., 24 Carpenter St., Gtn.
Ulman, Joseph F., 2629 N. Twenty-ninth St.
Ulrich, George A., 309 S. Twelfth St.
Umsted, William M., 2812 Oxford St.
Underbill, Eugene, Jr., 1904 Chestnut St.
Ungerleider, Harry E., 1831 Chestnut St.
Vaca, T. Seydel, IZJ N. Sixty-third St.
Vail, William Penn, Blairstown, N. J.
Valentine, August C, 6609 Torresdale Ave.
Van Buskirk, James, 2130 N. Hancock St.
Vance, David C, 2618 N. Eleventh St.
Van Dervoort, Charles A., 112 N. Broad St.
Van Dolson, William W., 7240 Germantown Ave.
Vaii Gasken, Frances C, 115 S. Twenty-second St -
Van Korb, William, 5623 Wyalusing Ave.
Van Pelt, William T., 1100 Widener Bldg.
Vansant, Eugene L., 1929 Chestnut St.
Vattier, Louis C, 805 N. Sixty third St.
Vaughn, J. Webb, 5919 (>dar Ave.
Vitanza, Fortunato, 1216 S. Thirteenth St.
Vogt, Mametta E., Twenty-first St. and N. College
Ave.
Voss, Frederick J., 2549 E. Indiana Ave.
Wachs, Charles S., 1941 S. Ninth St.
Wadsworth, William S., 3914 Baltimore Ave.
Wagers, Arthur J., 4638 Larchwood Ave.
Wagnetz, John A., 220 E. Allegheny Ave.
Wainwright, Maud, 5233 Walnut St.
Walker, Holmes, 5429 Lansdowne Ave.
Walker, Jacob, 712 Pine St.
Walker, John K., 2038 Locust St.
Walker, John T., 1606 N. Eighth St.
Walker, Warren, 2038 Locust St.
Wallace, Charles H., The Covington, Thirty-seventh
and Chestnut Sts.
Wallis, J. Edward, 2642 Richmond St.
Walsh, Joseph, 2026 Chestnut St.
Walsh, Maria Constanline, 902 Pine St.
Walsh, William H., Apartado 170, Cartagena, Col-
ombia, S. A.
Walters, B. Frank, 19 E. Sixth St., St. Paul, Minn.
Ward, E. Tillson, 2006 Mt. Vernon St.
Warlow, Margaret A., 1831 Chestnut St.
Warmuth, Mitchell P., 1701 Chestnut St.
Warner, Miriam, 839 N. Twenty-fourth St.
Watson, Arthur W., 126 S. Eighteenth St.
Watson, Charles J., 5617 N. Third St.
Watson, Edward W., 38 S. Nineteenth St.
Watson, Matthew S., 537 Pine St.
Watson, W. Newbold, 1524 CJiestnut St.
Watson, Walter W., 1712 Walnut St.
Watson, William R., 1805 Pine St.
Watt, Charles C, Jr., Wayne Ave. and Hortter St., Mt.
Airy.
Watt, Robert, 3142 Frankford Ave.
Weaver, Albert P., 879 Belmont Ave.
Weaver, W. Warren, 6105 Woodland Ave.
Weber, Edith M. Clime, 5931 N. Park Ave.
Weber, Harry F., 4601 Wayne Ave.
Weber, Randall J., 2403 N. Seventeenth St.
Weber, William. M., 119 South Eighteenth Si.
Webster, Aubrey B., Medical Arts Bldg.
WeMman, Fred D., 242 N. Sixty-first St.
Weigle, Henry S., 1014 S. Fifty-eighth St.
Weiland, Carl, Jr., 617 Vine St.
Wetnstcin, George L., Foulkrod and Griscom Sts.,
Franrfford.
Weinstein, Morris A., 615 Pine St.
Weintraub, Sarah Louise, 1239 S. Broad St.
Weisblum, Maurice. 1638 S. Broad St
Weisenburg, Theodore H., 1909 Chestnut St.
Weiss, Benjamin P., 630 Spruce St.
Weiss, Hervey B., 1929 N. Howard St
Wells, J. Ralston, 754 N. Fortieth St.
Wells, P. Fraley, 754 N. Fortieth St.
Wenner, E. Bruce, 3805 Baring St.
Wentz, Benjamin F., 6602 Woodland Ave.
Wenzel, Mary, 3711 Old York Rd.
Werner, Julius L., 1533 S. Sixth St
Wessels, Lewis C, 1918 N. Twenty-second St.
West, Charles W., 2131 Delancey St.
West, John W., 1125 Wallace St.
West, Stanley Q., 138 W. Walnut Lane.
Westcott, Thompson S., 1720 Pine St.
Weyl, Esther M., 757 N. Twentieth St.
Whaland, Berta, 2335 Berks St.
Wharton, Henry R., 1725 Spruce St.
Whetstone, William B., 4820 Chester Ave.
Whitaker, William, 5448 Germantown Ave.
Whitall, J. Dawson, 2124 N. Twentieth St.
White, Abraham E., 2123 Jefferson St.
White. Courtland Y., 6611 N. Tenth St.
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THE PENNSYLVANIA MEDICAL JOURNAL
July, 1921
White, Ellen P. Corson, 1920 Rittenhouse St.
White, Frank, 4331 Chestnut St.
White, Howard K., 460 Green Lane.
White, Milton N., 701 N. Forty-second St.
Whiting, Albert D., 1523 Spruce St.
Whitlock-Rose, Elise, 2201 DeLancey St.
Widdowson, Frank R., 6201 Lansdowne Ave.
Widmann, Bernard P., 1321 Spruce St.
Wieder, Henry S., 1512 Diamond St.
Wiggins, E. Harvey, 4415 N. Uber St.
Wiggins, Susan W., 1831 Chestnut St.
Wilcox, William B., 914 N. Forty-fourth St.
Wilderman, Henry, 1318 S. Fifth St.
Wiley, Harry Eugene, 1440 S. Broad St.
Wiley, John J., 1413 Tioga St.
Wiley, Louis R., 219 W. Tabor Rd.
Wilkinson, R. Powers, 1613 S. Broad St.
Willard, DeForest P., 1630 Spruce St.
Williams, Carl, 69 Schoolhouse Lane, Gtn.
Wlliams, Horace T., 5908 Greene St., Gtn.
Williams, Philip F., 262 S. .Twenty-first St.
Williams, Rachel R., Eighth and Markets Sts.
Williamson, Ernest G., 1311 N. Sixtieth St.
Williamson, James, 2030 Tioga St.
Williamson, Katherine A., 1410 Pine St.
Willits, Charles H., Provident Life and Trust Co.,
Fourth and Chestnut Sts.
Willits, L Pearson, 31 W. Walnut Lane, Gtn.
Wilmer, Hariy B., 138 W. Walnut Lane, Gtn.
Wilson, George, 5000 Walnut St.
Wilson, James C, 1509 Walnut St.
Wilson, Samuel M., 1517 Arch St.
Winheld, Morris, 943 N. Fourth St.
Winkelman, Nathaniel W., 319 S. Eighteenth St.
Winter, S. Elizabeth, Inwood Sanitarium, West Con-
shohocken (Montg. Co.).
Wise, Heniy M., 1427 Erie Ave.
Wiseman, Katharine Fridct, State Hospital, Middle-
town Conn.
Wojczynski, Leo J., 1716 Hunting Park Ave.
Wolf, Samuel, 1814 S. Sixth St.
Wolf, Wilbert J., 3474 Frankford Ave.
Wolferth, Charles C, 1704 Pine St.
Wolfson, Louis, 1735 N. Thirty-first St
Wollman, Cecilie H., 5907 Christian St.
Wonders, Homer F., N. W. Cor. Sixteenth and Wal-
nut St.
Wood, Alfred C, 2035 Walnut St.
Wood, George B., 1830 Spruce St.
Wood, Horatio C, Jr., 1905 Chestnut St.
Wood, J. K. Williams, 4005 Chestnut St.
Wood, Walter A., 256 S. Sixteenth St.
Wood, William Charles, 1907 Chestnut St.
Woodbury, Frank, 3345 N. Seventeenth St.
Woodward, George, 708 N. American Bldg.
Woody, Samuel S., Second and Luzerne Sts.
Worden, Charles B., Medical Department, John
Wanamaker, Phila.
Wrigley, Arthur, 1019 Pine St.
Wray, William S., 2007 Chestnut St.
Yaeger, Christian G., 2403 E. York St.
Yaskin, Joseph C, 1719 N. Fifty-second St.
Yawger, Nathaniel S., 2117 Chestnut St.
Yeager, George C, 1419 E. Susquehanna Ave.
Yost, George Garfield, 643 N. Sixteenth St.
Youell, George J., 7^ E. Allegheny Ave.
Young, Anna Gardner, 1419 Spruce St.
Young, Charles H., 4813 Baltimore Ave.
Young, James K., 222 S. Sixteenth St.
Yubas, Morris L., 907 Pine St.
Zabarkes, R. Vera, 3228 W. York St.
Zacks, Myron A., 1900 Venango St.
Zahn, Samuel F., 6201 Chestnut St.
Zall, Bernard C, 923 N. Sixth St.
Zentmayer, William, 1506 Spruce St.
Zettlemoyer, Jonas, 5629 Whitby Ave.
Ziegler, S. Lewis, 1625 Walnut St.
Ziegler, Walter M. L., 1418 N. Seventeenth St.
Ziegler, William H., 3127 Frankford Ave.
Zimlick, Arthur J., N. W. Cor. Greene and Ritten-
house Sts., Gtn.
Zimmerman, Mason W., 1522 Locust St.
Zulick, Howell S., 1729 Ardi St.
Zulick, J. Donald, 2029 Walnut St.
POTTER COUNTY SOCIETY
(Organized April 5, 1898.)
President. . .Elwin H. Ashcraft, Coudersport.
V. Pres Nathan W. Church, Ulysses.
Secretary... F. Gurney Reese, Coudersport.
Treasurer. . .James T. Hurd, Galelon.
Censors El win H. Ashcraft, Coudersport.
James T. Hurd, Galeton.
Committee on Public Policy and Legislation :
Elwin H. Ashcraft, Cjoudersport.
Stated meetings the second Tuesday in May, July,
September and November, at ti.e Court House, O-u-
dersport. Election of officers in May, to take office
the following January.
MEMBERS (14)
Ashcraft, Elwin H., Coudersport.
Bentley, J. Irving, Galeton.
Church, Nathan W., Ulysses.
Farwell, Franklin P., Galeton.
Hart, Henry D., Genesee.
Hurd, James T., Galeton.
Jacobs, David E., Coudersport.
Jones, Ross H., Coudersport.
Knight, Robert B., Coudersport.
Laye, Hal A., U. S. P. H. S. Hosp., Fox Hills, Staten
Island. N. Y.
Page, John H., Austin.
Reese, F. Gurney, Coudersport.
Steele, John G., Galeton.
Winlack, Alexander E., Shingle House.
SCHUYLKILL COUNTY SOCIETY
(Organized 1845.)
President... Christian Gruhler, Shenandoah.
1st V. Pres.. John J. Dailey, McAdoo,
2d V. Pres. .. Merchant C. Householder, Pottsville.
Sec.-Rept... George O. O. Santee, Cressona.
Treasurer. . .David Taggart, Frackville.
Censors J. Spencer Callen, Shenandoah.
Arthur B. Fleming, Tamaqua.
Christian Lenker, Schuylkill Haven.
Committee on Public Policy and Legislation:
John J. Dailey, McAdoo.
James A. Lessig, Schuylkill Haven.
Arthur B. Fleming, Tamaqua.
Exec. Com.. Christian Gruhler, Shenandoah.
George O. O. Santee, Cressona.
George R. S. Corson, Pottsville.
Stated meetings in Pottsville (or elsewhere as mav
be selected) the first Tuesday of each month. Electio.*'
of officers in January.
MEMBERS (102)
Auchmuty, John E., Tamaqua.
Austra, Joseph J., Shenandoah.
Bacon, Walter A., Pottsville.
Bailey, Harry W., Tamaqua.
Barnd. Franklin P., Hegins.
Barr, W. H., Ashland.
Bartho, Benjamin F., Mt. Carmel (Northumberland
Co.).
Berk, John K., Frackville.
Berkheiser, Arthur John, Shenandoah.
Biddle, Jonathan C, Ashland.
Biddle, Robert M., Ashland.
Boord, Paul C, New Bethlehem (Clarion Co.).
Bowers, Walter G., Schuylkill Haven.
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MEMBERSHIP LIST
773
Bowman, Henry C, Gilberton.
Bredt, Charles E., Mahanoy City.
Bretz, Gilbert F., Pottsville.
Bronson, Albert F., Girardville.
Burke, William A., Pottsville.
Bums, Joseph V., Coaldale.
Callen, J. Spencer, Shenandoah.
Carlin, Oscar J., Pottsville.
Carpenter, J. Stratton, Pottsville.
Casey, Thomas D., Ashland.
Conidutn, Frank J., Morea Colliery.
Conrad, John W., Port Carbon.
Constein, Rudolph A., Ashland.
Corson, George R. S., Pottsville.
Dailey, John Joseph, McAdoo.
Dechert, Harry W., Orwigsburg.
Doyle, William F., Pottsville.
Espy, Carl W., Pottsville.
Fegley, Theodore C, Tremont.
Fenton, Ivor D., Mahanoy City.
Fisher, Albert W., Gordon.
Fleming, Arthur B., Tamaqua.
Freudenberger, Katrina, Tamaqua.
Gallagher, John C, Shenandoah.
Gillars, Alexander L., Pottsville.
Gillette, Qaude W., Schuylkill Haven.
Gruhler, Christian, Shenandoah.
Heim, Lyman D., Schuylkill Haven.
Heller, James B., Pottsville.
Hensyl, George S., Mahanoy City.
Hinkel, William H., Tamaqua.
Hobbs, Harry K., Shenandoah.
Hoffman, J. Louis, Ashland.
Holderman, Herbert H., Shenandoah.
Householder, Merchant C, Pottsville.
Jones, William G., Tamaqua.
Kennedy, Louis T., Pottsville.
Kingsbury, Mary B., Pottsville.
Kramer, Joseph G., Pottsville.
Lenker, Christian, Schuylkill Haven.
Lenker, Robert W., Schuylkill Haven.
Lessig, James Alfred, Schuylkill Haven.
McGeehan, Edward J., McAdoo.
McGurl, Thomas J., Minersville.
Marshall, D. Samuel, Ashland.
Matten, William H., McKeansburg.
Merkel, George A., Minersville.
Miller, Charles D., Pottsville.
Monahan, John S., Shenandoah.
Moore, George H., Schuylkill Haven.
Moore, John J., Pottsville.
Mullahey, Leo T., Shenandoah.
Murphy, Joseph T., 215 Mohantonga St., Pottsville.
O'Hara, Patrick H., Pottsville.
Parry, Leo D., Frackville.
Price, Harvey A., Port Carbon.
Quinn, Francis M., Minersville.
Rentschler, Walter R., Ringtown.
Ressler, George W., Ashland.
Rhoads, John, Ringtown.
Riley, John D., 200 E. Mahanoy Ave., Mahanoy City.
Roberts, J. Pierce, Shenandoah.
Robinhold, Lewis C, Auburn.
Rogers, Jerome B., Pottsville.
Roth, James P., Fountain Springs.
Roth, Victor T., Pottsville.
Rutter, Thomas C, Schuylkill Haven.
Ryan, John T., St. Clair.
Ryland, Albanus S., Pottsville.
Rynkiewicz, Ella L, Shenandoah.
Santee, George O. O., Cressona. ,
Scanlan, William J., Shenandoah.
Schultz, J. William, Tremont.
Seligman, Abram P., Mahanoy City.
Simonis, Arthur E., Tremont.
Stein, Newton Henry, Silver Creek.
Stein, William N., Shenandoah.
Stewart, Harry H., 307 W. Market St., Pottsville.
Striegel, John G., Pottsville.
Stutzman, Raymond H., Tower City.
Sweeney, John J., Heckscherville.
Taggart, David, Frackville.
Walter, Frank J., Pine Grove.
Wame, Josei^ Lloyd, Pottsville.
Weaver, William A., Coaldale.
Weisner, Edwin E., Tamaqua.
Wertman, Samuel E., Mahanoy City.
Williams, T. Lamar, Mt. Carmel (Northumberland
Co.).
SNYDER COUNTY SOCIETY
(Organized May 18, 1905.)
President... Charles N. Brosius, Shamokin Dam.
V. Pres A. Jerome Herman, Middleburg.
Sec.-Rept... Percy E. Whiffen, McClure.
Treasurer... Edwin M. Miller, Beavertown.
Censors Milton E. Wagner, McClure.
Russell W. Johnston, Selins Grove.
Maraud Rodirock, Mt. Pleasant Mills.
Committee on Public Policy and Legislation:
Edwin M. Miller, Beavertown.
John O. Wagner, Beaver Springs.
Official Publication: The Bulletin.
Issued Monthly.
Editor: Percival Herman, Selins Grove.
Annual meeting in January. Stated meetings at 11
a. m. (unless odierwise ordered) the first Friday of
each month at Middleburg.
MEMBERS (12)
Brosius, Qarles N., Shamokin Dam.
Hassinger, G. Edgar, Middleburg.
Herman, A. Jerome, Middleburg.
Herman, Percival, 114 Independent St., Selms Grove.
Johnston, Russell W., Selins Grove.
Long, Dwight E., Freeburg.
Miller, Edwin M., Beavertown.
Rothrock, Marand, Mt. Pleasant Mills.
Toole, Edward W., Selins Grove.
Wagner, John O., Beaver Springs.
Wagner, Milton E., McClure.
Whiffen, Percy E., McClure.
SOMERSET COUNTY SOCIETY
(Organized Oct. 29, 1889.)
President. . .Charles B. Korns, Sipesville.
V. Pres Henry S. Kimmel, Somerset.
Sec.-Rept. ..H. Clay McKinley, Meyersdale.
Treasurer... Carl W. Frantz, Confluence.
Censors Charles R. Bittner, Hooversville.
Mosheim W. Kuhlman, Jenners.
Henry I. Marsden, Somerset.
Committee on Public Policy and Legislation:
George F. Speicher, Rockwood.
Charles I. Shaffer, Ralphton.
J. Earl Dull, Somerset.
Prog. Com.. Charles P. Large, Rockwood.
Bruce Lichty, Meyersdale.
George G. Berkheimer, Windber.
Official Publication: The Call.
Issued Semi-monthly.
Editor: H. Clay McKinley.
Stated meetings at place selected on the third Tues-
day of January, March, May, July, September and
November. Election of officers in November and offices
assumed at January meeting.
MEMBERS (44)
Berkheimer, George C, Windber.
Bittner, Charles R., Hooversville.
Bowman, Jacob T., Somerset.
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THE PENNSYLVANIA MEDICAL JOURNAL
July, 1921
Dull, J. Earl, Somerset.
Frantz, Carl W., Q>nfluence.
Geissler, Elmer E., Jerome.
Glass, Creed C, Meyersdale.
Grazier, George C, Hollsopple.
Heffley, Robert, Berlin.
Heikes, Lloyd A., Boswell.
Hemminger, Charles J., Rockwood.
Hemminger, J. Ross, Somerset.
Hertzler, Henry, Jenners.
James, Jerry M., Hooversville.
Keim, Albert F., Stoyestown.
Keim, William W., Jerome.
Kimmel, Henry D., Somerset.
Koms, Charles B., Sipesville.
Kuhlman, Mosheim W., Jenners.
Large, Charles P., Meyersdale.
Lichty, Bruce, Meyersdale.
Long, Benjamin H., Boswell, R. D. 2.
Lyon, Samuel E., New Central City.
McClellan, W. Roy, Garrett.
Mclntyre, Milton U., Boswell.
McKinley, H. Clay, 203 Sali*ury St., Meyersdale.
Marsden, Henry Irving, Somerset.
Masters, George B., Macdonaldton.
Miller, Irwin C, Berlin.
Noon, George A , Listie.
Pollard, Richard T., Garrett.
Rowe, William T., Meyersdale.
Sass, Frank, Boswell.
Saylor, Clinton T., Rockwood.
Shaffer, Charles I., Ralphton.
Shaffer, Fred B., Somerset.
Shaw, William P., Berlin.
Smith, Bart J., Windber.
Speicher, George F., Rockwood.
Swank, Peter L., Elk Lick.
Uphouse, Albert M., Somerset.
Wenzel, John W., Meyersdale.
Wilson, Henry, Somerset.
Zimmerman, Henry A., Hollsopple.
SULLIVAN COUNTY SOCIETY
(Organized Aug. 9, 1907.)
President... George C. Swope, Mildred.
1st V.Pres.. Justin L. Christian, Lopez.
2dV. Pres...Hugh K. Davis, Sonestown.
Secretary... Carl M. Bradford, Forksville.
Treasurer... Justin L. Christian, Lopez.
Censors Theodore Wright, Dushore.
Hugh K. Davis, Sonestown.
Committee on Public Policy and Legislation:
Martin E. Herrmann, Dushore.
Philip G. Biddle, Dushore.
Justin L. Christian, Lopez.
Exec. Com... George C. Swope, Mildred.
Carl M. Bradford, Forksville.
Philip G. Biddle, Dushore.
Meetings shall be held quarterly, the January meet-
ing to be held at Dushore, the other meetings at time
and place to be fixed by vote of the society or by the
Program Committee.
MEMBERS (8)
Biddle, Philip G., Dushore.
Bradford, Carl M., Forksville.
Christian, Justin L., Lopez.
Davis, Hugh K., Sonestown.
Herrmann, Martin E., Dushore.
Randall, William H., Avis (Clinton Co.)
Swope, George C, Mildred.
Wright, Theodore, Dushore.
SUSQUEHANNA COUNTY SOCIETY
(Organized Nov. 19. 1838.)
President... Arthur J. Denman, Susquehanna.
Sec.-Treas.. Edward R. Gardner, Montrose.
Reporter Horace D. Washburn, Susquehanna.
Censors Homer B. Lathrop, Springville.
Warren W. Preston, Montrose.
Fred S. Birchard, Montrose.
Exec. Com. .Arthur J. Denman, Susquehanna.
Edward R. Gardner, Montrose.
Abram E. Snyder, New Mil ford.
Annual meeting in Montrose the second Tuesday of
January. Other meetings, morning and afternoon ses-
sions, second Tuesday of May, August and October
at places designated at previous meeting.
MEMBERS (19)
Birchard, Fred S., Montrose.
Blair, A. Stryker, Hallstead.
Caterson, Clarington W., Montrose.
Condon, William J., Susquehanna.
Denman, Arthur J., Susquehanna.
Fry, Harvey M., Rush.
Gardner, Edward R., Montrose.
Johnson, Charles A., Harford.
Lathrop, Homer B., Springville.
Miller, Morgan L., Susquehanna.
Newman, GJeorge W., Bichardville.
Peck, Dever J., Susquehanna.
Preston, Warren W., Montrose.
Snyder, Abram E., New Milford.
Taytor, Arthur J., Hopbottom.
Trimmer, Harry VV., South Gibson.
Vanness, Clarence N., Hallstead.
Washburn, Horace D., Susqudianna.
Williams, T. Oliver, Brooklyn.
TIOGA COUNTY SOCIETY
(Organized 1861. Reorganized Jan. 24, 1896.)
President. . .Lloyd G. Cole, Blossburg.
V.Pres Fay X. Field, Wellsboro.
Sec.-Treas.. .Solomon P. Hakes, Tioga.
Reporter John H. Doane, Mansfield.
Exec. Com. . . Lloyd G. Cole, Blossburg.
Solomon P. Hakes, Tioga.
Henry C. Harkness, Mansfield.
Censors Famham H. Shaw, Wellsboro.
Charles R. Smith, Tioga.
William C. Wilson, Morris Run.
Committee on Public Policy and Legislation :
John C. Secor, Westfield.
Clarence C. (Gentry, Knoxville.
Hiram Z. Frisbie, Elkland.
Stated meetings the first Friday of each month at
places selected. Election of officers in January.
MEMBERS (33)
Clark, Edwin E., Knoxville.
Cole, Lloyd Gamble, Blossburg.
Davies, John R., Blossburg.
Ditchbum, David T., Arnot.
Doane, JoJin H., Mansfield.
Farwell, Howard M., Westfield.
Field, Fay X., Wellsboro.
Frisbie, Hiram Z., Elkland.
Gentry, Clarence C, Knoxville.
Gentry, John M., Wellsboro.
Hakes, Solomon P., Tioga.
Harkness, Henry C, Mansfield.
Hobbs, L. L, Blossburg.
Howland, Harry W., Gaines.
Hughes. Lee W.. Wills Hospital, 18th & Race Sts.,
Phila. (Phila. Co.).
Humphrey. Wilmot G., Elkland.
Kennedy, Foster H., Middleburg Center.
Kingsley, Harry O., Gillett (Brad. Co.).
Kiley, John H., Morris Run.
Longwell. John P., Wellsboro.
Mastin, Nathan W., Wellsboro.
Meaker. Hughes G., Tioga.
Nye, Orrin S.. Rutland.
. Patterson, David A., Westfield.
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July, 1921
Secor, John C, Westfield.
Shaw, Farnham H., Wellsboro.
Sheldon. Charles W., Wellsboro.
Smith, Charles R., Tioga.
Smith L. Chapman, Lawrenceville.
Webb, Clarence W., Wellsboro.
Webster, Jesse G., Wellsboro.
Wheeler, Edith Flower, Mansfield.
Wilson, William Caldwell, Morris Run.
MEMBERSHIP LIST
775
UNION COUNTY SOCIETY
(Organized July 27, 1904.)
President. ..Anios« V. Persing, Allenwood.
1st V.Pres.. Weber L. Gerhart, Lewisburg.
2d V.Pres... Charles H. Dimm, Mifflinburg.
Sec. -Treas.. Charles A. Gundy, Lewisburg.
Reporter Oliver W. H. Glover, Laurelton.
Censor Charles H. Dimm, Mifflinburg.
Committee on Public Policy and Legislation:
Thomas C. Thornton, Lewisburg.
Weber L. Gerhart, Lewisburg.
Oliver W. H. Glover, Laurelton.
Charles H. Dimm, Mifflinburg.
Stated meetings in either Bucknell Hall or Bucknell
Laboratory, Lewisburg, the third Thursday of April,
July, October and December. Election of officers in
July.
MEMBERS (17)
Bikle, Paul H., Mifflinburg.
Dimm, Charles H., Mifflinburg.
Focht, Martin Luther, Lewisburg.
Gerhart, Weber L., Lewisburg.
Glover, Oliver W. H., Laurelton.
Gundy, Charles A., Lewisburg.
Hill, Albert Harrison, Mifflinburg.
Leiser, William, Jr., Lewisburg.
Matzke, Eklith, 311 Wayne Avenue, Wayne.
Metzgar, William E., Allenwood, R. D. 2.
Persing, Amos V., Allenwood.
Sampsell, David M., Winfield.
Steans, Ralph, Lewisburg.
Thornton, Harry R., Lewisburg.
Thornton, Thomas C., Lewisburg.
Wolfe, Lewis E., New Berlin.
Wolfe, Mary M., Lewisburg.
VENANGO COUNTY SOCIETY
(Organized May 8, 1867.)
President... Ford M. Summerville, Oil City.
V.Pres Charles S. Bridenbaugh, Emlenton.
Sec.-Treas...John F. Davis, Oil City.
Censors Paul R. Cunningham, Franklin.
Ardus C. Thompson, Franklin.
Jacob P. Strayer, Oil City.
Committee on Public Policy and Legislation :
Harry F. McDowell, Franklin.
Ardus C. Thompson, Franklin.
Jacob P. Strayer, Oil City.
Official Publication: The Bulletin of the Venango
County Medical Society.
Issued Monthly.
Editors: Ford M. Summerville, Oil City.
John F. Davis, Oil City.
Fred W. Brown, Franklin.
Stated meetings on the third Tuesday of January,
March, May, July, September and November at 1 p.
m., in Franklin or Oil City. Two meetings each year
are "outings" and are held at Monarch Park and the
State Institution for Feebleminded. Election of offi-
cers in January.
MEMBERS (57)
Ashton, Charles H., Franklin.
Black, Burton A., Polk.
Bolton, Earle W., Oil City.
Bovard, Forrest J., Tionesta (Forest Co.).
Boyd, Irwin H., Oil City.
Bridenbaugh, Charles S., Emlenton.
Brown, Alexander M., Franklin.
Brown, Frederick W., Franklin.
Bruner, Paul, Oil City.
Cooper, Clifford, Titusville (Crawford Co.).
Cunningham, Paul R., 1026 Liberty St., Franklin.
Davis, John F., Box 28, Oil City.
")ctar, Carm Y., Oil City.
Dickey, Elmer L., Oil City.
Dille, George W., Cooperstown.
Dunn, Rose M., Franklin.
Eshelman, Fayette C, Franklin.
Fawcett, William E., Grandview Sanatorium, Oil City.
Gaynor, Henry B., Polk.
Gilmore, William G., Emlenton.
Hadley, John L., Oil City.
Hammond, Henry P., Franklin.
Henderson, Earl F., Clintonville.
Irwin, Thomas A., Franklin.
Jackson, Frank B., Oil City.
Jobson, George B., Franklin.
Jobson, William R., OU City.
Jones, Theodore H., West Hickory (Forest Co.).
Lamb, Harry H., Oil City.
McBride, Lewis E., Franklin.
McDowell, Harry F., Franklin.
McDowell, Samuel W., Pittsville.
McKee, M. Ada, Oil City.
McLaJn, Paul J., Oil City.
Magee, F. Earle, Oil City.
Moore, Edwin W., 2825 Twenty-ninth St., San Diego,
California.
Murdoch, J. Moorhead, Polk.
Nicholson, William Addison, Franklin.
Perrine, Jonathan B. Wesky.
Ricketts, Audley W., Oil City.
Roth, William R., c/o P. R. R. Med. Examiner, 413
Market St., Harrisburg (Dauphin Co.).
SerriU, W. W., Kellettville (Forest Co.).
Sharp, James R., Oil City.
Sharpnack, William F., Oil City.
Siggins, James B., Oil City.
Slater, Sidney A., Worthington, Minn.
Snyder, Charles P., Manor (Westmoreland Co.).
Spencer, Elwood P., Cooperstown.
Stone, Harry S., Franklin.
Strayer, Jacob P., Oil City.
Summerville, Ford M., Odd Fellows Temple, Oil City.
Thompson, Ardus C, Franklin.
Thompson, Edgar V., Franklin.
Waid, John M., Titusville (Crawford Co.).
Wilkins, John C, Oil City.
Wilson, Calvin M., Franklin.
Zerbe, J. Irwin, Franklin.
WARREN COUNTY SOCIETY
(Organized 1871. Reorganized Sept. 19, 1881.)
(Warren is the post office when street address only is
given.)
President... Roy L. Young, Warren.
1st V. Pres.. Willis M. Baker, 205 Third Ave.
2d V.Pres... Robert B. Mervine. Sheffield.
Sec.-Treas...Erwin S. Briggs, 32 Water St.
Reporter.... Michael V. Ball, 310 Third Ave.
Censors Paul G. Weston, State Hospital for
Insane.
Richard B. Stewart, 214 Liberty St.
Christian J. Frantz, 128 Pennsylvania Ave.
Committee on Public Health Legislation :
Edwin S. Africa, 304 Liberty St.
Christian J. Frantz, 128 Pennsylvania Ave.
William M. Robertson, Warren.
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THE PENNSYLVANIA MEDICAL JOURNAL
July, 1921
Stated meetings the third Monday of each month.
Election of officers in January.
MEMBERS (48)
Africa, Eklwin S., 304 Liberty St.
Baker, Willis M., 205 Third Ave.
Ball, Michael V., 214 Penna. Ave. W.
Bea^, Elizabeth S., 10 Pennsylvania Ave. W.
Bennett, George Everett, ZS'/i N. Center St., Corry
(Erie Co.).
Bradshaw, George M. B., Sugar Grove.
Brewster, Benjamin F., Tidioute.
Briggs, Erwin S., 32 Water St.
Brown, Otis S., 6 Pennsylvania Ave. W.
Chapman, LeRoy E., 1913 Pennsylvania Ave. E.
Clancy, William Patrick, 316 Second Ave.
Condit, George S., Warren.
Cowden, Ernest J., North Warren.
Darting, Ira A., State. Hospital for Insane.
Durham, James R., 104 Market St.
Dutter, (juy E., Ludlow.
Ellsworth, Adelaide, State Hospital for Insane.
Flatt, Anna H. S., Corydon.
Flatt, Clayton C, Corydon.
Frantr, Qiristian J., 128 Pennsylvania Ave. W.
Haines, Franklin G., 203 Third Ave.
Hamilton, John W., 106 Pennsylvania Ave. W.
Hyer, Irving G., Clarendon.
Kelley, Ernest J., Oianglers Valley.
Kibler, Charles B., Corry (Erie Co.).
Knapp, Ralph, Youngsville.
MacDonald, Alden B., 220 Liberty St.
McKee, Edwin D., 220 Liberty St.
Mervine, Robert B., Sheffield.
Mitchell, Harry W., State Hospital for Insane.
Mitchell Mary P., State Hospital for Insane.
Noeson, Frank T., Bear Lake.
Paige, Laveme D., Spring Creek.
Phillips, Hubert J., Bear Lake.
Pryor, George T., Sheffield.
Robertson, William M., 418 Third Ave.
Russell, Hiram B., Sheffield.
Russell, John C, 207 Pennsylvania Ave. E.
Schmehl, Charles W., Warren Nat. Bank BIdg.
Schuler, Floyd G., Leonhart Block.
Shorkley, Thornton M., Tidwute.
Shortt, William H., Youngsville.
Smith, Monroe T., 507 Pennsylvania Ave. E.
Stewart, Paul B., 211J4 Market St.
Stewart, Richard B., 214 Liberty St.
VerMilyea, Charles H., Russell.
Weston, Paul G., State Hospital for Insane.
Young, Roy L., 306 Third Ave., Warren.
WASHINGTON COUNTY SOCIETY
(Organized May 19, 1R55.)
President. .
V.Pres.
Sec.-Treas.
Censors. . . .
Reporter.
Librarian.
Committee
..Charles L. Harsha, Canonsburg.
..Edgar M. Hazlett, Washington.
..Charles C. Cracraft, Qaysville.
..John N. Sprowls, Claysville.
Robert E. Conner, Hickory.
Boyd A. Emery, Eighty-four, R. D. 1.
.Homer P. Prowitt, Washington.
.Robert S. Stewart, Washington,
on Public Policy and Legislation;
George B. Woods, Washington Trust
Bldg., Washington.
William Douglass Martin, Dunn's station,
R. D. 2.
Albert E., Thompson. Washington.
Exec. Cx)m... Charles L. Harsha, Canonsburg.
Charles C. Cracraft, Qaysville.
Robert E. Conner, Hickory.
John N. Sprowls, Qaysville.
Boyd A. Emery, Eighty-four.
Official Publication: The Program.
Issued Monthly.
Editor : Charles C. Cracraft, Qaysville.
Stated meetings in rooms in New Armory BuilJing,
Washington, second Tuesday of each month except
July and August, at 2 p. m.
MEMBERS (125)
Alexander, William H., Canonsburg.
Bailey, Harry F., Monongahela.
Beveridge, David, Washington.
Booth, Alexander Nelson, Bentleyville.
Botkin, William Lester, Cokeburg.
Boyer, Samuel P., Finleyville.
Braden, LeRoy W., Ten Mile.
Burns, William James, 111 W. Chestnut St, Wash-
ington.
Gary, John Hersdiel, Prosperity.
Clark, Roy S., 141 W. Chestnut S., Washington.
Cobb, F. Floyd, Marianna.
Conger, George R., Taylorstown.
Connor, Robert Evert, Hickory.
Corwin, James H., Washington.
Cracraft, Charles Clinton, Claysville.
Cummings, Ralph E., Bentleyville.
Dague, Samuel N., Hbuston.
Davis, Alden O., Charleroi.
Day, Minor H., Donora.
Dickson, William R., McDonald.
Dodd, Cephas T., Washington, R. D. 6.
Donahoo, J. Frank, Washington.
Donaldson, Arthur Van E., Canonsburg.
Dunkle, Gaily Barr, Washington.
Edwards, David Henry, Washmgton.
Ellis, Edwin M., Ellsworth.
Emery, Boyd Alfred, Eighty-four, R. D. I.
Enos, J. Clive, Charleroi.
Faddis, Thomas M. C, CharleroL
Farquhar, John W., California.
Ferman, John W., Charleroi Bank Bldg., Charleroi.
Frantz, George B., Coal Center.
Furlong, R. Grant, Donora.
Gemmill, Walter D., Morganza.
Gormley, J. A., Canonsburg.
Graves, Charles T., Donora.
Haines, Dempsey D., AUenport.
Hanlon, Torrance J., Monongahela.
Harsha, Qiarles Lloyd, Canonsburg.
Hart, William Ernest, Washington.
Hays, George K., Monongahela.
Hazlett, Edgar Marion, Washington.
Hazlett, Esten L., c/o W. W. Thompson, Avella.
Hill, H. Hugh, 517 Fallowfield Ave., Charleroi.
Hindman, Audley O., Burgettstown.
Honesty, Leonard C, Washington.
Hook, John S., Bentleyville.
Hoon, LeRoy W., Monongahela.
Hunter, Joseph William, Charleroi.
Huston, Samuel W., Denbo.
Ildza, John W., Canonsburg.
Johnson, Elbin J., Claysville.
Johnston, John Alton, Canonsburg.
Kelso, John C, Canonsburg.
Kirchner, Louis F., Washington.
Knox, Frank L., Claysville.
Knox, John C, Washington.
Knox, Robert A., 104 W. Wheeling St., Washington.
Lacock, Horace Mortimer, West Finley.
Lamp, Clyde B., Courtney.
LaRoss, William A., McDonald.
Lewis, Orville Garrett, 315 E. Wheeling St., Washing-
ton.
Lewis, William H., Donora.
Linn, Charles Francis, Monongahela.
Livingston, Walter R., Ellsworth.
Lutz, Loyal G., Roscoe.
Lynch, Harry Pierce, 140 Main St., Monongahela.
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July, 1921
MEMBERSHIP LIST
777
McCarrell, David Leander, Hickory.
McCullough, Wm. John L., Slater Bldg., Washington.
McDonough, Oscar T., Washington.
McElroy, Joseph A., Hickory.
McKay, Edwin M., Charleroi.
McKee, George L., Burgettstown.
McKennan, James Wilson, Washington.
McMurray, John Boyd, Washington.
McNinch, James R., West Alexander.
MacKay, William H., Slovan.
Manning, Milton F., Beallsville.
Martin, William Clayton, California.
Martin, William Douglass, Dunn's Station, R. D. 2.
Maxwell, John Rali*, Washington.
Moore, Loyal H., Houston.
MuriAy, George H., Monongahela
Parry, Roger Sammons, 401 Washington Trust Bldg.,
Washington.
Patterson, Frank lams, 188 Duncan Ave., Washington.
Patterson, Guy Egbert, Washington.
Patterson, John A., Washington.
Pearce, Albert J. B., 407 Caldwell Ave., Wilmerding
• (Allegheny Co.).
Perkins, G. Alden, Burgettstown.
Prowitt, Homer Persell, Washington.
Ramsey, George W., Washington Trust Bldg., Wash-
ington.
Repman, Harry Joseph, Charleroi.
Reuben, Samuel A., Washington.
ReynoWs, John M. C, Washington.
Runion, A. LaGrand, Canonsburg.
Sargent, Larry Dodd, 6 S. Main St, Washington.
Scott, Stanley L., Roscoe.
Scott, William L., Joflfre.
Shannon, James H., Washington.
Shidler, Walter J., Houston.
Sickman, Albert S., Lock No. 4.
Snodgrass, Henry Lane, Buffalo.
Spahr, Robert A., West Brownsville.
Sprowls, Jesse Addison, Donora.
Sprowls, John Nelson, Qaysvillc.
Sprowls, William W., Houston.
Stahlman, Frederick C., Charleroi.
Stewart, Richard A., 26 E. Maiden St., Washington.
Stewart, Robert S., Washington.
Stewart, R. Vance, Monongahela.
Stunkard, Harry, Avella.
Swan, George, McDonald. ,
Teagarden, William David, Washington.
Thompson, Albert Ely, Washington.
Throckmorton, Charles Benton, Canonsburg.
Tibbons, Qyde E., Washington Trust Bldg., Wash-
ington.
Underwood, Frank H., Monongahela.
Vieslet, Victor P., Charleroi.
Wall, Porter M., Monongahela.
Weirich, Collin Reed, Washington.
Wilson, James E., Canonsburg.
Wilson, Thomas Dent Mutter, Washington.
Wolfe, Russell Wilson, Taylorstown.
Wood, Charles Bennett, Monongahela.
Woods, George Brown, Washington Trust Bldg.,
Washington.
WAYNE COUNTY SOCIETY
(Organized May 25, 1905.)
President... Alexander Marshall Cook, South Canaan.
1st V.Pres. .William T. McConvill, Honesdale.
2d V. Pres.. .William H. Tassell, White Mills.
Sec.-Treas... Edward O. Bang, South Canaan.
Censors Edward W. Bums, Honesdale.
Harry B. Ely, Honesdale.
Fred W. Powell, Honesdale.
Comniittee on Public Policy and Legislation:
Fred W. Powell, Honesdale.
Edward W. Bums, Honesdale.
Stated meetings held the third Thursday of May,
July, October and December at location decided on at
previous meeting. Annual meeting in December.
MEMBERS {J!3)
Baer, Jacob A., Honesdale.
Bang, Edward Otto, South Canaan.
Bang, Sarah Allen, South Canaan.
Bennett, John E., Starrucca.
Berlin, Allen A., Newfoundland.
Bums, Edward Ward, Honesdale.
Catterall, Alfred H., Hawley.
Cook, Alexander Marshall, South Canaan.
Corson, Charles G., Honesdale, R. D. 5.
Ely, Harry B., Honesdale.
Frisbie, Frank C, Equinunk.
Gavitte, Edward B., Lilly (Cambria Co.).
Lobb, Frederick A., Hawley.
McClellan, Henry Joseph, Callicoon, Sullivan Co., N. Y.
McConvill, William T., Honesdale.
Merriman, George C, Lake Como.
Miller, Edwin S., Pleasant Mount.
Nielsen, Louis B., Honesdale.
Noble, Homer C, Waymart.
Peterson, Pierson B., Honesdale.
Powell, Fred W., Honesdale.
Rodman, George T., Hawley.
Simons, Arthur J., Newfoundland.
Smith, Frank L, Shohola (Pike Co.)
Tassell, William H., White Mills.
Voight, Amo C, Hawley.
White, Harry Cummings, Ariel.
WESTMORELAND COUNTY SOCIETY
(Organized Nov. IS, 1859.)
President... D. Ray Murdock, Greensburg.
1st V.Pres.. Ida E. Blackbum, Greensburg.
2d V. Pres... D. Allison Walker, Southwest.
Sec.-Treas.. Myers W. Homer, Mount Pleasant.
Reporter James F. Trimble, Greensburg.
Censors Frank C. Katherman, Whitney.
R. E. Lee McCormick, Irwin.
Charles D. Ambrose, Ligonier.
Coimnittee on Public Health Legislation:
Charles E. Taylor, Irwin.
James P. Strickler, Scottdate.
Urban H. Reidt, Jeannette.
Exec. Com... D. Ray Murdock, Greensburg.
Ellsmer L. Piper, Export.
Myers W. Homer, Moimt Pleasant
Official Publication: Bulletin.
Issued Monthly.
Editor: Myers W. Homer, Mount Pleasant.
There shall be twelve meetings of the society, one
each monA. All will be held in Greensburg, in City
Hall, at 8 p. m., on the first Tuesday.
MEMBERS (148)
Abbaticchio, Nicholas, Latrobe.
Alexander, Ray M., Bolivar.
Anderson, John S., Greensburg.
Ankney, Edward G., Pleasant Unity.
Aspey, Lewis S., Smithton.
Bailey, Jean C, Greensburg.
Bailey, Louis J. C, Greensburg.
Baldwin, Clifford C., Forbes Road.
Barclay, Hugh Baily, Greensburg.
Barkley, John W., Ligonier.
Beacom, Albert A., Mammoth.
Bell, Winfield S., Youngstown.
Blackburn, Arthur B., Latrobe.
Blackburn, Ida E., Greensburg.
Boale, John A., Vandergrift Heights.
Bortz, Walter M., Greensburg.
Bowman, Greorge, Irwin.
Brisbine, John C, Cope Bldg., Greensburg.
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THE PENNSYLVANIA MEDICAL JOURNAL
July, 1921
Brown, Walter H., Youngwood.
Burkholder, John Lewis, 401 E. Washington St., Mount
Pleasant.
Byers, W. Craig, Webster.
Caldwell, John D., Irwin.
Carnahan, William J., 202 Washington St, Vander-
grift.
Caven, Alva H., Youngwood.
Clifford, Edward M., Greensburg.
Cochran, Albert M., Salina.
Cole, Thomas P., Greensburg.
Copeland, William A., Vandergrift.
Crawford, John S., Greensburg.
Crouse, Charles C, Greensburg.
Croushore, Charles C, Greensburg.
D'Alessio, Joseph, Monessen.
Day, Howard W., Monessen.
Dickson, George M., Adarasburg.
Doncaster, W. Trail, Fourth and Hullit Aves., Jeannette.
Dunlap, Eihe Belle, Ligonier.
Earnest, Simon Peter, Delmont.
Easter, Daniel M., Youngwood.
Emerson, Howard B., Yukon.
Fairing, John Walker, Greensburg.
Farquhar, David Clifford, Monessen.
Ferguson, Rutherford Hayes, Box 546, West Newton.
Fetter, William H., Scottdale.
Fichthom, Lewis L., Avonmore.
Gemmill, William P., Monessen.
Gilbert, Levi T., Scottdale.
Goble, Charles A., 413 Clay Ave., Jeannette.
Gray, Samuel Brown, Scottdale.
Greaves, John D., New Alexandria.
GrifKth, Martin E., Monessen.
Hamer, W. Irvine, Greensburg.
Haughwout, Bert, Derry.
Haymaker, William J., Export.
Highberger, Harry L., Madison.
Homer, Myers Worman, Mpunt Pleasant.
Hunter, Robert J., Greensburg.
Hunter, William D., Monessen.
Hutton, David S., Smithton.
Israel, Isaac Joseph, Monessen.
Jack, James Renwick, New Alexandria.
Johnson, J. Barton, Ligonier.
Jordan, David C, Derry.
Katherman, Frank C, Whitney.
Kepple, Adam S., Hannastown.
Kerr, Norman L., Scottdale.
Kimmel, Harry P., Derry.
Klingensmith, Thomas A., Jeannette.
Koegel, William F. H., Monessen.
Krebs, A. Bryan, Bolivar.
Kreger, Oliver J., Monessen.
Lawhead, James H., West Newton.
Leatherman, Daniel J., 215 Pennsylvania Ave., Greens-
burg.
Leatherman, Kate W., Greensburg.
Lemmon, James Quinn, Latrobe.
McAdoo, Elmer E., Ligonier.
McClellan, Robert P., Jr., Irwin.
McCormick, R. E. Lee, Irwin.
McDowell, William J., Scottdale.
McKee, Claude W., Greensburg.
McKinniss, Clyde R., Torrance P. O.
McMurray, H. Albert, Youngwood.
McNish, George T., 13 College Ave., Mount Pleasant.
Mason, John C, Rillton.
Marsh, Florence L., Mount Pleasant.
Marsh, William A., Mount Pleasant.
Mather, Homer R., Latrobe.
Megahan, Alvin Ray, Latrobe.
Miller, George W., Greensburg.
Miller, Wesley W., Jeannette.
Montgomery, Mary L., Mount Pleasant.
Moran, Thomas W., Latrobe.
Murdock, Dennis Ray, Greensburg.
Newill, Domer S., Donegal.
Ober, Bert Frank, Latrobe.
Ober, Irwin J., Greensburg.
Owaroflf, Abraham, Jeannette.
Painter, Theodore P., United.
Patton, James M., 147 Jeflferson Ave., Vandergrift
Peairs, William F., SutersviUe.
Pierce, Carl F., Greensburg.
Pile, Phillip S., Latrobe.
Piper, Ellsmer Landis, Export.
Pogue, Frank Milton, Trafford.
Portzer, Iden M., Greensburg.
Potts, William Joseph, Greensburg.
Prothero, Harold Mey, Jeannette.
Reese, Leroy J., Bolivar.
Reidt, Urban H., Jeannette.
Ringer, Josej^ H., Jeannette.
Robinson, John Q., Jr., West Newton.
Rugh, Carrol Bancroft, New Alexandria.
Rupert, David A., Webster.
St.- Clair, Thomas, Latrobe.
Sankey, Lee Monte, Jeannette.
Seaton, Charles F., Crab Tree.
Shepler, David R., West Newton.
Shirey, Charles A., Manor.
Silliman, James W., Bradenville.
Silsley, Nathaniel Eldridge, Scottdale.
Singer, John J., Greensburg. •
Skelley, Charles J., Irwin.
Skirpan, John M., Monessen.
Sloan, Charles M., Madison.
Sloterbeck, Edgar B., Monessen.
Smith, L. B. Raymond, Jeannette.
Smithgall, Melvin H., Export.
Snyder, Charles E., Greensburg.
Snyder, Oscar B., Greensburg.
Sowash, Joseph L., Irwin.
Speer, Ross H., Vandergrift.
Stahlman, JosejA C, Vandergrift.
Stauffer, Harry H., Jeannette.
Stockberger, Harry J., Slickville.
Strickler, Albert W., Scottdale.
Strickler, James P., Scottdale.
Taylor, Charles E., Irwin.
Taylor, William H., Irwin.
Tittle, Harry W., New Florence.
Waide, Arthur A., Scottdale.
Walker, D. Allison, Southwest.
Walker, Wilder J., Greensburg.
Watkins, Benjamin M., New Derry.
Watson, Joseph H., Jeannette.
Wilson, Arthur R., Monessen.
Wilson, Louis F., 215J/2 S. Main St, Greensburg.
Wilson, Robert L., Jeannette.
Wright, Samuel S., Pleasant Unity.
Wynn, Charles A., Greensburg.
WYOMING COUNTY SOCIETY
(Organized Aug. 11, 1903.)
President.. .Van C. Decker, Nicholson.
V. Pres George M. Harrison, Meshoppen.
Sec.-Treas.,
Rept Herbert L. McKown, Tunkhannock.
Censors William W. Lazarus, Tunkhannock^
William B. Beaumont, Laceyville.
Committee on Public Policy and Legislation :
George M. Kinner, North Mehoopany.
George H. Rauch, Noxen.
Annual meeting in Tunkhannock on the seconrf
Wednesday in January. Other meetings, not less than
two, to be held as determined by vote of the society.
MEMBERS (12)
Baird, Thompson M., 23 W. 43d St., New York Gtj.
c/o Federal Board of Vocational Education.
Beaumont, William B., Laceyville.
Digitized by VjOOQIC
JuiY, 1921
MEMBERSHIP LIST
779
Boston, Clarence L., Noxen.
Decker, Van C, Nicholson.
Diller, Warren L., Nicholson.
French, Kennard J., Factoryville.
Harrison, George M., Meshoppen.
Kinner, George M., North Mehoopany.
Lazarus, William W., Tunkhannock.
McKown, Herbert L., Tunkhannock.
Niles, Ralph M., Nicholson.
Ranch, George H., Noxen.
YORK COUNTY SOCIETY
(Organized May 11, 1873.)
(York is the post office when street address only is
given.)
President... Louis S. Weaver, 3 E. Market St.
1st V.Pres.. Brantley F. Parker, 3 E. Market St.
2d V. Pres... David E. Posey, Brogueville.
Sec.-Rept.... Gibson Smith, 222 S. George St.
Treasurer. . .Raymond E. Butz, 103 E. Market St.
Librarian. ..Wesley C. Stick, Hanover.
Trustees. .. .James C. May, 1207 N. (jeorge St.
Nathan C. Wallace, Dover.
Censors... Alfred A. Long, 34 S. Beaver St.
Samuel K. Pfaltzgraflf, 440 W. Market
St.
Lawton M. Hartman, 412 W. Market St.
Exec. Com.. Louis S. Weaver, 3 E. Market St.
Gibson Smith, 222 S. George St.
Charles H. May, 1207 N. George St.
Committee on Public Policy and Legislation :
Horace M. Alleman, Hanover.
Joseph H. Bittinger, Hanover.
Austin M. Grove, Lehmayer Bldg.
Official Publication: The Bulletin.
Issued Monthly.
Editor: H. Malcolm Reed, 535 W. Market St.
Stated meetings in York, in Colonial Hotel parlor,
first Thursday of each month at 1 p. m. Election of
officers in January.
MEMBERS (122)
Alleman, Horace M., Hanover.
Atkins, Joseph C, Red Lion.
Bacon, William F., 50 S. George St.
Bailey, Martha L., Dillsburg.
Baird, Homer Dale, 452 S. (jeorge St.
Barshinger, Martin L., 308 E. Market St.
Bennett, John H., 469 W. Market St.
Bittinger, Joseph H. Hanover.
Blanck, John K., Wrightsville.
Bobb, Arthur A., Spring Grove.
Bortner, Oayton E., Hanover.
Bowers, Stewart C, New Freedom.
Bowles, (Jeorge W., 112 W. King St.
Brodbeck, John R., (xidorus.
Butz, Raymond E., 103 E. Market St.
Comroe, Julius H., 259 S. George St.
Crawford, William L.. Dillsburg.
Danner, William D., Glenville.
DeHoflF. John E., 485 W. Market St.
Delle, Oscar A.. York. New Salem.
Dice, Laura J., 151 S. Oueen St.
Dunnick, J. Nelson, 200 E. Cottage Place.
Eisenhower, Charles W., 211 S. Oorge St.
Ellis, Robert L., York.
Ensminger. Samuel H.. 409 W. Market St.
Fackler, Lewis H.. 451 W. Market St.
Farkas. Herman H.. Hartman Bldg.
Frey. Clarence W.. Dallastown.
Gamble, Boyd E.. Manchester.
Gable, Isaac C, 46 S. Beaver St.
Gemmill. W. Frank. 135 E. Market St.
Gerry, Carl H.. Shrewsbury.
Gilbert, John, 373 W. Market St.
Gittens, William W., 307 E. King St.
Gress, Henry V., Manchester.
Gross, Jacob M., 706 W. Market St
Grove, Austm M., Lehmayer Bldg.
tiamyie, Curtis J., Dover.
Harbold, John T., Dallastown.
Hartman, Lawton M., 412 W. Market St.
Hetrick, Homer C, Lewisberry.
High, William B., 600 E. PhiUdelphia St.
iijhLe, .viartm. Spring Grove.
Holtzapple, George E., (jeorge and Princess Sts.
Hoover, Benjamin A., Wrightsville.
Horning, Frank, Hellam.
Howard, James H., 137 S. Beaver St.
Hyson, J. Miller, Red Lion.
Jamison, James L., Wrightsville.
Jessop, Roland, 500 W. Market St»
Jones, Harry H., 743 E. Market St.
Kain, John B.,-414 E. Market St.
Keagy, Charles A., Hanover.
King, Harry B., 257 E. Market St
Klinedinst, J. Ferdinand, 220 S. George St
Kohler, Horace W., Red Lion.
Krout, G. Elmer, Jacobus.
Landes, William L. S., 38 S. Penn St
Uu, Robert E., 627 W. Market St
Lawson, Thomas A., Dallastown.
Lecrone, Harris R., W. Market St
Long, Alfred A., 34 S. Beaver St
Long, W. Newton, 34 S. Beaver St
Lutz, Jeremiah F., Glen Rock.
McConkey, Frank Vance, 549 Madison Ave.
McDowell, S. Ira, (Jeorge and King St
May, (diaries H., 1207 N. (Jeorge St.
May, James C, 1207 N. George St.
Meisenhelder, Edmund W., Jr., 342 W. Market St
Meisenhelder, John E., Hanover.
Meisenhelder, Robert N., Hanover.
Melsheimer, John A., Hanover.
Miller, Joseph S., 3 E. Market St.
Neff, Charles C, 127 E. Market St.
Noll, Pius A., 117 S. George St
Overmiller, N. Allen, East Prospect
Parker, Brantley F., 3 E. Market St
Perry, (Jeorge R., Fawn Grove.
Pfaltzgraff, Samuel K., 440 W. Market St.
Posey, Benjamin F., Rupp Bldg.
Posey, David C, Brogueville.
Ramsey, R. Warren, Delta.
Rasin, Robert C, York.
Rea, Charles, 107 E. Market St.
Read, H. Malcolm, 535 W. Market St
Schellhamer, William H., 417 W. Market St
Seitz, Clyde Le Grande, Glen Rock.
Shatto, Arthur B., 220 S. George St
Shenberger, William J., Windsor.
Shirey, Bernard W., 136 E. Market St
Shower, John A., 105 S. Beaver St.
Sieling, Jacob H., New Freedom.
Small, J. Frank, 161 E. Market St.
Smith, Charles H., 507 W. Philadelphia St.
Smith, Gibson, 222 S. George St.
Smithson, William H., New Park.
Snyder, Francis J., 342 S. (Jeorge St
Spaeder, Philip J., 131 S. Beaver St.
Spahr, Charles E., 14 W. Market St.
Spangler, Charles C, 141 W. Market St
Spotz, G. Emanuel, HE. Market St
Stambaugh, Elmer S., 658 W. Market St.
Sterner, Lewis H., 230 York St., Hanover.
Stick, Edward W., Hanover.
Stick, Wesley C, Hanover.
Strack, David, 1508 W. Market St.
UflFelman, Harry W., Windsor.
Venus, Charles H., 817 E. Market St.
Wallace, Nathan C, Dover.
Weakley, William S., 117 E. Market St.
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THE PENNSYLVANIA MEDICAL JOURNAL
July, 1921
Weaver, Louis S., 3 E. Market St
Wentz, Alexander C, Hanover.
Wentz, Maurice C, Weiser Bldg.
Wentz, Parker N., 705 W. Princess St
Wertz, Theodore H., Hanover.
Williams, Louis V., 126 E. Philadelphia St
Wise, Francis Roman, 129 E. Market St
Wolf, Charles N., Hellam.
Yagle, George N., Red Lion.
Yagle, James L., New Freedom.
Zech, Harry W., 1100 W. Market St.
Ziegler, John S., Hanover.
LIST OF PRESIDENTS OF THE STATE
SOCIETY, 1848-1921
♦1848. Samuel Humes Lancaster Co.
*1849. Samuel Jackson Philadelphia Co.
*1850. WiLMER WoRTHiNCTON Chester Co.
*1851. Charles Innes. Northampton Co.
♦1852. Hiram Corson Montgomery Co.
♦1853. John P. Heister Berks Co.
♦1854. Jacob M. Gimmill Huntingdon Co.
♦1855. James S. Carpenter Schuylkill Co.
♦1856. Rene La Roche Philadelphia Co.
♦1857. John L. Atlee Lancaster Co.
. ^1858. Smith Cunningham Beaver Co.
♦1859. D. Francis Condie Philadelphia Co.
♦1860-61. Edward Wallace Berks Co.
♦1862. George F. Horton Bradford Co.
♦1863. Wilson Jewell Philadelohia Co.
♦1864. J. D. Ross Blair Co.
♦1865. William Anderson Indiana Co.
♦1866. James King Allegheny Co.
♦1867. Traill Green Northampton Co.
♦1868. John Curwen Dauphin Co.
♦1869. William M. Wallace Erie Co.
♦1870. Samuel D. Gross Philadelphia, Co.
♦1871. J. S. Crawford Lycoming Co.
♦1872. A. M. Pollock Allegheny Co.
♦1873. S. B. Kiefer Cumberland Co.
♦1874. Washington L. Atlee Philadelphia Co.
♦1875. Crawford Irwin Blair Co.
♦1876. Robert B. Mowry Alleghenv Co.
♦1877. D. Hayes Agnew PhiladeliAi'a Co.
♦1878. J. L. Stewart Erie Co.
♦1879. Andrew Nebinger Philadelphia Co.
♦1880. John T. Carpenter Schuylkill Co.
♦1881. Jacob L. Zeigler Lancaster Co.
♦1882. William Varian Crawford Co.
♦1883. Henry H. Smith Philadelphia Co.
♦1884. Ezra P. Allen Bradford Co.
♦1885. E. A. Wood Allegheny Co.
♦1886. Rees Davis Luzerne Co.
♦1887. Richard J. Lews Philadelphia Co.
♦1888-89. J. B. Murdoch Allegheny Co.
♦1890. Alexander Craig . .■ Lancaster Co.
♦1891. Samltel L. Kurtz Berks Co.
♦1892. Henry L. Orth Dauphin Co.
1893. H. G. McCormick Lycoming Co.
1894. John B. Roberts Philadelphia Co.
1895. William S. Foster Allegheny Co.
1896. E. E. Montgomery Philadelphia, Co.
♦1897. W. Murray Weidman Berks Co.
♦1898. Webster B. Lowman Cambria Co.
♦1899. George W. Guthrie Luzerne Co.
♦1900. Thom.\s D. Davis Allegheny Co.
♦1901. Francis P. Ball Clinton Co.
♦1902. William M. Welch Philadelphia, Pa.
♦1903. William B. Ulrich Delaware Co.
1904. Adolph Koenig Allegheny Co.
1905. William H. Hartzell. Lehigh Co.
1906. Isaac C. Gable .' York Co.
1907. William L. Estes.. ..Northampton Co.
♦1908. George W.. Wagoner Cambria Co.
1909. Theodore B. Appel Lancaster Co.
♦1910. John B. Donaldson Washington Co.
♦1911. James Tyson Philadelphia Co.
1912. Lewis H. Taylor Luzerne Co.
1913-14. Edward B. Heckel Allegheny Co.
1915. John B. McAlister Dauphin Co.
1916. Charles A. E. Codman Philadelphia Co.
♦1917. Samuel G. Dixon Philadelphia Co.
1917. Walter F. Donaldson Allegheny Co.
1918. Frederick L. Van Sickle Lackawanna Co.
1919. Cyrus Lee Stevens Bradford Co
1920. Henry D. Jump Philadelphia Co.
1921. Frank G. Hastman Lancaster Co.
♦Deceased.
IN MEMORIAM
The following resolutions on the death of Dr.
Oscar H. Allis were adopted by the Montgomery
County Medical Society, at their meeting held at
Montgomery Hospital, Norristown, Pa., on June the
first:
On May i6, 1921, death removed our honorary
member. Dr. Oscar H. Allis, of 1604 Spruce Street,
Philadelphia. He was a close student and a very orig-
inal thinker. He graduated from Lafayette College
in 1864, and from Jefferson Medical in 1866. A few
years ago he received the degree of LL.D. from La-
fayette, and later the same from Temple University
of Philadelphia. He was the first surgeon of the
Presbyterian Hospital. He was recognized as one of
the greatest of orthopedic surgeons. He was for a
number of years surgeon at the Jefferson Hospital,
consulting surgeon to the Roosevelt and the Ameri-
can Oncologic Hospitals. He was a recognized au-
thority on dislocations and was the recipient of the
Gross prize in 1895 for a treatise on dislocations of
the hip. This little book is now accepted as a stand-
ard authority in affections of that joint. He has now
in the hands of the publishers a work on scoliosis.
At the time of his death he was busy gathering mate-
rial to refute the statement by Dr. Ashurst that the
deformity to the elbow joint caused by the angular
splint did not in any way interfere with the useful-
ness of the arm. He was a member of the A. M. A,
the State Medical Society, an honorary member of the
Montgomery County Medical Society, and a fellow of
the American Surgical Association. Dr. Allis was the
Mutter lecturer at the College of Physicians in 1903
and the Lane lecturer at Cooper Medical College, San
Francisco. He was a member of the Second Presbyte-
rian church of Philadelphia and for many years su-
perintendent of the Sabbath school.
Resolved, That we, the Montgomery County Medi-
cal Society hereby record our appreciation of Dr.
Allis as a scholar, a surgeon, and a Christian gentle-
man; that we extend our sympathy to his family;
that these resolutions be spread upon our minutes,
published in our Medical Bulletin, and that a copy be
sent to his son and daughter.
Committee,
Wm. McKenzie,
J. Newton Hunsbesger,
E. S. Buyers,
Herbert A. Bostock,
Wm. G. Miller.
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The Pennsylvania Medical Journal
Owned, Controlled and Published by the Medical Society of the Sute of Pennsylvania
Issued monthly under the supervision of the Publication Committee
Volume XXIV
NUHBBR II
August, 1921
Subscriptiom:
$3.00 Pea Yka*
ORIGINAL ARTICLES
CANCER OF THE BREAST WITH A
STUDY OF THE RESULTS OB-
TAINED IN 218 CASES*
W. E. SISTRUNK, M.p.
MAYO CI,IN1C, ROCHESTER, MINNESOTA
I have recently made a detailed study of the
histories of 246 patients operated on for cancer
of the breast in the Mayo Clinic during the
years 191 1, 1912 and 1913. I was very fortu-
nate in having at my disposal for this study de-
tailed histories, complete pathological reports
and good descriptions of the operative proce-
dures. After much effort we were able to se-
cure fairly accurate data as to the results ob-
tained in 218 of these 246 patients. On account
of the large number traced it was thought best
to use only these in the study made. This
paper, therefore, is based upon the results ob-
tained in 218 consecutive cases in which pri-
mary radical amputations for cancer of the
breast had been performed from five to eight
years previously and. who recently had been
traced.
One could not help being impressed in mak-
ing this study with the feeling that little more
can be expected, as far as results are concerned,
through a change in the operative technique
used at present for this condition. The recur-
rences were found to occur largely in late cases
and evidently came because cancerous tissue
was left in regions inaccessible to the knife,
while the highest percentage of cures and the
infrequent recurrences occurred in patients
operated on early in the course of the disease
before glandular involvement could be demon-
strated. The end results obtained are probably
better than those obtained from operations in
any other type of cancer with the exception of
•the basal celled epitheliomas of the skin and
cancers of the lip.
Only a comparatively short time has elapsed
since surgeons looked upon cancer of the breast
in a most pessimistic way. Practically all per-
*Read before the Section on Surgery of the Medical Socie^
o{ the State ot Pennsylvania, Pittsburgh Session, October 6,
1920.
sons who developed the condition died and it
was very generally believed that the condition
was a systemic instead of a local disease. Too
much credit cannot be given to the surgeons
who have contributed toward the perfection of
the operation as it is now generally performed,
and have made it possible by surgery to achieve
such results as those now obtained in a former-
ly almost hopeless condition. When the public ■
is better educated as to the necessity of seeking
surgical aid early for all breast tumors and
when it is generally recognized by the entire
medical and surgical profession that the day of
watching breast tumors is past, it seems Hkely
that as high as 75 or 80 per cent, of cancers of
the breast should obtain five to eight-year cures.
The operation as now done is based largely
upon a knowledge of the lymphatic supply of
the br£ast. Without going into detail, the fol-
lowing may be said regarding this distribution :
The lymphatics draining the breast largely ac-
companying the blood vessels and may be ex-
pected to be found along the course of the large
vessels supplying the breast. The lymphatic
drainage empties largely into the subscapular
group of lymphatics, the group of lymphatics
lying along the axillary vein, and those accom-
panying the vessels which perforate the chest
wall (branches of the internal mammary and
intercostal arteries). Investigators have also
been able to prove the presence of lymphatic
vessels which drain from the upper, inner quad-
rant of the breast directly into the supraclavicu-
lar region, of vessels which drain from the
lower inner quadrant of each breast into the op-
posite axilla and of vessels which pass down to
the epigastric region and thence into the ab-
dominal cavity along the round ligament of the
liver. It does not seem practical to remove the
supraclavicular glands in all patients operated
on for cancer of the breast and it is doubtful
that much good would be accomplished by such
a procedure. It is also impossible to remove all
of the lymphatics accompanying the perforating
branches of the internal mammary and inter-
costal arteries. Recurrences in the opposite
axilla, except in advanced cases, are extremely
rare and when seen are probably due to the fact
that a recurrence has occurred which has 1
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m
THE PENNSYLVANIA MEDICAL JOURNAL
August, 1921
drained into this axilla. For these reasons
operative measures are necessarily largely lim-
ited to the wide removal of the skin, subcutane-
ous fat, superficial and deep fascias and the sub-
scapular and axillary lymphatics, the other tis-
sues which it would be of advantage to remove
being beyond the scope of surgery. When com-
plete axillary dissections are made, even in in-
stances where these glands are involved, recur-
rences seldom occur in the axilla. In the series
studied local recurrences are known to have oc-
curred in only 10.5% of the patients in whom
no glandular involvement could be demon-
strated at the time of operation. In 46 cases in
which local recurrences occurred the glands
were involved at the time of operation in 80.4%
of the cases, which tends to show that it is in
the late cases that local recurrences are likely to
come.
The operation which was performed in this
series of cases was of the type usually done for
cancer of the breast. A wide removal of the
skin and subcutaneous fat is made and both
pectoral muscles are removed. An extensive
dissection of the subscapular and axillary lym-
phatics is made, removing also the glands and
fascia from the infraclavicular triangles. A
portion of the fascia covering the upper portion
of the rectus muscle is also removed. A skin
incision, which is a slight modification of the
Rodman incision, is used and in practically all
instances it is possible to unite the skin edges.
The function of the arm following such opera-
tions is almost perfect. It seems to be impaired
only in those patients who are timid and who
fail on account of pain and discomfort to sys-
■ tematically work the shoulder joint following
operation. The scar following such an incision
lies above the axilla so no pain occurs in the
axilla following operation.
The results obtained and the deductions made
from these will be discussed under the follow-
ing headings :
Glandular Involvement. — The axillary glands
were found to be involved in 60.5% of the cases,
a fact well worth noting because it clearly dem-
onstrates that the majority of patients with
cancer of the breast come to operation in what
might be called a late stage of the disease. In
8fi patients operated on before the glands were
involved 64% are alive from five to eight years
after operation, with known recurrences in only
six of these patients who are alive. In 132 pa-
tients in whom the glands were found to be
involved at the time of operation, 19% are alive
from five to eight years after operation, and
three of these are known to have recurrences at
the present time. When the 218 patients are
studied collectively, without reference to gland-
ular involvement, 36.7% are alive from five to
eight years after operation, with known recur-
rences in nine of the patients who are alive at
the present time. The difference in the per-
centage of five to eight-year cures in patients
operated on with glandular involvement and
those operated on before the glands were in-
volved is striking, 19 in the former and 64 in
the latter. The involvement or non-involve-
ment of the glands seems to be the greatest
factor in the prognosis following operation.
In studying the eflfect of glandular involve-
ment upon the prognosis, a very interesting fact
was noted which allows one to determine quite
accurately at the time of operation the niunber
of patients.who will be likely to die within eight
years and those who will be likely to live eight
years ; that is, it was found that a death may be
expected to occur within eight years for each
patient who has the glands involved at the time
of operation. While this rule is not absolute it
was found to be so nearly true in studying the
prognosis from so many standpoints when the
question of glandular involvement was consid-
ered as to make it a good and fairly accurate
working rule. For instance, the glands were
found to be involved in 60.5% of our patients,
and 63.3% are dead ; the glands were not in-
volved in 39.5% of the patients and 3,6.7% are
alive. In 86 patients of the entire series no
glandular involvement could be demonstrated,
and 80 patients of the entire series are alive.
The glands were found to be involved in 132
patients and there were t38 deaths in the series.
From almost any standpoint that this rule was
applied it was found to be correct within a very
small per cent. Not that all of the patients
with glandular involvement die, but the number
who die when the glands are not involved at
the time of operation seems to very closely
equalize the number who live when the glands
are found to be involved.
Sex. — :A11 of the patients comprising this
series were females, so it was impossible to
make any comparison of the prognosis in the
two sexes.
Age. — The highest percentage of deaths oc-
curred in the youngest and oldest groups of pa-
tients, but in this series of cases the glands were
involved in from 70 to 75 per cent, of these
cases and it is probable that this and not the
age accounts for the high mortality in these
groups. One hundred and eight of the patients
were over 50 years of age and no were under
50. Forty-one and seven-tenth per cent, of the
patients over 50 were alive from five to eight
years following operation, while only 30.9% of
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August, 1921
CANCER OF THE BREAST— SISTRUNK
783
the patients under 50 were alive for a corre-
sponding length of time. Nearly twice as many
of the patients over 50 who had glands involved
at the time of operation were alive as compared
with the similar patients under 50 (25.4% and
13.1% respectively). The percentage of chance
for cure seems definitely higher in patients over
50. Whether this was due to the age or to the
cessation of menstruation in this group could
not be determined, as almost similar findings
were present in the women past the menopause
w^hen compared with those who were still men-
struating. The highest percentage of cures oc-
curred in the patients between 50 and 60 years ;
28.6% of this group who had glands involved
being alive from five to eight years after opera-
tion, while only 19% of the entire series who
had glandular involvement were alive for this
period of time. Seventy-one per cent, of those
between 50 and 60 without glandular involve-
ment were alive five to eight years after opera-
tion and only 64% of similar patients in the
entire series were alive for a similar length of
time. The glands also were found to be in-
volved in only 47.4% of the patients from 50 to
60, while they were involved in 60.5% of the
patients of the entire series. From every stand-
point the prognosis is better in this group of
patients comprising 59 cases between the ages
of 50 and 60.
Menstruation. — One hundred and eleven pa-
tients of the series had passed the menopause,
while 107 were still menstruating at the time of
operation. There was very little difference in
the percentage of cures in these two groups,
38.7% of those past the menopause and 34.6%
of those still menstruating being alive from five
to eight years after operation. On the other
hand, twice as many of the patients who had
glands involved at the time of operation and
who had passed the menopause were alive from
five to eight years after operation as compared
with similar patients who were still menstruat-
ing (24.6% and 12.7%). As mentioned above,
it is impossible to state whether this difference
was due to the age or to the cessation of men-
struation.
Child-B earing. — Fifty- five (55) of the pa-
tients had never borne children, while 157 had
borne one or more children. Forty-three and
six-tenth percent, of those who had not
borne children were alive from five to eight
years after operation while only 35% of the pa-
tients who had borne children were alive, and
when the glands were not involved in these
groups, 75% of those who had not borne chil-
dren were alive while only 58.3'^> of those who
had borne children were alive from five to eight
years after operation. The glands were found
to be involved slightly more frequently in pa-
tients who had borne children than in those who
had not. It would seem from these findings
that the bearing of children and the subsequent
lactating period probably increases the lym-
phatic supply of the breasts and that the prog-
nosis in such women is more unfavorable than
that in women who have not borne children.
Pregnancy. — In two patients the carcinoma
was present during pregnancy. The mortality
was found to be 100% in this group, one of the
patients having lived two years and the other
five years after operation.
Lactating Breasts. — In four patients a carci-
noma was found in a lactating breast. All four
of these are dead, although the glands were in-
volved in only 50%. They lived one, two, three
and five years respectively. The mortality in
this group was loo^o.
Ulcerating Growths. — In 20 patients ulcerat-
ing carcinomas were found at the time of opera-
tion. Of course, these were extremely late
cases. The glands were involved in 90% of
these and 85% are dead, the prognosis being ex-
tremely bad in this group of patients.
Location of the Growth. — The growth was
found to be located in the upper and outer
halves over twice as often as in the lower and
inner halves of the breast, 46.8% being located in
the upper half, 45.8% in the outer half, 20.7% in
the lower half and 17.4% in the inner half. The
mortality was highest when the growths were
lotated in the lower inner quadrant and the
H jhest percentage of cures was found when the
g. owth was located in the upper inner quad-
riint. When diffuse growths were present, that
is, growths involving almost the entire breast,
the glands were found to be involved in 93.7%
of the patients at the time of operation and at
the present time all of these are dead, the mor-
tality having been 100% in the diffuse type or
the type which apparently develops on a pre-
existing diffuse mastitis. When the growths
were centrally located, that is, around the nip-
ple, the glands were found to be involved in
69.2% of the patients and at the present time
94.4% of these patients are dead. However,
when the glands were not involved in the cen-
trally located tumors, 75% were alive from five
to eight years after operation.
Attachment of the Growth to the Skin. — In
38.5% of the 218 cases the growth was noted as
being attached to the skin. The glands were in-
volved in only 53.6% of these and 30% of those
in whom the glands were involved are alive
from five to eight years after operation. When
the growth was not attached to the skin the
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784
THE PENNSYLVANIA MEDICAL JOURNAL
August, 1921
glands were found to be involved in 6i.8% of
no cases and only 16.2% of these patients are
alive. The prognosis seemed better in this
series when the growth was attached to the skin.
In such cases the growth is usually found in the
.superficial portion of the breast. Such growths
attract attention earlier and earlier operation is
sought. When the growth is not attached to the
skin it is probably deeply placed and often not
recognized until the glands are involved. Then
too, the lymphatic drainage from the deeper
portions of the breast is probably more active
than that in the periphery.
Location of Recurrences. — In 97 patients we
have a fair idea as to the location of the recur-
rences. The glands were involved in 75.2% of
these 97 patients. In the 97 patients recur-
rences had occurred locally, that is, around the
region of the operative scar, or locally and in
some other region at the same time in 47.4%.
The glands were involved at the time of opera-
tion in 80.4% of the patients in whom local re-
currences had occurred, a fact which would
tend to show that local recurrences are to be
expected largely in the late cases. One hundred
and thirty-two patients had involvement of the
glands at the time of operation and local recur-
rences are known to have occurred in 37 of
these, showing that local recurrences may be
expected in at least 28% of the patients who
have glandular involvement at the time of
operation. In 86 patients no glandular involve-
ment was demonstrated at the time of operation
and local recurrences are known to have oc-
curred in nine of these, so local recurrences may
be expected in at least 10.5% of the patients
without glandular involvement at the time of
operation. Evidences of metastases in other
regions at the time that the local recurrence was
noted were present in all except 18 of the pa-
tients where local recurrences occurred. This
would tend to show that when a local recur-
(cnce occurs, metastases in other regions are to
be expected in the majority of patients.
In 21 of the 97 patients in whom the location
of the recurrence was known there were chest
metastases (either in the lung, pleura or medi-
astinum). The glands were involved in 71.4%
of these. This would tend to show that chest
metastases may be expected to occur in at least
9.6% of the breast cases who are opeirated upon
for cancer. The glands were not involved as
often in the patients who developed chest me-
tastases as in those in whom local recurrences
had occurred, the malignancy in the former
cases probably having entered the chest through
the lymphatics accompanying the perforating
branches of the internal mammary and inter-
costal vessels.
In 17 of the 97 patients recurrences occurred
in the bones, 14 of these being in the spine and
3 in the femur. The glands were involved in
only 64.7% of these cases. This would tend to
show that bone metastases may be expected to
occur in at least 7.870 of the patients operated
on for cancer of the breast and that recurrences
may be expected to occur in the spine in at
least 6.4% of the patients operated on. In 11
instances intra-abdominal metastases were pres-
ent, a fact showing, that recurrences may be
expected to occur in the abdominal cavity in at
least 5% of the patients operated upon for can-
cer of the breast. The glands were involved in
81.8% of these. In 3 instances brain metastases
were found. The glands were involved in only
33-3% of these. Brain metastases may, there-
fore, be expected to occur in at least 14% of
the total number of breast cases operated on for
cancer. In 6 instances the condition had re-
curred in the other breast. It was impossible to
say whether these recurrences were direct me-
tastases or whether a primary carcinoma had
developed in the other breast.
Primary Mortality. — Only one patient in the
series studied died before leaving the hospital,
making an immediate mortality of .4% In
this case death occurred ten days post-operative
from pneumonia and nephritis.
Cause of Death in the Dead. — Of the 138 pa-
tients known to be dead, 104 are known to have
died from recurrence of the cancer; in 23 we
have no knowledge as to the cause of death nor
as to whether there was a recurrence of the
cancer; in ii instances the cause of death was
supposed to be from disease other than cancer.
Duration of Life in Patients Knorvn to bt
Dead. — Of the 218 patients studied, six or 2.7^
died within six months following operation. By
the end of the first year 21.1% were dead,
34.9% per cent, were deat at the end of two
years, 42.4% at the end of three years, 49.1%
at the end of four years and 55% at the end of
five years, 2.3% only died after five years. In
thirteen instances or 5.9% the time of death
could not be ascertained.
Three-Year Cures. — It seems to be generally
recognized at the present time that freedom
from a recurrence for three years does not con-
stitute a cure. Five years freedom from recur-
rence oflFers a much better chance for cure. In
the series studied only 2.3% of the 218 patients
died after five years. It was found that at the
end of three years 48 or 36.3% of the 132 pa-
tients who had the glands involved at the time
of operation were alive and that 65 or 75.6%
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August, 1921
CANCER OF THE BREAST— DISCUSSION
785
of the 86 patients without glandular involve-
ment at the time of operation were alive. When
considered without reference to glandular in-
volvement, 113 or 51.8% of the 218 patients
were alive at the end of three years. Some of
these patients had recurrences at this time and
later died.
Five-Year Cures. — At the end of five years
29 or 22% of the 132 patients in whom glandu-
lar involvement was demonstrated at the time
of operation were found to be alive, and of the
86 patients in whom the glands were not in-
volved at the time of operation, 56 or 65.1%
were alive. When considered without refer-
ence to glandular involvement, 85 of the 218
patients or 39% were found to be alive at the
end of five years. The percentage of five to
eight-year cures obtained in this series when the
group was studied collectively without reference
to glandular involvement is almost identical
with that obtained in a previous group of 510
cases reported by Judd and me in 1914 — 39.8%
of five-year cures — and no doubt is a very fair
estimate of the cures to be expected five years
after operation.
Simple Amputations of the Breast. — In the
group of breast cases studied there were six pa-
tients in whom a simple amputation of the
breast was done for supposed mastitis, in whom
the condition was later reported by the patholo-
gists as being early cancer. In these patients a
radical amputation was never done. We have
been able to trace five of the six. One is alive
eight years after operation, two are alive seven
years after operation and one is alive six years
after operation. One died four years after
operation, but we were unable to ascertain the
cause of death. The other patient of these six
was alive and without recurrence when last
heard from two years after operation.
The patients mentioned in this group were
not included in the 218 cases reported in this
paper on account of the fact that radical ampu-
tations were not done. This group, however,
shows the excellent results which may be ob-
tained when even incomplete operations are per-
formed during the early stages of the disease,
66.7% of the group being known to be alive and
without recurrence from six to eight years after
operation, with a possibility of another of the
group still being alive.
Removal of Tumor for Diagnosis Before
Doing a Radical Operation. — In five patients in
the series the original tumor had been removed
from two days to two months before operation,
and in another patient an abscess had been
drained and a .specimen removed for diagnosis
1 1 days before the radical amputation was per-
formed. Four of these six patients — 66.7% —
are known to be alive from five to eight years
after operation. In four other instances men-
tion was made of the fact that the tumor was
removed for microscopical diagnosis and that a
radical amputation was done immediately after
the condition was recognized as being malig-
nant. Three of these patients — 75% — are liv-
ing and without recurrence from five to eight
years after operation. The other patient is
dead. The carcinoma in this instance, however,
was diffuse in character and was cut into during
the removal of the tumor for diagnosis. The
mortality in the diffuse type of cancer, as men-
tioned above, has been 100%. These cases
would tend to show that removal of the tumor
for diagnosis, provided the tumor is not cut into
during its removal, followed by a radical am-
putation later, does not necessarily give a bad
prognosis.
DISCUSSION
Dr. Moses Behrend (Philadelphia) : I did not
want to be the one to open this discussion, but the
subject is one of such tremendous importance that I
feel it is only right and proper that someone should
start the discussion. The little (hat I can give has
really been said by Dr. Sistrunk and the paper has
been so thorough that really very little can be added;
but this is characteristic of all work that comes from
Rochester and Dr. Sistrunk's paper is no exception to
this rule. Statistics of this sort are worth while and
if all of us would tabulate operations and results of
operations as Dr. Sistrunk has done, we should be
very much the wiser. His results are remarkable be-
cause he does such a thorough operation. The last
picture on the screen shows the character of the work
that he is doing. In order to get results it is abso-
lutely essential to clear out all diseased tissue and it
is of special importance to clear out the glands that
one (eels and sees. I think his admonitions regarding
the glands o( the axilla are probably the most im-
portant thing he stated here this afternoon (or he has
shown that i( the glands are involved the case is much
more lethal in character than if they are not involved.
This leads me to ask whether all of these cases where
the glands were not involved, showed, on histological
study, that they were cases of cancer of the breast?
I feel that we are possibly becoming a little bit too
radical in some instances and Dr. Sistrunk has thrown
out a little suggestion that I have followed. First
remove the tumor ; note whether these tumors are
malignant; if they are perform the radical operation.
One must not be too positive that simply because he
does not feel-any glands in the axilla that the glands
in the axilla are not enlarged. I feel we have sacri-
ficed a great many breasts that should not have been
removed, but these things cannot be helped because
they were done to the best of our ability and the best
o( our judgment. The incision that Dr. Sistrunk uses
is a very good one, although I have never used it. I
still stick to the incision made and advocated by Dr.
Rodman. This is a little variation (rom that, but they
all the modifications o( the incision as performed by
Warren. The Rodman incision will lead you down to
the axilla at once. The most important point in the
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786
THE PENNSYLVANIA MEDICAL JOURNAL
August, 1921
performance of the radical operation is not to en-
croch too mtich on the arm and axilla.
Dr. Donald Cuthrie (Sayre) : 1 should not per-
sume for a moment to add anything to this very ex-
cellent paper of Dr. Sistrunk's, but a few of his con-
clusions I think should be emphasized. His statistics
show a marked difference between the number of pa-
tients who remain well without axillary involvement
as compared with the number who had axillary in-
volvement at the time of the operation. Our cases of
breast tumor should be gotten to the surgeon earlier,
and in the nation wide cancer campaig^n directed by
the American Society for the Control of Cancer it
seems that we should lay special stress upon the im-
portance of early surgical treatment of tumors when
we talk to the laity and to the profession. Dr. Sis-
trunk showed that the three and five-year periods of
safety which were formerly thought to be the time
sufficient after operation for a cure are really not
long enough. I wish to report a sad case of recur-
rence in one of my patients seven years after opera-
tion in whom the supraclavicular glands on both sides
became involved. The importance of giving x-ray
treatments to these patients after operation should be
emphasized. Dr. Wainwright, of Scrantpn, has made
a valuable suggestion of applying x-rays to the wound
at the time of operation before the skin flaps are
closed. X-ray men tell us that the skin filters out
many of the rays and it seems to me that a valuable
way to attack cancer cells is at the time of operation
before the skin flaps are closed.
Dr. Sistrunk (in closing) : I wish to thank Doctor
Guthrie and Doctor Behrend for so kindly discussing
this paper. I have been very much interested in what
they have said. In regard to Doctor Behrend's ques-
tion as to the pathology : all of these were absolutely
proved cases of carcinoma. During those years 246
patients were operated on for cancer of the breast.
We discarded from. the series cases operated on for
recurrent growths and those in which partial or in-
complete operations were done, and we also discarded
about half a dozen cases where there was some ques-
tion as to whether or not malignancy was present —
the pathologist in these cases having diagnosed the
condition as early carcinoma with a question mark.
All the patients who had complete primary operations,
regardless of the stage of the disease, were included
in the group studied. The study was made in an ef-
fort to learn just what might be expected from pri-
mary operation for cancer of the breast. Doctor
I'.ehrer.d has asked about the glands in the axilla : I
think that in many instances it is impossible to palpate
involved glands. I believe the glands usually felt are
those lying along the subscapular vessels. It is hard
to feel involved glands which lie high in the axilla.
I was interested in Doctor Guthrie's remarks re-
garding the x-ray and the preliminary treatment of
these cases with x-rays. 1 believe it is an excellent
preoperative measure. After hearing Doctor Clark's
I)aper here to-day I feel that it would be a very good
plan to treat all cases with heavy doses of radium or
x-ray before as well as after operation. I recently
had an interesting case in this connection: a young
woman, thirty-four years old, with extensive cancer
of the cervix. On account of her age I removed a
specimen with the cautery to make sure of the diag-
nosis. The specimen removed proved to be a very
active epithelioma. Because she was so young I had
her treated with radium just as if I were never going
to operate. She received three or four treatments with
large doses of radium during a period of about three
weeks time. She was then sent to the hospital and a
extensive hysterectomy was done. The operation wis 2
very easy one on account of the almost conipkte ab-
sence of oozing due to the effect of the radium u^
the small blood vessels. The pathologists were mob';
to demonstrate malignancy in any of the tissue n-
moved at operation. I think Doctor Clark's paper m:
Doctor Guthrie's remarks in regard to the use o;
radium are certainly worthy of careful consideratio:.
BUBONIC PLAGUE: ITS FREVALENXE
IN THE UNITED STATES AND HOW
THE DANGER SHOULD BE MET*
EDWARD B. KRUMBHAAR, M.D.
PHIl^DELPHIA
To the average doctor "bubonic plague" re-
calls indistinct memories of the Black Death oi
the fourteenth century, De Foe's account of th
Plague of London in 1665, perhaps Thucydid^
description of the Plague of Athens durii^ tk
Peloponnesian War, or Biblical references ic
sudden death amid a plague of rats and similar
"far off things of long ago." Little does k
realize that for the past 26 years practically the
whole world has been suffering from a pan-
demic that has caused literally millions of death-
and will undoubtedly take rank in histor)' wit!:
the devastations previously referred to. Ina.-
much as the U. S. Public Health Service is con-
fident that this country will continue to be ex-
posed to the introduction of epidemics for ai
least another 50 years, a closer view of the pres-
ent pandemic becomes highly advisable.
From the fourteenth to the seventeenth cen-
turies the civilized world was frequently visitK
with epidemics of the plague of greater or le<<
severity, but since that time the infection has
remained relatively quiescent in endemic foci
in Asia with occasional outbreaks in Europe as
late as 1870. In 1894, a plague epideniK:
reached "dangerous proportions" in Canton and
Hong Kong, although sporadic cases had been
known in various locations in southern China
for at least 25 years before that. With a tola!
of several thousand deaths in Hong Kong ami
a weekly mortality in Canton that was measured
in the thousands.^ the epidemic was soon car
ried by shipping to Bombay and Calcutta.
whence it spread overland in truly appalhn?
proportions and its ravages have continued
throughout India until the present day. Ac-
cording to Sir Bromwell Leslie,t the total num-
•Read before the Section on Medicine of the "ediolj^
cicty of the St»te of Pennsylvania, Pituburgh Seuion. Ortiw'
6. 1020. , ^ -,»
JThis epidemic was also noteworthy not only for t«t '^
lomary observation of a KTcat coincident mortality """'?:(
l>Mt also for Kitasato's discovery of B. Pestis in iJM, •" ""
the flea transmission of the infection by Oiata in 1890.
tReport of Board of Health on Plague in New Sootk ""'
in 1907, p. 53, Sydney, 1908.
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August, 1921
BUBONIC PLAGUE— KRUMBHAAR
787
ber of deaths in the Punjab alone for the first
half of 1907 was not less than a half million, so
that the estimate of over a million deaths in
Jndia during the present pandemic may be con-
sidered conservative. With India and China as
the chief endemic foci, plague has spread
throughout the civilized world, so that epidemics
or sporadic cases have been observed in the
past decade in practically every country of
Europe and America. In Manchuria, starting
from the marmot, human cases became infected
with the pneumonic type of plague, which
spread so rapidly along the railroads and other
inland lines of communication that in 10 weeks
there were over 50,000 deaths. This epidemic
is of particular interest to us in the northern
states as an example of the pneumonic type of
plague that is especially prone to attack colder
regions, and also as a demonstration of the pos-
sibilities of overland transmission of this dread
disease. In this epidemic, as is usual in pneu-
monic plagiie, the mortality was practically
100%. Our own plague experiences from 1907
to 1914 in Porto Rico, Havana, New Orleans,
Seattle and San Francisco are, I hope, sufficient-
ly familiar to you to render further comment un-
necessary, but perhaps it is not so widely known
that in the past year separate outbreaks that
total in the hundreds have occurred in Mexico,
Paris, Fiume, and our own Gulf States.
In Seattle and San Francisco, due to the en-
ergetic action of the U. S. Public Health Serv-
ice, cooperating with the local authorities,
plague has apparently been eradicated from hu-
man and rat population, although in California
it was found among rats at least eight months
after the last human case and has become en-
demic and apparently ineradicable among tlie
ground squirrels. In New Orleans, the epi-
demic was found persisting among rats eleven
months after the last human case, and in spite
of the continuance of anti-plague measures,
human plague broke out again in that city last
October, after an apparent freedom of over two
years. In spite of anti-plague measures of the
most approved type, human cases are still oc-
curring there, and it is not perhaps an exag-
geration to state that the situation was brought
under control within two months and any note-
worthy spread of the infection prevented largely
by means of the rat proofing measures that had
been accomplished there in the previous six
years. Since October 16 human cases have oc-
curred with six deaths. During the same period
over 300,000 rats have been trapped and ex-
amined and about 600 found to be infected with
plague. And all this in spite of the fact that
several million dollars had been spent in rat
proofing most of the city and all but five of the
live miles of river docks.
In Galveston, the first case of plague was rec-
ognized on June 6th of this year, since which
time there have occurred 12 cases with nine
deaths. In Beaumont, Texas, the first human
case was observed on June 26th, since which
time there have been 12 cases with five deaths.
Although the source of these epidemics has not
been definitely traced, it was probably due to
shipping transmission in both instances. For
several months before these outbreaks, it had
been observed that the rats of the locality were
dying in unusually large numbers, and when rat
surveys were undertaken, it was found that as
high as 20% of the rats caught or found dead
were plague infected. Following anti-plague
measures this percentage was quickly reduced,
until for the week preceding the visit of the
Plague Conference in August, no plague in-
fected rats had been found.
Although the Galveston outbreak preceded
that of Beaumont and was apparently less wide-
ly distributed at its onset, it has not been as well
controlled on account of less successful coopera-
tion of the citizens with the state and federal
Public Health Services. In Beaumont, not only
were a special plague laboratory and isolation
hospital quickly established with adequate trap-
ping, rat proofing and wrecking squads and in-
spectors, but a special ordinance was passed giv-
ing the health authorities full authority to dis-
infect, survey and condemn all infected or rat-
harboring structures. If they were not demol-
ished or made satisfactorily rat-proof within 30
days of notification, the structures could be de-
molished or made rat-proof by the health au-
thorities at the owner's expense.
In the light of these and similar experiences
elsewhere, how then should the plague danger
be met, not only where it has actually gained a
foothold, but where it may at any time in the
near future be introduced (in other words, in
any seaport of this country) ? From an epi-
demiological standpoint, the case of human
plague is a mere incident, "the innocent by-
stander who is hit by the brick." All energies
and resources should therefore be devoted to
fighting the rat, whose flea is responsible for the
transmission of the plague, not only to rats and
other rodents such as ground squirrels, but to
man as well.
Anti-plague measures may be divided into the
following categories: (i) "rat-proofing", (2)
rodent extermination, (3) rat survey, (4) treat-
ment of cases, (5) research work.
( T ) "Rat -proofing." By far the most impor-
tant measure in the prevention of plague is the
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788
THE PENNSYLVANIA MEOICAL JOURNAL
August, 1921
process of "rat-proofing," i. e. rendering a local-
ity (houses, barns, sidewalks, yards, store-
houses, docks, shipping, station, freight cars,
etc.) unfit for the harborage of rats. This term
does not imply, nor is it necessary, that rats
cannot gain entrance to or exist in rat proof
buildings; but it does indicate that conditions
for existence and reproduction are so unfav-
orable that the few rats that do gain entrance
will soon leave for more favorable surround-
ings. That "rat-proofing" is important in the
eradication of plague, as well as in its preven-
tion, is shown by the strenuous and strikingly
Pic. I. Exposed rat harborage between doable walls
of frame dwelling house. Showing nest and accumu-
lation of several years debris.
successful measures adopted by the U. S. Public
Health Service in cooperation with the local
health authorities during the past 15 years.
The most important item in "rat-proofing" is
the safe guarding of buildings, either by con-
crete floors and "chain walls" (class A), or by.
elevation of house at least 18 inches from the
ground and maintenance of this space free from
rubbish. Incidentally, in New Orleans the eco-
nomic gain of rat-proofing was soon demon-
strated to be so great that the larger corpora-
tions willingly cooperated in rat-proofing meas-
ures that involved an expenditure of thousands
of dollars on their part. Thfs economic gain
comes from not only a diminution in claims for
damage by rats to the merchandise handled, but
also to greater efficiency in handling same
through less wear and tear to the building, to
the trucks, etc., and to the ability to move goods
over the smooth surface of the concrete floors
more rapidly and with less labor. Coincident
with the rat-proofing of buildings, sidewalks,
etc., all other factors favoring rat existence
should as far as possible be eliminated. This
included such details as the proper protection
of food stuffs, and feed bins, the proper dis-
posal of garbage, manure and rubbish. It is
obvious that such measures are also highly de-
sirable from a general sanitary as well as a
specific anti-plague standpoint.
Another important item in rat-proofing a lo-
cality is to prevent the entrance of foreign rats
from shipping. The measures commonly used
are : ( i ) Three foot f unnel-and-disc rat guards
on all hawsers, (2) "breasting" the ship at least
15 feet from the dock by means of suitable
rafts, and (3) loading or unloading only by day-
light or with strong artificial light, the gang-
plank (at least 10 feet of which is painted
white) being lifted at all other times. Even
these measures are not absolute protection (for
instance, against overhanging sheds or other
structures on the dock) and lose greatly in ef-
ficiency unless supported by a strong inspection
force and the public opinion of the community.
For instance in New Orleans to-day, many of
the ships which have rat guards for three-inch
cables placed on one-inch ropes, have omitted
the "breasting" or left the gang-plank down all
day and unguarded. Although introduction of
rats by inland freight is undoubtedly of minor
importance, it should be guarded against by in-
spection and opening of double walls of freight
cars at least one foot from the floor.
(2) Rodent extermination. In the presence
of human plague or of the epizootic in the rat<
of the locality, rodent extermination assumes
primary importance. This is best accomplished
by means of trapping and fumigating (espe-
cially for ships and freight cars) although it
has never been possible to render a locality en-
tirely rat free, and if this were possible it would
quickly become more or less infested under con-
ditions existing to-day. In fact, it is recognized
that even an extensive campaign of extermina-
tion is only of temporary benefit (unless accom-
panied by rat-proofing) because the greater fer-
tility and longevity of the survivors (due to
lessened competition and relatively greater food
supply) soon brings the rat population back to
its former level.
Rat trapping is best accomplished by dividing
the locality into districts (each trapper being
able to care for from 150 to 200 traps) which
are grouped into zones and areas, surpervised
by foremen and inspectors. In case the force ii
unable to cope with the whole area it is best tc
adopt some selective plan, such as that carried
out by Heiser in Manila. Trapped rats are ac-
curately tagged with place of capture, etc., and
brought daily to headquarters, where they are
rid of fleas by dipping in pure kerosene, and
preserved on ice for laboratory study. Here all
rats are nailed on shingles with magnetic ham-
mers, organs and lymphnodes exposed by a
median incision with lateral cuts on the limbs.
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August, 1921
BUBONIC PLAGUE— KRUMBHAAR
789
and smears made from all suspicious rats. This
is followed by rubbing suspected tissues on the
abrased, shaved abdomen of a guinea pig. This
should cause buboes and death within a week.
The typical lesions in the rat consist of (i)
subcutaneous and visceral congestion; (2)
buboes of inguinal, axillary and cervical lymph-
nodes (though these are common in rats from
other causes) ; (3) focal necrosis of liver
(granular or "peppery") or fatty degeneration;
(4) watery, hemorrhagic pleural effusion. (5)
"Resolving plague" may be accompanied by ab-
scesses or linear scars in the spleen. Confusion
may be caused by rat leprosy, nematode infec-
tion, pseudotuberculosis and hemorrhagic septi-
cemia of guinea pigs. In suspected human
cases blood cultures of bipolar staining. Fried-
lander's bacilli have caused difficulties in diag-
nosis. Fumigation is best obtained with hy-
drocyanic gas. This is performed in freight
cars of approximately 3,000 cubic feet as fol-
lows: With the door mostly shut and strips of
paper pasted over it, a bucket containing two
pints of commercial sulphuric acid and three
pints of water is placed inside. Into this is
dropped 18 ounces of sodium cyanide, and the
door shut and sealed before the gas begins to
arise. This is left for one hour, when both
doors are opened and the car well ventilated
before anyone is allowed to enter. Essentially
the same procedure is adopted on shipboard
(preferably empty of cargo), although it is not
considered possible to kill all the rats with one
fumigation as it is in freight cars, appropriate
blowers and exhaust fans are used and white
mice and cats in cages used to test subsequent
ventilation. Cage traps are only used where it
is necessary to get live animals for experimental
work (inoculation, number of fleas, etc.) or
when a female in heat is used to attract males.
Barrel traps are only occasionally used. Im-
portant items in rat trapping are to get or teach
experienced trappers and supervisors, confine
each trapper strictly to his own district, and to
place a bounty on the rats caught, live or dead.
(3) Rat Survey. This important measure
("the eyes of the campaign") may be conducted
cither when plague infection is suspected, is
present or has recently been eradicated. The
number of rats to be caught varies with local
circumstances, but to be entirely adequate
should be 10% of the human population. The
cost is estimated to be between 50 cents and
$1.30 per rat. If rats are caught and examined
•as above described, an accurate picture can be
obtained of the number and distribution of the
normal and infected rat population. It has al-
ways been the history of well-observed plague
outbreaks that the epizootic has existed in in-
creasing amounts in the rat population for sev-
eral months before it has attacked mankind, and
this has often become apparent through the ob-
servation of an unusual number of dead rats.
Occasional surveys, therefore, in cities, either
free from plague or where it has been recently
eradicated, will give accurate reassurance of
continued freedom in the near future. Without
adequate surveys the epizootic may reach dan-
gerous proportions, as in the recent case of New
Orleans, where human plague recrudesced after
Fic. 2. Interior (with flooring removed) of site
of first case of human plague. Beaumont. Prelim-
inary to disinfection.
two years of freedom had given an unwar-
ranted sense of safety.
(4) Treatment of Cases. Plague cases are
best treated with serum from horses immunized
with a variety of strains of B. Pestis. Immuni-
zation is accomplished by the usual subcutane-
ous and intravenous injection, and doses up to
200 cc. given at frequent intervals intravenous-
ly. These are usually preceded by morphine
and atropine. Unit standardization of the
serum had not yet been accomplished. Vacci-
nation of exposed individuals with B. pestis
(killed in the usual way) is also employed, al-
though if exposure has been grave (eg. a known
bite from a rat flea) serum prophylaxis is pre-
ferred. Good results follow the use of serum
in the South to-day, although it is admitted that
the epidemic is not a virulent one. Other reme-
dial measures such as sedatives, cardiac stimu-
lation and anti-febrile measures are of course
employed as indicated.
(5) Research Work. There still remain
many important facts to be elicited about the
control of plague. For instance, (i) as to the
biology of the rat flea, little is known as to its
viability after death of the host, how far it will
travel to seek a human. host, conditions govern-
ing such search, etc.: (2) importance of other
transmitters (such as bedbugs, lice, ants) and
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790
THE PENNSYLVANIA MEDICAL JOURNAL
August, 1921
of intermediate hosts other than the rat; (3)
conditions governing spread of infection by
land routes (4) and types of disease (bubonic,
pneumonic, or "pestis minor") ; (5) impor-
tance of substrains of B. pestis as to violence of
epidemic ; (6) production of immune serum ;
(7) production of immune serum of higher
titre and standardized strength.
As r^^ards the present plague problem in the
State of Pennsylvania and other northern states,
it would seem best to concentrate efforts on
"rat-proofing," so that when plague does appear
in this locality we shall be insured against its
Fig. 3. Lodging House in Beaumont, the site of
a case of human plague. Rat proofed with concrete
and elevation.
rapid extension. Combined with this, there
should be occasional rat surveys in our single
large seaport. In view of the present state of
the country perhaps the greatest step would be
to secure state or local ordinances that all fu-
ture building-construction should be "rat-proof"
in the present sense of the term. A regulation
that all repairs amounting to more than 50% of
the total cost should necessitate rat-proofing the
.structure would also be of great value. It is of
course obvious that even such measures would
cost considerable private expense if vigorously
enforced throughout the state, and that it would
be many years before their full effect would be
manifest.. Nevertheless, as an insurance against
plague, the expense would be justified many
fold and if the economic gain can also be prop-
erly demonstrated it is not unreasonable to ex-
pect a certain amount of public cooperation. It
must be recognized, however, that as long as the
public lacks the stimulus of the actual presence
of plague, it will take energetic action on the
part of health authorities and doctors to make
the people alive to the situation. I am happy to
say that a formal request has been made by the
State Department of Health to the commission
that is now revi.sing the building laws, that ade-
quate provision for rat -proofing all future struc-
tures be inserted.
Any funds available through the present in-
terest in the plague problem or for other rea-
sons, should best be spent in assuring the effi-
cient execution of the measures just described
or in publicity measures, which would educate
property holders and merchants as to th"e eco-
nomic losses and sanitary dangers of a rat in-
fested community. This would be carried out
in the hope that eventually individuals would to
a certain extent undertake rat-proofing and rat
control at their own expense. "Deratization,"
being only of temporary value, should not be
allowed to divert resources from permanent rat-
proofing measures, as long as plague has not
actually appeared in or near the community.
SUMMARY
1. The present pandemic of the plague, which
has caused literally millions of deaths in the
past 26 years, will be a constant threat to this
country for at least another half century. The
Manchurian pneumonic plague of 191 1 has
demonstrated the possibility of an extensive epi-
demic of the most virulent type, and transmitted
over land in a climate similar to our own.
2. Experience in this country for the past 15
years, and in the epidemic now existing in the
Gulf States, confirms the generally held opinion
that anti-plague measures should be directed
chiefly against the rat.
3. In the prevention of plague, by far the
most important measure is the process of "rat-
proofing", accompanied by an occasional "rat
survey."
4. In the actual presence of plague, both these
measures should be accompanied by extensive
rodent extermination, together with isolation
and serum treatment of human cases.
5. Many plague problems still await solution
by special investigations.
6. In this state, until stimulated by the actual
presence of plague in the neighborhood, efforts
at rat-proofing had best be restricted to the in-
clusion in building laws of the adequate rat-
proofing of new structures, and to publicity
measures which would educate property holders
and merchants as to the economic losses and
sanitary dangers of a rat infested community.
DISCUSSION
Dr. M. Howard Fussell, Chairman (Philadelphia):
I should like to ask Dr. Krutnbhaar if the pulmonary
form of plag^ue can be disseminated by the sputum of
the patient suffering from the plague.
Dr. Krumbhaar: Yes, unfortunately, it is chiefly
disseminated by direct contact. The bubonic form is
disseminated by the bite of the flea.
Chairman Fussell: How about the serum?
Dr. Krumbhaar: That has given very promising
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NEPHRITIS— SNOWDEN
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results. There are apparently very many different
strains of the plague bacillus differing in cultural
strength. We made serum by taking twenty-six of
the different strains secured on different geographical
sites; made serum in the usual way by injecting
small doses, then in larger and larger degree, and the
serum from that is given to the patient in as high as
200 c.c. doses, preceded by morphine and atropine, and
as soon as the patient seems able to stand it. It is
rather a heroic treatment, and the southern people
thought very highly of it. It is hard to estimate the
value of the serum. This has not been standardized
yet, and on top of that is the difficulty that the viru-
lence of the plague varies much. In Manchuria one
hundred per cent, die; not a recovery. In other
places of the bubonic form, seventy-five per cent
down to as low as thirty per cent. die. There is a
form called "pestus minor" that is very unimportant.
It is hard to test the value of the serum ; those who
use it think well of it, and they intend to get a more
potent and valuable serum.
Dr. Edward Martin, Commissioner of Health
(Philadelphia) : Acting as your agent, and because it
is obvious to any one who has given the least atten-
tion to this subject, and because the function of the
Health I>epartment is prevention, I>r. Krurabhaar was
delegated to attend the convention, from which he
has brought so many valuable suggestions.
As a result of this report, and in accordance with
the attitude taken by the Health Department of the
United States, there is now being incorporated in the
new building code a clause in virtue of which every
structure erected in Pennsylvania shall be rat proof.
This adds only moderately to the expense, and it gives
us the assurance of protection. It is acknowledged
by all who have struggled against these epidemics in
their large proportion, that rat extermination is im-
possible. It behooves Pennsylvania to act now, lest
it have to spend not only millions but billions in a
costly struggle against this destructive and fatal dis-
ease.
THE DIAGNOSIS OF THE FUNCTIONAL
CAPACITY OF THE KIDNEYS IN
THE VARIOUS TYPES AND
STAGES OF NEPHRITIS*
ROY R. SNOWDEN, M.D.
PITTSBURGH
The problems that confront the physician
who assumes responsibility for the proper care
of a case of nephritis fall into two groups. In
the first are the questions of the etiology, de-
gree, and probable course of the renal lesion,
while in the second group are the questions of
functional activity. The physician must, then,
understand not only the pathological condition
of the kidneys, but he must also determine ac-
curately to what extent this lesion has impaired
and will in the future impair the ability of that
kidney to perform its work of excreting waste
products. While from the general clinical
*Read hefore the Section on Medicine of the Medical So*
ciety of the State of Pennsylvania, Pittsburgh Session, October
6, 1930.
Standpoint the.se two questions are of equal im-
portance, yet from the practical standpoint there
is a difference in their urgency. In the proper
conduct of a case of nephritis the physician
must first concentrate his attention on func-
tional capacity since herein lies the immediate
danger. With this problem properly solved he
then turns his attention to the matter of the
pathological condition, its etiology, extent and
course, and the treatment best suited to aid in
recovery.
The physician in charge is faced by some-
what the same problems as the rider on the
back of a runaway horse. His ultimate aim is
to bring the horse under subjection, but while
he is doing this he must also see to it that the
horse does not dash itself into a ditch or over a
cliflf. If he is able to steer the horse clear of
such immediate dangers he has a good chance
of bringing it eventually under control. So it is
with the conduct of a case of nephritis. The
ultimate aim is to bring it under control, but
while doing this it is essential that functional
activity receive immediate attention lest tox-
cemia from retention of waste products result in
catastrophe.
Therefore, in order to properly treat nephri-
tis, the physician must be able to diagnose the
renal condition and to determine just what, if
any, functional disturbance is present as a re-
sult of this. The evidences of a renal lesion,
from the pathological standpoint, are to be
found in the urine almost entirely. They vary,
of course, with the degree and nature of the in-
flammatory process, but in general consist of :
(a) variations in the urine volume, (b) the pres-
ence of albumen, (c) the presence of casts, (d)
the presence of pus cells, (e) the presence of
red blood cells. In practically all cases albumen
and casts are found, although they vary greatly
in the diflferent types and in this variation they
are independent of each other. The presence of
pus and blood is usually found in the more acute
cases although certain chronic types may also
give rise to pus and blood.
The diagnosis of nephritis, theii, is made on
these urinary evidences of renal trouble. To a
limited extent the type and degree of the ne-
phritis can be determined from these evidences.
But as to the functional capacity of the kidneys
absolutely no deductions can be drawn. The
urinary findings give no indication what.soever
as to whether or not there is any disturbance of
the ability of the kidney to excrete waste prod-
ucts. There may be found only a faint trace of
albumen and a few hyaline casts, when the func-
tional capacity is so low that the patient is in a
dangerous state of toxaemia from retained waste
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THE PENNSYLVANIA MEDICAL JOURNAL
August, 1921
products. On the other hand the urine may
contain a high percentage of albumen, casts, pus
and blood, and yet the kidneys are functionally
perfect. In fact, some such cases may show an
actual increase in functional ability, this condi-
tion being described by Baetjer and others as
"hyperpermeabiUty." Tiic physician, therefore,
confronted by a case of nephritis cannot esti-
mate the functional c;^iacity of the kidneys on
the basis of tl.u urinary findings. What, then,
are the evidences from which such necessary
estimates can be drawn? These are: first, clin-
ical signs and symptoms and second, functional
tests.
It is not within the scope of this paper to de-
.scribe in detail the numerous tests for func-
tional ability of the kidneys that have been
developed and studied. Many methods of de-
termining renal function have been devised and
elaborate studies made. Out of this enormous
amount of observation and .study, with the in-
evitable early confusion, the basic facts are
emerging in their simplicity.
In general the function of the kidneys is the
excretion of the waste products of metabolism.
These waste products are :
(i) Nitrogen: urea, ammonia, uric acid,
creatinin, creatin, etc.
(2) Saks: chlorides, etc.
(3) Acid bodies.
(4) Pigments.
(5) Water.
All of these substances appear in the blood
under normal conditions and are excreted by
the kidneys. Now it has been well demonstrated
that the excretion of each one of these groups
is independent of the others. This is a mo.st
important fact and if it is appreciated and con-
stantly borne in mind much of the difficulty in
interpreting functional studies will be elimi-
nated. Thus there may be an almost total in-
ability to excrete chlorides while the capacity
as regards nitrogen, acids, etc., is absolutely
normal. Or the nitrogenous waste substances
may be eliminated with difficulty, the others
coming through normally. As a matter of fact
when there is injury, it is usually diffuse, so
that the functional impairment involves all
groups of waste substances. But it is not al-
ways so and therefore proper control of any
case of nei)hritis must be based on the inde-
pendent consideration of each class of waste
products. .Another important point that must
always be borne in mind is that the normal
functional capacity of the kidney is greatly in
evcess of that which, is necessary to excrete the
waste products of normal metabolism. Thus
the functional ability may be reduced by one-
half or even three-fourths and yet be suflficieni
to prevent the accumulation of any waste sub-
stances in the blood.
With these two laws in mind, one is able to
determine the significance and value of any
functional test. Much of the confusion and
misunderstanding in the literature can be traced
to failure to realize one or the other of the
above points.
To recapitulate, it is necessary that the phy-
sician, in assuming charge of a case of nephri-
tis, direct his attention first to the functional
capacity of the kidneys. In doing this he bears
in mind that the urinary findings do not give
any indication of the facts he is after, but that
he must bring them to light by a study of the
clinical symptoms and signs, aided by functional
tests. He realizes, moreover, that he must con-
sider the functional ability for nitrogen, salts,
acids and water as independent and study each
separately.
The symptoms, signs and tests which are of
value in determining the functional capacity for
each type of waste product are as follows :
Waste Nitrogen Elimination. The best test
to determine the abiUty of the kidney to excrete
the waste products of protein metabolism is the
phenolsulphonephthalein test. Nearly fifteen
years widespread use of this test has clearly
demonstrated its value. The phthalein is ex-
creted by the kidneys in apparently the same
way as the waste nitrogen. This has been
clearly demonstrated by evidence of many years,
in which thousands of tests have been carefully
performed and checked up. The results of the
'phthalein test, then, can be accepted as a relia-
ble indication of the functional capacity of the
kidney as regards nitrogen. However, it must
be clearly understood that it is an index of the
nitrogen elimination only. To carry out a
'phthalein test and then say that the kidneys
were functionally such, because the 'phthalein
was such, is not only inaccurate but criminally
careless. The best mental habit to develop in
regard to this test is to bear in mind that one is
testing the ability of the kidney to excrete
phenolsulphonephthalein and, having deter-
mined this ability, to deduce by analogy the
function as regards nitrogen on the grounds that
the two are parallel in excretion.
.An especially valuable feature of the 'phtha-
lein test is that it measures the total functional
capacity of the kidneys. This capacity is nor-
mally many times that necessary for the ex-
cretion of waste products. Hence, there can be
marked reduction before there is any accumula-
tion of waste products within the blood or de-
velopment of symptoms. By the 'phthalein test
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August, 1921
NEPHRITIS— SNOWDEN
793
one can note reduction of functional capacity
before any signs or symptoms are found. It is
rare to find any retention of nitrogen until the
'phthalein excretion is below twenty per cent,
in two hours, representing a functional capacity
of only one-third or even one-fourth the normal.
The symptoms that arise.apparently from the
retention of nitrogen are: headache, restless-
ness, insomnia, gastro-intestinal disturbances
and eventually uremia. Just how much the
blood pressure is affected by the nitrogen reten-
tion is a question. I am inclined to feel that a
high blood pressure always results when there
is intoxication from nitrogen retention. At
this stage, that is when there are symptoms and
signs, an analysis of the non-protein nitrogen
constituents of the blood will give the best index
of the extent of the retention.
Blimination of Acid Bodies. In determining
the functional capacity of the kidneys as regards
acids we do not possess any direct method such
as the 'phthalein test for nitrogen. It is impos-
sible to judge as to acid elimination until there
begins to be an accumulation within the blood,
when unmistakable signs and symptoms will
develop and very clear-cut tests can be made on
the blood.
For a considerable time after retention begins
there are no symptoms, because of the ability of
the blood and tissues to neutralize the acid
bodies by reason of its large alkaline reserve,
consisting of carbonates, amines and eventually
ammonia. Thus, in the early stages of acid re-
tention, before symptoms have appeared, one is
able to detect it by determining the carbonate
contents of the blood, its reduction indicating
that the alkaline reserve is being heavily drawn
upon. The simple tests advocated by Sillards
can be performed by any physician in his office,
do not require any special apparatus, and give
absolutely reliable results. Later, when there
is marked reduction in the alkaline reserve,
dyspnoea appears. This can be tested for by
the simple procedure of noting the length of
time the patient can hold his breath.
Eventually the retention of acids causes
drowsiness and coma.
Chloride Excretion. The estimation of the
ability of the kidney to excrete chlorides is a
rather difficult procedure, requiring considera-
ble apparatus, chemical skill, and close super-
vision of the patient. It is unfortunate we do
not possess so simple and direct a method for
chloride function as we have for nitrogen, since
the chloride tolerance is a most important point
in the proper regulation of any case of nephritis.
^Vhenever possible this should be determined.
If it is out of the question, then the safest plan
is to reduce the salt intake by instructing the
patient never to add salt to his food. This in-
gests only that which is naturally in the food-
stuffs or is added during cooking. Where chlo-
ride retention is taking place there' is either a
rise in blood pressure, with polyuria, or the de-
velopment of edema with the accompaniment of
diminished urinary output and increase in
weight. This is an indication of marked salt
retention.
Urinary Pigments. The roles played by re-
tained urinary pigments is unknown, but since
there are certain toxic symptoms in nephritis,
the causes of which are not yet known, it is pos-
sible that these pigment bodies may give rise to
serious disturbances.
Urinary Volume. The estimation of the abil-
ity of the kidneys to excrete water is always
difficult because salt tolerance, blood pressure
and cardiac efficiency play such a prominent role
in this mechanism. Where the ability to excrete
water is definitely impaired the forcing of water,
of course, does much harm. These cases do
much better if the water intake is diminished
and the strain on the kidneys reduced.
SUMMARY
The physician who assumes charge of a case
of nephritis must take immediate steps to de-
termine the functional capacity of the kidneys.
The urinary findings will give him no indication
of this, but he must depend on signs, symptoms
and functional tests. In diagnosing this func-
tional capacity he must consider separately the
excretion of : (i) nitrogen, (2) acids. (3) salts,
(4) pigments, and (5) water. Retention of
waste nitrogen is indicated by restlessness, ir-
ritability, headache, gastro-intestinal symptoms,
and increased blood pressure. This is con-
firmed by the phenolsulphonephthalein test and
the estimation of the waste nitrogen in the
blood. The retention of acid bodies do not at
first give clinical symptoms or signs but can be
accurately determined by estimating the alkaline
reserve of the blood by the simple method of
Sillards. Later the acid retention gives rise to
dyspnoea, weakness and eventually coma. The
estimation of the functional capacity of the kid-
neys as regards chlorides can be made very sat-
isfactorily but it requires chemical technique
and close supervision of the patient. Chloride
retention causes either high blood pressure and
polyuria or edema and diminished urine volume.
Profiteers will continue to flouri.sh as long as
we're content to say to the clerk, "Wrap it up"
instead of "how much ?"
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THE PENNSYLVANIA MEDICAL JOURNAL
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THE DUTY OF THE PEDIATRICIAN TO
THE MOTHER OF THE NEWBORN*
O. N. CHAFFEE, M.D.
ERIE
William Mayo, in his paper read at the 1920
meeting of the American Medical Association
said "The surgeon approaches his work with the
physical condition of the patient in view. He
achieves a tangible success, but occasionally is
not rewarded by the gratitude of the patient be-
cause of intangible changes in the nervous sys-
tem which follow the operation." So does the
pediatrician approach his work with the phys-
ical condition of the patient in view; he may
and does achieve a tangible success, but often
is not rewarded by the gratitude of the parent
because of intangible conditions which environ
the patient and which tend to combat all forms
of scientific reasoning.
It is with these ideas in mind that we are
prompted to present this subject as a partial
explanation of the many failures combating our
efforts to reduce the high mortality in infants.
The physician is frequently called by the mother
for advice in regard to the nursing of the baby.
What is the result should the physician be a
recent graduate, who is expected to be scientific
and ufHto-date, but whose medical training has
been woefully deficient in practical pediatrics,
and who now begins to experiment at the cost
of the infant's life?
Does he understand the physiology of lacta-
tion? Is he familiar with the rules governing
the diet of the mother of the newborn, and does
lie know whether the infant who receives insuf-
ficient milk should have one breast or both
breasts at a feeding, or if insufficient whether
the child should receive supplementary or com-
plementary feedings? Is he familiar with the
fundamental principals which stimulate a slow
breast, and does he understand why the stock
breeder who has a registered animal under test
for milk production subjects the cow to four
niilkings a day instead of two? Because of the
deficient training in our medical colleges the re-
cent graduate starts out in his work poorly
equipped to advise the mother in regard to the
rearing of her infant. On this account numer-
ous proprietary food factories have sprung into
existence and do an enormous bu.siness. Fail-
ing to receive the needed information from her
physician the young mother now falls a victim
to incompetent advisers on every hand, from
mid- wife to grandmother, from the solicitous
neighbor to the mother-in-law who by chance
•Rea<l heforc the Section on Pediatrics of the Medical So-
rie'y of the State of Pennsylvania. Pittsburgh Session, October
6. 19J0.
may live in some distant state giving a corre-
spondence course in the raising of the baby!
Finally when matters have gone from bad to
worse the poor sleepless, tired and almost dis-
tracted mother appeals to the pediatrician to
solve the problem.
The problem is ,a semi-living human being
weighing thirty-three per cent, less than it did
on the day of its birth and confined within the
four walls of a crib. Could a spectacle be more
heart-rending? Diagnosis: infantile atrophy.
Etiology: ignorance.
The history of these cases quite frequently is
as follows: The mother becomes alarmed be-
cause a thriving baby has from four to five
stools a day. Possibly by a careful optic analy-
."^^is she may detect a curd. The physician is
summoned. Something heroic and spectacular
must be done. He orders castor oil at once or
possibly calomel. As a result of the treatment
the baby cries and he is again summoned ; more
mild chloride or other physic. The following
day he returns and with all the professional
dignity that the circumstances command sol-
emnly announces, "Your milk is poisoning the
baby !" He then prescribes Pet Brand or Eagle
Brand Condensed Milk, or some other ridicu-
lous proprietary concoction. After a more or
less precarious existence for sometime on the
poorly balanced diet which these so-called foods
furnish, the mother as a last resort appeals to
the pediatrician, or the family physician out of
the generosity of his heart finally refers the case
to the child specialist. This then is the begin-
ning of the end of the tale which the poor dis-
tracted mother relates to the pediatrician.
There seems to be only two ways of correct-
ing this mismanagement of babies. First, the
proper training of the fourth year medical stu-
dent in the theory and practice of infant feed-
ing, supplemented by practical work under
competent supervision in the pediatric depart-
ment of a well equipped hospital during his in-
temeship. Second, taking steps to have the
subject of dietics in general, and infant feeding
in particular, drilled into the minds of our
young men and women during their high school
training so that when they become parents they
will realize the vital importance of this subject.
It is vastly more important for the young
l^l'y^ician to start out on his medical career with
a knowledge of the proper methods of feeding
and caring for the newborn of his species, who
has the entire future before it with all its pos-
sibilities, than it is for this young physician to
be able to prolong for five years the life of an
individual who has many times outlived his use-
fulness to society, by performing for him a
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August, 1921
DUTY OF THE PEDIATRICIAN— CHAFFEE
795
spectacular supra-pubic prostatectomy. No
one would presume to deprecate such a proce-
dure, but why concentrate so much attention on
the latter condition and dismiss the former with
a dose of calomel and castor oil
The education of the resident interne in the
obstetrical and general hospital should be di-
rected by the pediatrist in cormection with that
hospital. No detail should be too minute to be
emphasized. He should be taught the proper
treatment for fissured and retracted nipples
which play so important a part in the question
of maternal nursing. He should learn to study
the infant's stools in order to ascertain the con-
dition of the digestive functions. Excoriated
buttocks and their significance and treatment
should be considered. He should acquire ex-
perience in the operation of transfusion for
hemorrhage of the newborn, and the use of the
superior longitudinal sinus for intravenous med-
ication. He should have experience in the com-
mon contagious diseases of childhood, and
should learn that 50,000 units of diphtheria anti-
toxin should be given just as promptly to a
three months old infant with severe diphtheria
as half a million units in a similar condition to
an adult. He should be taught to properly ex-
amine the tympanic membrane and to be on the
lookout for otitis media as a frequent compli-
cation of the upper respiratory infections in
infants and children. His attention should be
frequently called to the fact that a baby nour-
ished upon human milk either escapes the many
maladies to which the artificially fed are sub-
jected or, if infected, has a much greater vital
resistance to disease.
The baby who has a divine right to be con-
ceived and to be born after conception has also
the same right to be nourished by its mother's
milk. Whether it be the baby with colic whose
mother is advised that the milk does not agree,
whether it be in the family of the rich where
some unscrupulous physician agrees with the
mother who desires to be relieved of the burden
of nursing or in the family of the poor because
circumstances prevent the mother from giving
the necessary time and attention to maternal
nursing, that child has a divine right to have its
mother's milk until it is old enough to be
weaned. With the well-to-do the automobile
trip or the golf course robs the child of its
proper food, and in the poorer classes the state
fails to provide the necessary pension for in-
digent mothers. We will be treading on safe
and sane grounds when we insist that Jacobi,
the father of pediatrics was right when he said,
"Over 90% of the mothers can nurse their chil-
dren and it is the divine duty of the mother to
<lo so."
The early professional contact with the
mother of the newborn presents the most fav-
orable opportunity for the right advice. The
primipara is always in a receptive mental atti-
tude, and could her fund of information come
from the right source happy results would be
accomplished. The motto which I frequently
give this new mother is something like this,
"Listen respectfully to the advice given by
friends, relatives and solicitous neighbors and
do the contrary." In advising an apprehensive
mother in regard to the stools of her infant the
rule of Hamburger of Vienna may be remem-
bered : "If a baby has 40 stools a day, with all
the colors of the rainbow and the baby is breast
fed ^nd thrives, disregard it; if on the other
hand it has four stools a day and is artificially
fed give it attention at once."
After the pediatrist has successfully tided
over the apprehensive period of the mother and
a thriving, happy baby has restored her confi-
dence, he should take advantage of this psy-
chological time to circumvent all the possible
fears coming later, the fanciful dreams of
worms, "liver grown," cold in the bowels, grow-
ing pains and the numerous other superstitions
handed down by our ancestors and often unfor-
tunately by our own medical profession.
In conclusion the duty of the pediatrist to the
mother of the newborn consists in :
1st. The education of the mother in the fun-
damental principles of infant feeding so that
she may know that proprietary mixtures are un-
natural and imperfect foods for the infant.
2d. The practical training of the fourth year
medical student and resident interne in as thor-
ough a manner in infant welfare work as he is
in surgery and adult internal medicine.
3d. Forewarning the new mother against
neighborly advice and the many mountains of
false ideas which never existed except in the
untrained minds of her presuming friends.
820 Sassafras Street.
DISCUSSION
I>R. Fred E. Ross (Erie) : The theme of Dr.
Chaffee's paper, although of course not new, is always
timely. Child welfare and the prevention of illness
by proper care and management is the basis of all our
endeavors.
Dr. Chaffee rightly attributes to ignorance the
ethology of improper development. He refers in turn
to the ignorance of the recent graduate, the young
mother, the family physician and nearly everybody in
general except the pediatrist ! He is very considerate !
Yet no one can deny that the remedy lies in proper
education of all concerned.
The vast importance to the human race of the
knowledge of the subject of dietetics is becoming more
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796
THE PENNSYLVANIA MEDICAL JOURNAL
August, 1921
and more realized, particularly as it applies to the
nutrition of the young. The discovery of the presence
and importance of the various vitamines in food has
almost revolutionized and greatly clarified the whole
subject. The study of nutrition of the infant should
not be delayed until the mother has a new born baby,
but should have been incorporated into the school cur-
riculum when that mother was a girl in high school
or even earlier. The high school graduate, girl or
l)oy, should know the meaning and value of fats, car-
bohydrates, proteids, salts, water and vitamines. In
that case they would understand early why breast milk
is the ideal food for the human infant, and the pro-
prietary foods, especially sweetened, condensed milk,
the worst
It is very evident that in the past these fundamental
principles of dietetics were either not emphasized in
our medical schools as they should have been, or not
grasped by the student or applied in his practice later.
Perhaps his better judgment has been overruled by
the alluring advertisements of these proprietry food
manufacturers in our reputable medical journals. In
this connection I beg leave to read an extract from a
paper read by Dr. Joseph S. Wall, of Washington, at
the last meeting of the American Child Hygiene As-
sociation at Asheville, N. C. "It seems to me repre-
hensible that ethical medical journals,, including the
Journal of the American Medical Association, should
carry in their advertising columns the seductive ap-
peals of these various infant foods while professing
abhorrence in other columns of the use of proprietary
medicines, the administration of which to the bodies
of adults possesses not a hundredth part of the ever-
lasting harm inflicated upon the young by the feeding
of patent foods." It seems to me that all bodies inter-
ested in infant welfare ought to endorse those state-
ments and take some action giving public expression
to their opinion. No one knows better than the
Pediatrist, to whom the victims of the prolonged use
of these foods are brought as a last resort, how seri-
ous are the ravages of such a diet.
In regard to the education of the mother, the Chil-
dren's Bureau at Washington is doing a noble work
by the issuing of pamphlets dealing with the subject.
However, very few mothers know of this or how to
obtain them. I hope the time will soon come when
not only every birth will be registered, but that the
receipt of the report by the State Department of
Health will be followed immediately by the receipt of
that mother of literature of this kind sent by the de-
partment and printed in whatever language the mother
is most familiar with. This would modify to some
degree the ill effects of the advice given the mother
by ignorant neighbors, and the correspondence course
by the mother-in-law mentioned in the paper being
discussed.
Dr. John F. Sinclair (Philadelphia) : Both Dr.
Chaffee and Dr. Ross in this admirable presentation
and discussion, have, I think, passed over in silence
one part of the educational campaign which to my
mind is most important and which can be made most
intensive because of the psychological surroundings at
the time. I speak of the work prenatally with the
mother. There is probably no time when the work of
education can be carried on with better effect than
when the mother is pregnant and her thoughts are
centered on the coming of the child, and she will learn
best what she is taught, with a great deal more effect,,
and with a great deal more certainty, than she does
when she is a school girl. I do not mean to decry
teaching the young man, or the young woman, the
boys and girls in school, but you teach with best effect
for good during the nine months of pregnancy.
Dr. Paul Cassiuv (Philadelphia) : I do not know
how many of the gentlemen present in the room are
aware of the very excellent work being done by one
of the largest insurance companies in the country in
relation to this prenatal work. ' There have been two
pamphlets distributed very extensively on the "Cve
of the Expectant Mother" and the "Care of the Baby."
These are distributed by the agents of the company to
mothers only (also by visiting nurses), and any phy-
sician upon request may have as many copies as de-
sired. These two pamphlets are very remarkably got-
ten up and have been gone over by men very thor-
oughly versed in work along these lines and make
very excellent reading and are very instructive and
helpful.
Dr. Chaffee (in closing) : To be sure we are as
far from the medical centers in our city as it is pos-
sible for anyone to be, living within the state, and for
that reason, I present this paper as a practical paper
and not a scientific one. Unfortunately so many of
the medical students come into our locality and we
know they have received the best kind of instruction,
as far as infant feeding is concerned, by the pedi-
atrician in the institutions which they represent, but
they immediately, at least many of them, start io
feeding their babies with condensed milk or some
other concoction and this is the thing we find difficuh
to explain. We believe that the prenatal time is the
time to instruct the mother but unfortunately the pre-
natal influences are under the observation of the ob-
stetrician and not the pediatrician.
PEDIATRICS IN THE SMALL CITY*
HERBERT E. HALL, M.D.
UNIONTOWN
Analysis of the trend and development of
medical treatment and preventive treatment of
infants and children during the past few years
makes vivid the neglect of this department of
medical practice. Going back still further into
the past it is cause for wonder that this spe-
cialty has been held so lightly by nearly every
medical teaching institution.
Until quite recent years no medical school in
this country gave its students a well planned,
adequate, course of instruction in the ftmda-
mentals of pediatrics. There may be, perhaps,
just excuse for this neglect, because there was
disagreement among the several schools and
teachers as to what constitutes the fundamentals
of the subject. The student was shown some
sick babies, instructed in the mathematics of
rather exact methods of milk modification,
quizzed from a standard textbook and this was
the extent of his preparation for dealing with
some of the most vital problems concerning the
*Read before the Section on Pediatrics of the Medical So-
ciety of the State of Pennsylvania, Pittsburgh Session, October
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PEDIATRICS IN THE SMALL CITY— HALL
797
welfare of human beings at a very important
period of their lives.
The beginning of pediatrics in America as a
distinct department of internal medicine dates
back scarcely half a century. Recognition at
first was scant and grudgingly given, and it was
not imtil many obstacles were overcome and
considerable time elapsed that full recognition
was granted this specialty in the establishment,
in one of the medical colleges, of a chair of
pediatrics, the incumbent holding the rank of
full professor. This was 32 years ago.
To persons familiar with facts, or even to
those only interested in the well-being of in-
fants and children, no argument is required to
establish the claim to recognition of pediatrics
as a legimate and distinct department of gen-
eral medicine; but its evolution in this country
has been so slow that at the present time, with
very few and widely scattered exceptions, no
recognition is given it as a specialty outside the
teaching centers and in the occasional place
where some practitioner, who has received a
little knowledge and much inspiration from
some good teacher, has had the courage to lo-
cate. To the great majority, both medical men
and all others, this specialty has not yet attained
the recognition and dignity it deserves, and in
few cities having a population of 50,00 or less
are there found physicians limiting their work
exclusively to the treatment of diseases of in-
fants and children. In contrast there is scarcely
a city or town too small to have its quota of
men confining their work to some of the other
well recognized specialties of medicine and sur-
gery.
It is natural that the scientific study of the
nutritional disorders and diseases of infancy
and childhood should have its origin where en-
vironment for normal health development is
unfavorable and where conditions making for
incidence of disease are favorable, where ignor-
ance and superstition abound, where food is
often inadequate, or poorly selected and easily
contaminated, where there is increased inci-
dence of bad heredity and hereditary disease,
where contacts are close and frequent and com-
municable diseases spread rapidly and are diffi-
cult to control — that is in the congested districts
or foreign quarters of our larger cities. It is
there that many of the real medical triumphs
have been achieved and we can point with pride
to a diminished death rate that seems in many
instances almost incredible. But all babies and
children do not live in our few largest cities,
nor are ignorance, superstition, bad food, poor
sanitation and all other things adverse to good
health and normal development found in them
and no where else. Rather, there is less of this
existent in the localities where formerly . it
abounded and to-day it is the smaller city, the
town, the rural community, places not yet
reached by any of the organized efforts that
have to do with infant and child welfare, where
infant mortality is often highest and an epi-
demic runs its course unchecked or loosely con-
trolled. It seems a reasonable conclusion that
the problem of extending to these localities
promptly the benefits that have been so mani-
fest in the larger and more densely populated
centers is important and should receive the seri-
ous consideration of medical colleges to the end
that more graduates possessing the required
special and technical knowledge be sent out
from their halls, and that more and better op-
portunities for post-graduate study be afforded
physicians who recognize the situation and are
willing, perhaps eager, to study this specialty.
The difficulties met by one who limits his
work exclusively to pediatrics in a small city are
many and of many kinds. If this work previ-
ously has not been done as a specialty in his
locality, by a qualified man, he will find at first
few, if any, of the medical men ready to recog-
nize hirn or his work. He is handicapped by the
lack of the several agencies that contribute so
largely to pediatric success in the larger cities —
the specially equipped children's hospital, the
dispensary, welfare station, milk bureau, milk
and ice station for the poor, the visiting nurse
and the specially trained nurse — all of which
factors have been evolved from the study and
experience of pediatrists and men doing this
special line of work and their institution made
possible, in many instances, by the generosity of
persons who have understood the importance of
these measures in lowering the death rate and
raising the health standard of individual and
community.
The application of private philanthropy to
pediatrics in the smaller communities seems yet
a long way off. More that the knowledge of an
existing need is required to attract contributions
from wealthy citizens and it is doubtful, even if
sufficient money were available, whether the
work would be carried on best by local organi-
zations financed in this way. It seems that
there would be difficulties almost impossible to
overcome that would detract from the effective-
ness of such a plan. Chief among them would
be a lack of harmony among the men selected
to do the work. In some localities there would
be. in the beginning, at least, insufficient work-
ers having the required skill and experience.
Unfortunately enthusiasm often is misdirected
and self-appointed leaders lack ability and
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THE PENNSYLVANIA MEDICAL JOURNAL
August, 1921
knowledge to carry through successfully the
things attempted by them. It soems, therefore,
that if the accepted methods, especially as re-
gards preventive pediatrics, be applied univer-
sally and promptly the work, of necessity, must
be done by some organization having definite
authority that will place it beyond any local in-
fluence that might detract from its effectiveness.
The increased interest shown recently by state
organizations, by the National Red Cross, and
one other association of nation-wide scope, in
infant and child welfare give promise that in a
reasonably brief period of time their activities
will be carried to almost every community in
the land. This move should be, and most cer-
tainly will be welcomed by the pediatrician in
the small city and town. It will necessitate a
certain readjustment of his work, but should
detract nothing from his ideals and responsi-
bilities. His aim should be to harmonize his
endeavor at all times and under every circum-
stance with the activities of any accredited of-
ganization, accepting any special facilities of
value to him or certain of his patients, afforded
by such organization and giving in return any-
thing requested of him that will add to the ef-
fectiveness of the work.
It is well known by the pediatrician that a
large percentage of a relatively high mortality
among infants and young children is preventa-
ble and in many instances by means that are
simple, if understood. The urgent need of the
present is that every individual in state and na-
tion should receive, without further delay, the
benefits that will surely result from the applica-
tion of standardized methods of infant and
child welfare in all its related phases. There is
now before us for consideration, as a people, no
question or measure or reform so important or
full of possibility for great and beneficent re-
.sults.
DISCUSSION
Dr. Theodorb J. Elterich (Pittsburgh) : Dr. Hall
has given a very graphic description of the situation
which was present in all of the large cities about
twenty or thirty years ago. I remember well that,
about thirty years ago, when I informed one of our.
older practitioners in the city that I intended to take
up the study and the practice of diseases of children,
he frowned and said, "Well I do not know why young
men want to specialize so much. What is to become
of the general practitioner? We have specialists in
eye and ear, nose and throat work and that is good,
for we know nothing about treating those conditions.
Why, we have men now who have taken up diseases
of women, and then some of the men who have been
doing a great deal of surgery are going to limit their
practice to surgery entirely. Now if you take the chil-
dren from us, what will be left to the general practi-
tioner?"
I informed him that he had just made the statement
that the general practitioner knew nothing about eye,
ear, nose and throat diseases. How much did he know
about the treatment of diseases of children? So it
was very hard work in the beginning for those of us
who first undertook to practice this specialty, not only
in training the profession to the idea that some nen
should undertake this specialty, but also the laity.
This holds true in the smaller communities but the
pediatrician is coming to stay in the small towns. His
place is now recognized and all his colleagues are
ready to uphold him in his work in every community,
I think, no matter how small it is at the present time.
PRACTICAL USE OF THE BARANY
TESTS AWAY FROM MEDICAL
CENTERS*
WILLIAM HARDIN SEARS, M.D.
HUNTINGDON
In presenting this paper, there is no thought
of bringing forth anything new, rather it is a
recapitulation of the ear tests, which have been
brought to a high degree of usefulness in the
greater medical centers but are receiving scant
attention in sections more remote, and is in-
tended as a plea for their more extended de-
velopment and use in these sections. The idea
of practical use is based on the writer's per-
sonal experience with a small town clientele,
while the cases reported serve to illustrate, in
part, some of the work waiting to be done
everywhere.
The award of the Nobel prize in 191 5 to
Robert Barany, for his researches on the in-
ternal ear, marked the culmination of an ex-
tended series of studies, experiments and re-
corded observations, not of one man but of
many, not for one decade but for a period cov-
ering almost a century. Purkinje and Flourens,
as early as 1820 and 1825 respectively, chron-
icled investigations dealing with equilibration.
From that time a long list of scientists, working
mainly along the line of physiology, aided in the
development of this study. Notable in this list
are Breuer, Ewald, Meniere, Mach, Crum-
Brown, Goltz, Von Stein and Hoyges. To
Barany in particular, and his associates, Alex-
ander, Kreidl, Kubo, Rutten and others, in gen-
eral must be given the credit for assembling the
scientific work already done and applying the
results to clinical use.
Barany's clinical studies were devoted first, to
the reactions, nystagmus and vertigo, induced
by rotating the patient in a chair or douching
his ears with hot or cold water, and to the com-
parison of responses from normal with those
from pathologic cases. Later, when the cerebel-
•Read before the Section on Eye, Ear, Nose and Throat
Diseases of the Medical Society of the State of Pennsylvania,
Pittsburgh Session, October 5. ijso.
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BAR ANY TESTS— SEARS
799
lar connection of the vestibular nerve had been
demonstrated histologically, he associated the
work of other investigators with his own and
developed a scheme of cerebellar localization
through the reactions from the internal ear.
AMERICAN CONTRIBUTORS TO THIS SCIENCE
It is gratifying to know that a number of
American investigators have done much to ad-
vance this study, not alone along lines of physi-
ological research, but also in simplifying and
standardizing a technique of examination.
Among these are Wilson and Pike, Shambaugh,
Fresner, Braun and Lewis, each one of whom
has made some special contribution to the sub-
ject. To certain members of the Medical So-
ciety of the State of Pennsylvania, most of
whom are members of this section, unquestiona-
bly belongs the honor of being first to develop
the study of the vestibular mechanism to a
broader and more general usefulness, in the
practical study of every day patients. These
men, as you all know, are Mills, Weisenberg,
Randall, Mackenzie, Jones, Fisher, Brumm,
Frazier and their coworkers. Important addi-
tions to the subject have been made by this
group, for they have established a definite and
consistent period for the duration of after turn-
ing nystagmus in normals ; they have suggested
a central differentiation in the paths of the
fibers from the horizontal and vertical semi-
circular canals ; they have suggested the trans-
mission of impulses producing nystagmus and
those inducing vertigo, by different tracts of
nerve fibers ; they have developed galvanism to
its greatest efficiency in relation to reactions
from the internal ear; they have standardized
a chart for recording the findings of vestibular
examination; they have improved and stand-
ardized a turning chair for the rotation of pa-
tients, and have aided largely in working out the
system employed by the government in testing
the balance mechanism of candidates for the
.Aviation Service.
Mackenzie, after observations covering a
period of eight years, reported an average dura-
tion of after turning nystagmus from the hori-
zontal semicircular canals in normals, of 24 sec-
onds. The researches of Jones, Fisher, Brumm,
and their coworkers confirmed this finding with
a variation of but two seconds, their result be-
ing 26 seconds. As Barany's records varied
from o to 120 seconds, the great importance of
this correction is readily seen. Weisenberg, as
stated by Jones, saw the potential value of these
ear studies to neurology and suggested to him,
their further development along this line. Thus
Jones and Fisher, aided by the group above
mentioned, initiated their investigations of the
intracranial paths of the vestibular nerve.
Their results, based on research both anatomical
and physiological as well as studies of many hun-
dreds of pathologic cases, with findings noted
during surgical operations or at autopsies, have
been given to the profession. They believe:
The vestibular portion of the eighth nerve,
after entering the brain stem, divides into two
tracts, one comprising the fibers from the hori-
zontal semicircular canal, the other those from
the vertical semicircular canals. Each of these
tracts subdivides into two parts, one set of fibers
carrying impulses producing nystagmus, the
other bearing impulses inducing vertigo. The
fibers from the horizontal semicircular canal go
to Deibert's nucleus in the medulla. From here
one subdivision proceeds through the triangular
nucleus to the posterior longitudinal bundle,
which connects it with the nuclei of the third
and sixth nerves, thus forming the nystagmus
tract. The other subdivision traverses the in-
ferior cerebellar peduncle to the cerebellar
nuclei, forming the vertigo tract. This tract
has been demonstrated histologically by Cajal
and forms part of the basis for postulation of
other tracts, not yet proved anatomically.
The path of the fibers, from the vertical semi-
circular canals leads upward into the upper half
of the pons, where at some point opposite to the
middle cerebellar peduncle it subdivides, one.
part of the fibers going to the posterior longi-
tudinal bundle, which cormects it with the nuclei
of the third and fourth nerves, thus forming its
nystagmus tract. The other portion proceeds
by way of the middle cerebellar peduncle to the
vestibular nuclei of the cerebellum, forming the
vertigo tract. From the vestibular nuclei in the
cerebellum, both tracts of vertigo fibers pass by
way of the superior cerebellar peduncle through
the cerebral crura, ending finally in the cerebral
cortical center for reception of vestibular im-
pulse. This center is postulated by Mills to be
in the temporal lobe near the auditory center.
This work alone has been a tremendous advance
in the development of a complex and intricate
science.
Mackenzie took up galvanic stimulation of
the labyrinth and the eighth nerve in its infancy,
developed it to its greatest efficiency in these
tests and is now probably its best known ex-
ponent in America. He also did first hand work
in the early study of equilibrium tests in irrita-
tive and destructive disease of the labyrinth, re-
porting a considerable number of cases in the
journals at an early period. Weisenberg and
Mills, while aiding materially in the neurological
researches of Jones and Fisher, alsa advanced f
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THE PENNSYLVANIA MEDICAL JOURNAL
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a comprehensive scheme of cerebellar localiza-
tion. The suggestion made that this group of
investigators, in view of the work they have ac-
complished and their teachings, be called the
Philadelphia School, seems most fitting.
THE REACTIONS OF VESTIBULAR STIMULATION
It is a far cry from the experiments and ob-
servations in equilibrium of Purkinje in 1820
and the finished technique of examination ex-
hibited by the neuro-otolc^ist a century later,
and yet the studies of both embrace exactly the
.same phenomena, viz, nystagmus and vertigo.
Purkinje ascribed these reactions to the brain.
We know to-day, they arise from stimulation of
the internal ear, the kinetic static labyrinth, the
end organ of that complex neural mechanism
described briefly above. Artificial stimulation,
in these studies, by turning the patient in a
chair or douching his ears with hot or cold
water, results in endolymph movement in the
membranous labyrinth ; endolymph motion pro-
duces movement of the cilia of the maculae of
the utricle and saccule and the cristae of the
semicircular canals; the impulses thus, set up
are carried by nerve filaments through the ves-
tibular part of the eighth nerve to be trans-
mitted to all parts of the vestibular apparatus.
These impulses through an intact mechanism
produce two reactions, nystagmus and vertigo.
Vestibular nystagmus is a rythmic movement of
the eyes, consisting of two components, a slow
movement in one direction followed by a rapid
return movement in the opposite direction.
There are three main planes of labyrinthine
nystagmus, horizontal, frontal and sagittal.
The rythmic movements in each being respec-
tively to right and left, rotatory or up and down.
Labyrinthine vertigo exhibits itself in the
same planes as nystagmus and consists in a sen-
sation of turning to right or left, or of falling
to right or left, or of falling forward or back-
ward; in accordance with the plane of the
canals irritated.
Associated with induced vertigo are the phe-
nomena of "past pointing" and "falling."
These are dependent upon vertigo and cannot
he demonstrated unless it is present. Past
pointing and falling are both dependent upon a
sensation of change in bodily position, not ex-
istent in fact. The first is a cerebral motor act
developed at the request of the examiners and
consists in failure to locate again a fixed object
he has just touched, placing his finger to right
or left, above or below the object according to
the plane of vertigo existent; an attempt at
orientation as it were. Falling likewise is a
conscious motor act, and is an effort to correct
a change of position, which has not occurred.
The patient having a sensation of falling in one
direction throws himself in the opposite and ac-
tually falls in an attempt to maintain his equi-
librium. Falling, like past pointing, is in the
same plane, but in opposite direction to the ex-
isting vertigo.
The presence of normal reactions of nyst^-
mus and vertigo and their associated phenom-
ena, past pointing and falling after stimulation
of the labyrinth, indicates an intact vestibular
mechanism. On the other hand failure to ob-
tain one or more of these responses indicates a
block in the vestibular apparatus at some point.
The interpretation of these responses gives in-
formation not alone of the functional condition
of the labyrinth itself but also of the eighth
nerve and its paths of distribution through the
brain stem to their neulear and cortical centers
in the cerebellum and cerebrum, as well as the
structures which these paths traverse and other
parts of the brain which are in direct connec-
tion through association tracts.
VALUE OP VESTIBULAR EXAMINATION IN SMALL
CITIES AND TOWNS
These tests of the vestibular apparatus are
utilized to-day as valued aids to diagnosis in
the various fields of medicine and surgerj' at all
medical centers where "group study" of disease
is made possible by adequate clinical facilities.
This is not true of the smaller cities and towns,
which may contain but one or at most two or
three practitioners, limiting their practices to
the eye, ear, nose and throat, and none whose
practice is still more circumscribed. Obviously
if this work is to be done at all in these smaller
centers, it must be taken up by an O. A. L. R.,
whose prior studies will aid him in more readily
acquiring the requisite training. The practical
benefits or use of this work, applies first to the
physician who develops it, second to his own
patients in their study and third to referred pa-
tients of other physicians in their examination.
I. SELF-DEVELOPMENT
In the development of this study, he increases
his knowledge, widens his experience and
broadens his outlook so that his view passes be-
yond his own specialties over the border land of
related neurology. The O. A. L. R. who is am-
bitious to attain his highest point of efficiency
must have more than a casual acquaintance with
intracranial structures for in his chosen field he
comes in direct relation, either by anatomic
structure or physiologic process, with all of the
cranial nerves and various parts of the brain.
To acquire a working knowledge of these is a
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BARANY TESTS— SEARS
801
large order and the suggestion that the oculist
and aurist study at a neurological clinic, while
the neurologist gathers helpful data at an eye
and ear infirmary seems not impractical. The
evolution of this work will aid him in correlat-
ing his present knowledge of these structures
and, combining it with additional information,
in placing the whole in a position of much
greater usefulness to him. The necessity for
accurate observation and noting of findings in
these cases will give an added stimulus to deeper
study and the keeping of better and more sys-
tematic records of all his patients.
11. STUDY OF HIS OWN PATIENTS
(a) Eye Conditions : The nuclei of the oculi
motor nerves being in direct connection with the
internal ear, it is possible by ear stimulation to
move the eye in any given direction, up or down,
in or out, etc. By this means some ocular
palsies may be studied to advantage, the extent
of nerve or nuclear involvement determined to
some degree, in fact a refinement in diagnosis
with, a possible helpfulness in prognosis. All
conjugate paralyses should be studied by this
.method. If ear stimulation induces normal
movements of the eyes, we have thereby evi-
dence of an open and functionating pathway
from the ears to the ocular muscles, hence the
lesion, if any, must be supra-nuclear. Hysteri-
cal paralyses often affect the conjugate type and
here, in certain instances, we may determine
whether or not there is an organic lesion. In
the presence of such lesion, the responses may
offer suggestion as to its location.
Case I. W. S., white, male, age 20 years. This
young man referred on account of his vision having
failed so much as to interfere with his going about.
His face was smooth and expressionless and his eyes
partially closed. His gait was slow and stiff and he
walked with his head bent well forward. Examina-
tion of the eyes showed a partial ptosis of the upper
lids of both eyes. The vision was 20/30 in each eye.
The eye grounds were negative with no indication of
pressure. Both visual fields were much contracted.
The movement of the eyes were very much restricted
in all directions, the lateral excursions being very
small, but larger than those of upward rotation, while
rotation downward was practically nil. Spontaneous
rythmic nystagmus was present with both eyes di-
rected straight ahead and in all directions of ocular
movement. Attempt at rotation downward resulted in
rapid and violent nystagmic movements in the same
direction. Turning the patient in a rotary chair to
the right ten times in twenty seconds induced a hori-
zontal nystagmus to the left, of large aplitude with a
marked tendency to conjugate deviation to the right
and a duration of fifty-five seconds. Turning the pa-
tient to the left ten times in twenty seconds produced
a horizontal nystagmus to the right of large amplitude
with a mvked tendency to conjugate deviation to the
left and a duration of seventy seconds.
From these responses alone the following conclu-
sions were drawn : The large lateral excursion of
both eyes evidences an open and functionating path-
way from the horizontal semi-circular canals to the
oculi motor, nuclei, nerves and muscles and indicate a
supra-nuclear lesion. This is further intimated by the
marked tendency to conjugate deviation and the limi-
tation of willed ocular movement. The prolonged
duration and large amplitude of the nystagmus sug-
gests irritation. A lesion affecting the upper part of
the pons near the junction of the cerebral crura might
be suggested in this case. Further study of this pa-
tient resulted in a diagnosis of lethargic or epidemic
encephalitis.
Spontaneous Nystagmus: There are three
vital essentials in the study of nystagmus. The
examiner must be near enough to the patient to
see easily and clearly the slightest movement of
the eyes. The eye must be under good illumi-
nation. The upper lid must be drawn up suffi-
ciently to give a good view and the eye closed
occasionally to keep it normally moistened.
Usually one readily differentiates between the
coarse oscillations or undulations of equal
length and rapidity of an ocular nystagmus and
the rhythmic movement of a labyrinthine one.
In ca.ses where the eye movements are less char-
acteri.stic, history of duration, examination of
the eyes, visual accuity and amplitude and rap-
idity of excursion will aid in decision. Study
of such cases, however, by vestibular reaction
will give definite information of the integrity
of the intracranial tracts and should be used in
every case where an obvious ocular lesion is not
in evidence.
Case 2. S. N. A., white, male, age 21 years. For
several weeks, when reading, his eyes twitch and some
times the print jumps up and down. If he persists in at-
tempting to read, severe pain in the head ensues and he
becomes dizzy. Nine years ago, he lost the sight of his
right eye by a penetrating wound, resulting in a trau-
matic cataract, largely absorbed at this time. The eye
deviates outward in a comitant squint of about thirty
degrees. Vision of O. D. equals 6/200 with S. Plus
lO.D equals 20/100, O. S. equals 20/15. Looking at a
distance there is no nystagmus. Rotation of the eyes
to the extreme right or left induced a small horizontal
nystagmus in the same direction. With the eyes fol-
lowing a pencil held about eighteen inches distant,
movement to right or left, up or down, produced a
violent oscillatory nystagmus of small amplitude.
Vestibular stimulation was followed by normal reac-
tions of nystagmus and vertigo with normal past
pointing and falling. The question in this case,
whether spontaneous attacks of nystagmus associated
with head pains and vertigo if attempt at reading con-
tinued, were due to an organic lesion affecting the
vestibular apparatus was decided in the negative by
the normal responses. This patient seems to belong
to one of the not frequently observed, or at least less
frequently reported, types and might be classed under
latent or under induced nystagmus.
That these movements were due to an overbalanc-
ing of normal vestibular tonus by the excessive nerv-
ous impulses sent to the third nerve nuclei in violent
effort to induce binocular fixation at the same time
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THE PENNSYLVANIA MEDICAL JOURNAL
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stimulation (or accommodation and convergence was
in force, was the conclusion based on the following
observation: i. The small horizontal rhythmic nystag-
mus noted on extreme lateral rotation with eyes look-
ing at a distance was of the physiologic type, so fre-
quently observed, z Violent nystagmic movements
developed only when the patient used both accommo-
dation and convergence in fixing the finger or pencil
at a distance of one to two feet, and then in any di-
rection of movement. 3. Spontaneous development of
the nystagmus while reading was coincident with a
convergent movement of the squinting eye. 4. Band-
aging the squinting eye had a marked although not
absolutely inhibitory effect.
(b) Ear Conditions: At least one vestibular
test, should be included as a routine in the ex-
amination of ear cases. All that may be neces-
sary to note, after rotation of the patient to the
right and then to the left, the presence of a
normal after turning nystagmus in each direc-
tion, thus proving an intact end organ. If im-
paired responses are noted, further study is in-
dicated.
Diseases of Cochlear Labyrinth. In the pres-
ence of obscure or doubtful findings in the
study of cochlear disease, impaired vestibular
reactions may aid materially in establishing
diagnosis.
Diseases of the Kinetic Static Labyrinth. Of
still greater value are these reactions in dis-
criminating between the various forms and
stages of labyrinthitis to the end, in some cases,
of saving the patient's life. Consequently, no
radical mastoid operation should be decided
upon without preliminary investigation of the
labyrinth when, if pre.sent, a circumscribed or
latent diflFuse suppurative labyrinthitis will be
discovered and the surgical procedure modified
or extended to meet the existing complication.
In differentiating between diffuse serous and
diffuse suppurative labyrinthitis, the presence of
some, even though slight, reaction from any
portion of the labyrinth, is invaluable for diag-
nosis and in decision to postpone operation;
while a total absence of responses is equally
valuable in the conclusion for immediate opera-
tion.
The following case is reported because it was
the first in which the writer determined a com-
plete destruction of the labyrinthine function,
by use of the Barany tests.
Case 3. Mrs. J. C. was admitted to the Blair Hos-
pital complaining of dizziness, occasional headache
and feeling of confusion in her head. Her past med-
ical history included scarlet fever at five years, com-
plicated by acute middle ear suppuration of right ear,
measles at twelve years and no other illness until
about two and one-half years before admission, when
she had t>-phoid fever. .After typhoid fever a pro-
longed convalescence, complicated with weakness of
left arm and leg and numbness of the ulnar side of
both arms and little iMigcrs, took almost a year for
return to good health. Her right ear discharged for
about nine years after onset, when she had an acute
mastoiditis. Six years later, the ear became quiescent
for about ten years but for the past eight or nine
years, purulent secretion has been present the greater
part of the time.
History of Present Illness : Almost five months ago,
she became suddenly dizzy, nausea vomiting and cold
sweat were associated. Objects in the room whirled
around. She could not recall the direction of move-
ment. The attack lasted for an hour or more, after
which she was able to go about her work. Two simi-
lar attacks, each less severe, followed at intervals of
about four weeks. A fourth and the last attack came
two months later, between two and three weeks ago.
This one was more severe' than the preceding two.
Examination of right ear showed presence of pus
and debris. After cleansing the ear, the tympanic
membrane and ossicles were found missing in large
part, necrosis of the attic wall in evidence.
Tests for Hearing: Hearing of left ear was normal
Right Ear: Hearing was absent for voice, tuning
forks and Galton's whistle. With noise apparatus in
left ear and ccmversation tube in the right ear, a loud
voice could not be heard. Weber's test lateralized to
the left ear. This gave every evidence of a dead
cochlea.
Spontaneous Nystagmus: A rotatory nystagmus to
the left side was noted, none to the right side.
Equilibrium Tests. Rhomberg: Palls to the right,
changing position of head; changes direction of fall-
ing. In walking staggers to the right.
Vestibular Reactions: Douching the ear, the head
upright, with cold water for five minutes produced
neither nystagmus nor vertigo, with the head back at
60 degrees the same results obtained.
Diagnosis: Absence of all responses from the en-
tire labyrinth, indicated either a dead labyrinth or a
nonfunctionating eighth nerve. Spontaneous nystag-
mus to the opposite side as well as the varying direc-
tion of falling, pointed to a peripheral as opposed to a
central lesion. In the presence of a suppurating ear
with necrosis and in view of the above findings, a
diagnosis of suppurative destruction of the labyrinth
was made.
Radical mastoidectomy and exenteration of the laby-
rinth followed. Six years later, the patient is living.
III. STUDY OP REFERRED PATIENTS
These will come solely from the general prac-
titioner to the otologist of the smaller center,
for here there are no neurologists, pediatrists,
syphilologists or gynecologists, as such, whose
practice is limited to one branch of medicine
and but few surgeons, whose work is sharply
circumscribed to surgery. As a consequence,
the practical use of the so-called Barany tests is
much more limited than in large centers and the
work requisite in making a complex study i-*
much more burdensome. For example, in the
study of suspected intracranial disease at a
metropolitan hospital, there may be a report by
the neurologist, internist, syphilologist, oph-
thalmologist, rhinologist and laryngol(^st, otol-
ogist, pathologist and roentgenolc^st with de-
ductions from each one, an expert in his line.
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BARANY TESTS— SEARS
803
In the smaller town these reports will be sub-
mitted by the general practitioner, the x-ray
man and the laboratory technician while the em-
bryo neuro-otologist wrestles with the balance.
Necessarily, then, the work is more circum-
scribed. At the same time it is of distinct value
and should be carried out by all otologists.
Of the patients sent for examination, many
will come on account of dizziness or vertigo.
To the general practitioner, the most important
work of the Philadelphia School has been their
teaching that vertigo, in every case in its last
analysis, is the result of vestibular affection and
that examination of the vestibular mechanism
will give helpful information in the large ma-
jority of cases. In analysis of these cases, our
first step will be to study the responses from
the balance mechanism. If these are normal,
search for a transient toxemia. Ocular imbal-
ance or functional neurosis will follow in order.
Should the reactions be abnormal, we try to de-
cide by their character whether the lesion is
peripheral affecting the ear or the nerve, or cen-
tral affecting the brain stem, cerebrum or cere-
bellum.
Case 4. White, male, age 37. Mr. S. M. L. was
brought to my office with a history of headache, dizzi-
ness, abdominal pain and vomiting for three months
past ; for past six weeks, headache and dizziness in-
creasing. He has pain also in arms, legs and breast
and eyes feel sore. For past four days headache has
been so severe as to prevent sleep. Affects right side
of head only. There is a tender spot on crown on
percussion. His past medical history includes rheu-
matism and syphilis.
Examination : Well nourished ; face in repose, right
eye brow more elevated than left; action of frontalis
muscle normal; right palpebral fissure wider than
left; constant winking of both eyes. Action of facial
muscles normal. Protudes tongue in mid line. Eyes:
Right pupil two milimeters, reacts slowly to light,
more active to accommodation and convergence, media
clear, edge of disc clear, physiologic cup shows no
gross fundus lesion. Left pupil 2 : 5 mm., reacts free-
ly to light, accommodation and convergence, fundus
negative. Ocular rotations normal and no muscular
imbalance. Spontaneous Nystagmus : Looking
straight ahead, none ; to the right or left, a marked
horizontal and rotary nystagmus combined to the
same side; looking up, a very pronounced vertical
nystagmus upward; looking down a rotatory nystag-
mus to the right. Ears: Hearing normal, no head
noises. Equilibrium : Rhomberg — with eyes closed,
falls to left Change in position of head makes no
change in direction of falling. Walks (with eyes
closed) to left. Vestibular Reactions : There was op-
portunity for turning tests only and but partial re-
turns from these, due to taking time to get the other
necessary data incident to a case of this nature and
not having opportunity to finish the vestibular tests
at another visit. A diagnosis was made at the first
visit, treatment instituted and improvement followed
so rapidly, the patient saw no necessity for further
study.
After Turning: to right — horizontal nystagmus to
left of good amplitude for 23 seconds ; to left — hori-
zontal nystagmus to right of large amplitude for 40
seconds. Vertigo : After turning to right, there was
vertigo to left for 27 seconds. The reverse was not
recqrded. Past Pointing: Each arm past pointed cor-
rectly to both right and left, although somewhat re-
duced. Douching of both ears could not be done, so
that the most valuable part of the tests is not known.
A peripheral lesion was contra-indicated by i. nor-
mal hearing both ears, 2. absent head noises both
ears, 3. functionating horizontal semicircular canals
both ears. A central lesion was indicated by i.
marked vertical nystagmus. 2. falling in same direction,
regardless of position of head, 3. marked increase of
reaction from one side as opposed to the other, not
accounted for peripherally.
Diagnosis: A history of syphilis 10 years ago, a
plus 4 Wassermann at this time, with the above find-
ings made the decision Specific Encephalitis. Sal-
varsan intravenously brought rapid relief from his
symptoms.
Finally, among the patients referred to you
for various reasons, other than vertigo, such as
headache, failing vision, twitching eyes, etc.,
there will be some whose symptoms may point
vaguely to intracranial disturbances. Here '
again, abnormal responses from vestibular stim-
ulation may be the deciding point, sufficient to
make a diagnosis and in some instances, aid in
localizing the lesion.
Case 5. White, male, age 24 years, laborer. Mr.
W. H. referred on account of failing vision. Past
medical history includes nothing of value except in-
jury to head by the kick of a horse at nine years of
age, confined to the house for four weeks at that time.
Since then perfectly well and always active. Three or
four months ago, he noticed black spots before his
eyes, when stooping at his work. These gradually
grew worse, until two weeks ago, he stopped work on
account of loss of vision. Frontal headaches de-
veloped three or four months ago and have continued
to date.
Examination of the Eyes: O. D. pupil 4mm.. reacts
slowly to light, media clear, choked disc 4 D in height,
vision — counts fingers at three feet. O. S. pupil 4 mm.,
reacts to light slowly, media clear, choked disc 4,D
in height, vision equals 6/200. Perimetric fields,
showed a binasal hemiopia. Spontaneous nystagmus,
none.
Equilibrium: Rhomberg — slight swaying; change
of position of head has no effect.
After turning: to right — horizontal nystagmus to
left of good amplitude for 48 seconds ; to left — hori-
zontal nystagmus to right of good amplitude for 48
seconds.
Vertigo: to right — 10 second to left; to left — 12
seconds to right.
Past pointing: Each arm past pointed correctly to
right and left, the right arm continuing to past point
two or three times after left arm touched.
Douching with cold water at 68 degrees : Right ear,
head forward at 30 degrees; nystagmus — after 4 min-
utes— none, past pointing — each arm past pointed 4
inches to right.
Head back at 60 degrees ; nystagmus — horizontal to
left of good amplitude, past pointing — each arm past
pointed 12 inches to right.
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THE PENNSYLVANIA MEDICAL JOURNAL
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Left ear, head forward at 30 degrees: nystagmus —
after 45 seconds, rotatory to right of good amplitude ;
past pointing — each arm past pointed 8 inches to left.
Head back at 60 degrees; horizontal to right, ten-
dency to conjugate deviation to left, each arm past
pointed 24 inches to left.
.-\s a matter of course, the diagnosis in this case is
clear and is brain tumor.
This diagnosis could have been made easily without
the vestibular tests ; in fact, in a thorough study of
the case by a neurologist, the bilateral choked disc and
headache added to his other findings would probably
have made it. The interesting feature of the tests is
that they help to clear part of the brain from sus-
picion and to point in the direction of a possible lesion.
The reactions themselves suggest normal end organs
and nerves, medulla and cerebellum. Failure to elicit
nystagmus from the right vertical canals points to
blocking of the path in the upper half of the right
pons. Tendency toward conjugate deviation of left
horizontal canal by douching, points likewise to a
pressure high up in the pons. The extended nystag-
mus and past pointing suggest pressure irritation.
Further this would seem to act more on the right side.
The binasal hemiopia indicates pressure in the region
of the chiasm. The much smaller perimetric field of
the right side as well as the much lower visual acuity
as compared with the left side would also indicate
greater pressure on the right.
A temporal decompression was done, witn tempo-
rary improvement of the symptoms. For a year, I
have had no report of the patient.
SUMMARY
The so-called Barany or newer ear tests are
of great practical value in the smaller cities and
towns through their use by the eye, ear, nose
and throat specialist :
1 . In the .study of spontaneous nystagmus not
obviously ocular, and certain ocular palsies, giv-
ing definite assistance in assigning a point of
lesion.
2. In the study of various forms of laby-
rinthine disease, giving findings essential to
diagnosis and differential diagnosis not to be
.secured in any other way.
3. In the study of vertigo, where in most in-
stances the presence or absence of an organic
ctiologic lesion may be demonstrated. In its
jiresence. possible suggestion as to the region
involved and the possibility of treatment may be
given.
4. In the study of intracranial disease. Here
definite findings indicating such le.sion and a
suggestion toward its localization have in some
instances been given.
DISCUSSION
Dr. Seth a. Urumm (Philadelphia) : Doctor Sears
has brought to your attention the working of an in-
strument that every otologist can and should use in
the vestibular tests.
Just what are the vestibular tests? It has been my
experience on meeting many otologists in this coun-
try that they are regarded as a form of magic, that
they are not well understood and have but little prac-
tical value. This of course is not true. They are
tests which give almost mathematical conclusions and
are very definite in their constancy. We all know that
in the ear you have three canals and that you can
. stimulate these canals so that you get two distinct
phenomena : first your patient will experience vertigo ;
second you produce nystagmus. Further you get a
certain type of nystagmus if you stimulate the hori-
zontal canal and another type if you stimulate the
verticals. You get a rotary or oblique by stimulating
various combinations of canals and so it is that you
are able to produce different phenomena by sending
impulses along various tracts.
Of what use are these tests? They arc not theo-
retical postulations but have a distinct value to the
otologist and neurologist in otitic and intracranial
diagnoses, and the otologist who does not know how
to use the vestibular tests is no more an otologist than
the ophthalmologist who does not know how to do a
rhinoscopy.
Up to the time of the use of the vestibular tests we
had simply the fork tests, which at best informed us
as to the function of the auditory portion of the
eighth nerve and then our data was purely subjective;
while in the vestibular tests you do have conclusive
data, i. e. vertigo and nystagmus. Further, we are
<<ble to trace at least the vestibular tracts to a very
definite termination in the cerebral cortex which you
can readily $ee means access to much brain anatomy
and brain physiology.
This is a large subject and far too great to treat
within the short time given me but there is this mes-
sage I want to bring to you to-day that these tests are
not intricate, that it is not necessary to be a neurolo-
gist and that they are entirely within the scope of the
otologist. But the otologist must know the termina-
tion of his cochlear and vestibular branches and the
various structures with which they are closely asso-
ciated.
I hope if this paper of Dr. Sear's docs nothing else
it will be a stimulus to the men in this branch of
medicine to do their work intelligently and to remem-
ber that no otologist can make a reliable diagnosis
unless the vestibular tests are correctly used.
THE RELATION OF INTRANASAL
PRESSURE TO HETERO-
PHORIA*
J. MILTON GRISCOM, M.D.
PHILADELPHIA
During the past twenty-five years the intimate
and important relation existing between the
nose, its accessary cavities and the eyes have
been the subject of a vast amount of research
and study. Ophthalmologists and rhinolc^sts
are now well informed regarding the effect of
inflammatory lesions of the nose on the orbital
contents, and accordingly the present communi-
cation is not concerned with this relationship.
There is, however, another variety of influence
exerted by the nose on the eye about which but
•Read before the Section on Eye. Ear, No»e and Throat
Diseases of the Medical Society of the State of Pennsyhanii,
Pittsburgh Session, October 6, 1920.
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August, 1921
INTRANASAL PRESSURE— GRISCOM
805
little appears in the literature, namely the reflex
ocular phenomena secondary to intranasal pres-
sure.
In a paper reporting a number of cases of
asthenopia relieved by removal of pressure be-
tween the middle turbinate and septum, Stauf-
fer (Annals of Ophthal. V. 26, P. 13) com-
plains of the scarcity of literature on the sub-
ject. Commenting on his paper the editor of
the N. Y. State Medical Journal (V. 106, P.
227) agreed that this relation between the eye
and the nose was not a matter of common
knowledge or investigation, although its exist-
ence had been recognized by others.
Several writers, among them Dr. Emil Grue-
ning, as early as 1886 called attention to the
leflex ocular symptoms in nasal affections, but
almost without exception the cases observed
and the conditions discussed were those con-
cerning inflammatory lesions of the nasal ac-
cessary sinuses. In 1887 Nieden (Archives of
Ophthal, 1887, 415) observed that there were
many cases of asthenopia with inability to use
the eyes for any length of time for which no
cause could be found other than a chronic nasal
catarrh, all the asthenopic symptoms disappear-
ing when the nasal disease was relieved.
During the discussion of Veasey's paper on
"Paralysis of Accommodation" (Trans. Amer.
Ophthal. Soc. 1919, v. 12, P. 440) Duane said
that for several years past in all cases of sub-
normal accommodation he insisted on having
the nose examined, since it was his experience
that accommodation weakness was often de-
pendent on conditions of pressure within the
nose without perhaps any sinus involvement at
all. He was often surprised at the effect the
removal of such pressure had on the accommo-
dation. Thus while the reflex influence of in-
tranasal pressure on the third nerve has been
fully recognized, so far as the writer has been
able to determine observations have been made
only on the accommodation, with one excep-
tion. In 1908 Ziegler (N. Y. Med. Jour., Nov.
7, 1908) called attention to heterophoria and
muscular asthenopia secondary to abnormalities
of the nose. He was probably the first to em-
phasize the reflex influence of simple mechanical
intranasal pressure on the eyes, and he states
that we must accept as an infallible rule the
dictum that pressure contact in the nose will
always excite some reflex disturbance when any
hyperesthetic area is impinged upon. In view
of the scant repftrts in the literature the writer
considered the subject of sufficient interest and
importance to justify again calling attention to
it. The details of two cases will illustrate the
condition under discussion.
(i) C. M. B., Jr., white, male, age 30. Since
childhood he had suffered from headaches,
ocular discomfort and inability to read for any
length of time. The media and fundi in each
eye were entirely negative. Under atropine
cycloplegia his correction was O.D. S. — 0.12-
Cyl. — 0.50 axis 90°=2o/i5. O.S. Cyl.-fo.25
axis 90° Cyl. — 0.50 axis i8o°=20/i5. With this
correction he had no esophoria or exophoria at
20 feet, but there was a hyperphoria of variable
degree. During the test with the Maddox rod
the vertical error would fluctiate from 2 to 5
Prism Dioptres, and was never constant. The
futility of attempting to satisfactorily correct the
hyperphoria was shown by the fact that he had
worn glasses for fifteen years with prisms which
were changed every few months with consist-
ently unsatisfactory results. During the search
for the cause of the fluctuating heterophoria it
was discovered that a sharp septal spur was
pressing on a swollen middle turbinate. The
nasal condition was corrected by Dr. Walter
Roberts in March, 1911. On May 31, 1911, the
writer found a hyperphoria of 4 prism dioptres
with no variation at all. This correction was
incorporated in his glasses and his relief from
all muscular asthenopia was marked. The pa-
tient gained in weight and could read at night
or on the train with greatly increased comfort.
Several examinations have been made during
the past nine years and the hyperphoria has re-
mained constant. In this case there was no
ethmoid or sphenoid sinus involvement.
(2) H. W. P., white, male, age 29, came in
June, 1915, complaining of ocular pain and
frontal headaches following the use of his eyes
for near work. He was a first-year law student
and had about decided that it would be impossi-
ble for him to continue his studies. He had
been refracted several times withouf relief.
Under atropine cycloplegia his correction was
O.D. S-fo.50Cyl.-fo.75 axis oo°=2o/i5.
O.S.S+o.25Cyl.-fioo axis 90°=2o/i5. This
was substantially the same as he had been wear-
ing. The near point with correction was 20 cm.
in each eye. The muscle test with Maddox rod
revealed no hyperphoria, but there was an
esophoria varying from 15^° to 8° and never
remaining stationary. An examination of the
nose revealed a septal spur on the right side
pushing into the middle turbinate. The spur
was removed by Dr. Wm. P. Vail, and one
month later a muscle test with Maddox rod
showed an esophoria of i>4° constant in char-
acter. There was no involvement of the eth-
moid or sphenoid sinuses. A recent letter from
the patient stated that he had been able to corn-
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THP: PENNSYLVANIA MEDICAL JOURNAL
August, 1921
plete his college course without any ocular dis-
comfort.
The interesting feature in the above two cases
was the variable heterophoria associated with
intranasal pressure, and the cessation of the
muscular instability after the pressure had been
removed.
The writer is well aware of the fact that the
ethmoid or sphenoid sinuses may be the seat of
trouble without any gross evidence of inflam-
matory involvement, but in the cases reported
there was every reason to believe that the pre-
dominating etiologic factor was the pressure be-
tween the septum and the middle turbinate
which reflexly caused an irritability of certain
extraocular muscles.
The connection between the sensory stimulus
in the nose and the reflex motor effect on the
eye has been traced by Schaeffer (The Nose
and Olfactory Organ, p. 286) as follows : "The
cells of the sensory or terminal nucleus of the
trigeminal nerve together with their processes
constitute neurons of the second order in the
common sensory pathway from the nose. The
centrally directed processes or axons form a
distinct bundle, the trigeminothalamic tract,
which passes cranialward through the reticular
formation and the tegmentum to end in a spe-
cial portion of the thalamus by synopsing with
(he neurons of the third order in the pathway
from the nose to the cerebral cortex. Axon.s
from the nucleus of termination of the trigemi-
nal nerve and collaterals from the trigemi-
nothalamic tract in its course through the me-
dulla are given to various motor nuclei, espe-
cially the facial, ma.sticator, and the nucleus
ambiguous (of the vagus and glossopharyngeal
nerves) for simple reflexes. Moreover some of
the reflex or association axons from the cells
in the nucleus of termination of the trigeminal
nerve contribute fibres to the medial longitudi-
nal fasciculus, some of which are long and de-
.scend below the level of the second cervical seg-
ment, terminating in the gray substances of the
spinal cord. Since one of the salient features
of the medial longitudinal fasciculus is to a.sso-
ciate the oculo motor, trochlear and abducent
nuclei, the association axons from the trigemi-
nal terminal nucleus coursing in the bundle
doubtless are brought into relationship with the
nuclei of the eye-moving mu.scles."
With the chain established between the sen-
sory stimulus and the motor effect it is evident
that intrana.sal pressure can have a very marked
influence on the nuclei of the eye-moving mus-
cles, reflexly producing motor stimuli of a char-
acter that would result in an inconstant hetero-
phoria. Indeed, when we recall that nasal dis-
turbances are the cause of such different reflex
jihenomenon as sneezing, asthma, lacrymation,
indigestion, alteration of cardiac rhythm, and
numerous sexual reflexes, it would be surpris-
ing if the ocular muscles remained immune
from this influence.
The above communication is submitted with
the knowledge that nothing essentially new has
been presented, but with the hope that in cases
of varying and fluctuating heterophoria atten-
tion may be directed to the nose as the possible
underlying etiologic factor.
DISCUSSION
Dr. William W. Blair (Pittsburgh): I r^fret ex-
ceedingly that I have not had access to Doctor Gris-
com's paper in time to prepare a formal discussion,
and I really feel that I have nothing of value to offer
in this line. I think it is an extremely interesting
topic because we are all constantly brought face to
face with these cases of eye muscle involvement which
are apparently connected in some manner with dis-
turbance of the accessory sinuses. I know that work
done in the laboratory established in connection with
the ear service in the ward, developed very many
curious and apparently discordant facts with regard
to the effect of air in the sinuses, in the eustachian
tube, etc. Various heterophorias were quite common-
ly observed. These were roughly attributed to air
pressure, but whether the air pressure acted in the
manner that has been indicated by Doctor Griscom's
paper, I am unable to say. I am very sorry that I
know so little about the subject. I should like to hear
from some one more familiar with it
Dr. David I. Giarth (Ford City) : I desire to em-
phasize the importance of clinical examination of the
nasal chambers. In all my cases of refraction or
strabismus I make it a practice after determining the
squint to examine the nostrils, and almost invariabl;
you will find some difficulty, some deformity or hyper-
trophic condition which requires treatment. Of courst
if the nasal ducts are obstructed that adds to the dis-
comfort of the patient by the moisture constantly
there. Therefore I would urge that you always make
it a point to inspect the nasal passages and, of course,
if it is necessary the sinuses and antrum, in adolb
particularly. I am very much interested in this paper.
To me it is very timely and one that should demand
our careful consideration in practice.
ALTERED BLOOD PRESSURE AND ITS
RELATION TO IMBALANCE*
D. J. McCarthy, m.d.
Professor of Medical Jurisprudence, Univermtjr of
Pennsylvania.
PHILADELPHIA
Two fundamental factors are involved in the
consideration of the subject assigned to me:
(a) The influence and effect of normal and
faulty nervous enervation on visceral function
and (b) The cross effect of this on infections
•Read before the General Meeting of the Medical SocielT "f
the State of Pennsylvania, Pittsburgn Session, October 6, 19^^
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August, 1921
ALTERED BLOOD PRESSURE— McCARTHY
807
and of infections and infectious processes on
the nervous reserve.
We might well indeed take as a text for the
paper that it makes not so much diflference what
disease the patient has, as what patient (what
kind or tyj)e of individual) the disease has.
Any slight disturbance of visceral function in
some individuals becomes a disease, a matter
for medical consideration; whereas in others
even severe organic disease may exist without
much disturbance of the normal functioning of
the individual.
If we make a study of the former group, the
so-called functional group, we will find that we
are dealing either with machines damaged by
age, or infections, or abuse ; that a medical con-
dition exists when there is either an inherent
Jack of nerve reserve (which I take to be the
rare exceptiwi) or where some condition has
existed in one of the critical as differentiated
from the fundamental age periods, that has led
to some damage to the nervous mechanism, or
has acted as a continuing nervous drag, absorb-'
ing nervous energy that is necessary for carry-
ing on the purely vegetative functions of the or-
ganism.
The physician often fails to recognize that an
organ does not function automatically, but that
it needs a nervous mechanism and that the nerve
potential, the charge of the battery so to speak,
must be kept above a certain level if the func-
tion of the organ is to be kept up to normal.
He fails too often to recognize the added im-
portance of this nervous reserve level when or-
ganic disease is present. Mitchell indeed is
gone, and with him went the rest treatment.
The more is the pity, because we are rapidly
losing sight of the value of rest and the rest
treatment, not as Mitchell intended it for the
purely functional conditions, but indeed for the
organic condition of the various viscera. How
many men are there to-day trained to the rather
highly technical use of rest? Rest is admitted
to be one of the most important factors in the
treatment of chronic lung, heart and kidney
cases, and yet one goes through hospitals and
sanatoria and finds that the conception of rest is
to put the patient to bed. To build up that
nervous reserve that means success or failure in
a severe heart case requires much more skill
than putting the patient to bed, and leaving the
rest to nature and digitalis. This indeed is
very crude technique, when the detailed scien-
tific method was given to us by one of the mas-
ter minds of medicine. The important matter is
to bear in mind that he who neglects the nervous
reserve back of the functioning of a damaged
organ is going to fail in many cases that would
otherwise yield to treatment ; that in some cases,
nerve drags and nerve leaks must be corrected
and a deliberate attempt made to recharge the
batteries and to correct the damaged disturbed
functions of other organs due to the faulty
functioning and nerve drag of the organ mainly
diseased.
If our war experience, medicine en masse,
taught us any one thing it was this, that fatigue
and exhaustion, nerve exhaustion, if you will,
were very potent factors in the production of
diseased conditions, incapacitating conditions,
affecting the heart, the lungs, the gastro-intes-
tinal tract and other organs. We met here in
Amenca, in the camps, cases where a deficient
machine refused to function because its nerve
reserve was too low and functional heart and
gastro-intestinal disorders were a fairly large
class demanding attention. In the selected
group that was sent to France we were dealing
with relatively good machines, but where phys-
ical and nervous exhaustion factors produced a
somewhat similar group of cases. I am not
dealing here with shell-shock, so-called, but
cases admitted to a general medical service.
Here again we might differentiate between that
individual group produced by actual shell fire
and the exhaustive group produced by the ex-
haustion of the march in from the old line to the
Rhine.
When we begin to apply the theory of a fully
functioning nerve reserve, to the diseases of
civil life we are met with the same problem as
in the army. Why does this machine fail to
function properly under stress and strain, when
the examination gives no evidence of organic
disease or at least no such organic disease as the
clinician is accustomed to diagnose as pathologi-
cal. The range of disabling function extends
from simple exhaustion without other clinical
.symptoms to support it, tachycardia, dyspnoea
on exertion up to the typical neurasthema .syn-
dromes and the insanities.
To take the grosser cases: Why in a group
of ten physically fit men in the march into Ger-
many did one show mental symptoms whereas
the others showed a simple exhaustion, recu-
perated from in a few days' rest? In order to
understand this we must not only survey the
machine from the viewpoint of its physical ca-
pacity for the work in front of it, but we must
attempt to estimate its nerve reserve. It goes
without saying that a man of 150 pounds weight,
who carries day after day, from twenty to thirty
miles, a pack varying from forty to sixty
pounds, is going to suffer more from exhaus-
tion than a man who weighs 170 to 180 pounds.
A man who smokes twenty cigarettes in a day
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THE PENNSYLVANIA MEDICAL JOURNAL
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is going to show more nerve symptoms in ref-
erence to his heart and circulation than one of
equal weight who is moderate in the use of to-
bacco. A man who starts out on such a test
with a low blood pressure, to which are added
the other factors, is going to show symptoms
earlier than the other groups.
In the gas groups we are dealing with the
.same factors in many cases, and with the same
results. Men equally gassed give the widest re-
actions from a purely nervous and visceral
functional derangement symptomatology. In
the milder acute infections we were met by the
same problem.
Almost uniformly when dealing with func-
tionally deficient individuals, those who, on in-
spection, gave bad reactions to stress-conditions
gave the first clue to the differentiation of the
really deficient from the malingerer. The regu-
lar life in the army gave to the normal infection
free, individual a ruddy healthy glow. A
washed-out appearance with poor color and re-
laxed skin and muscles, was the clue to some
damage to the machine. In other words we
were dealing with a potentially sick individual.
A further detailed study revealed as a rule the
underlying cause of the condition. This might
be organic or it might be a functional derange-
ment.
It is with this latter group that we are mainly
concerned. Whether dealing with pseudo-gas
cases or sequellae from mild gassing incipi-
ent pulmonary diseases following gas or the
"flu," transient albuminuria, nervous exhaustion
groups, or mental disea.ses, we were concerned,
in order to arrive at a proper estimate of the
case, with the functional potential of the organ
involved and the machine as a whole. If the
machine was a poor machine, damaged in the
making or by recent experiences, functionally
inefficient and with a low nerve reserve, it was
best to recognize this and ship the man home
rather than send him back to the line, where he
would break again from some new experience.
In dealing with visceral inefficiency we were led
to conclusions along similar lines. The army
was the test of a well balanced machine, phys-
ical, nervous and mental. In the estimation of
the functional value of the machine, it will be
seen that we are dealing not only with the
normal constitution, so to .speak, but also with
subsequent changes.
So much has been written on the subject of
arterial hypertension that it would be as well in
this paper to consider the subject of imbalance
from the viewpoint of hypotension.
.■\fter birth the mental and nervous develop-
ment is very rapid up to the fourth year. In
many ways this is a critical period. It is the
l^eriod during which the crawling quadruped is
stood on his hind legs, so to speak, placed on
his feet. Up to the adolescent period the natu-
ral growth and adjustment is more or less auto-
matic up to the second critical period — that of
adolescence. After adolescence is passed the
machine again is stationary and resistant to dis-
ease up to the involutional period, when a period
of decline of function and a progressive failure
of resistance takes place. The period of great-
est danger from damage to the maclxine is in
the first post-birth period, next to this is the
period of growth and preparation, next the
adolescent period and finally the results of sec-
ondary changes at the period of involution.
The balancing factors in the prenatal and
postnatal periods are the glands of internal se-
cretion, the so-called endocrine system. .It is, I
think, admitted that any fault in any one of the
important endocrine glandular structures leads
to an essential fault in the blood pressure mech-
anism and any fault here leads to serious
damage to the developii^ brain and nervous
system. A statistical study by Barr shows, for
example, that tuberculosis in the parents is one
of the important factors in the production of
imbecility. In dealing with tuberculosis we are
dealing with a disease that has a fairly constant
action in depressing the arterial tension. It is
the one great constant causative factor in pro-
ducing hypo-tension. It will serve, therefore,
as the best example of a chronic infection in the
post-natal period, in that its action on the de-
veloping machine and the continuing effect can
be followed through the life history of the indi-
vidual. Tuberculosis is in many ways better
than syphilis to study, inasmuch as the primary-
infection occurs at the early period, and its sec-
ondary manifestations reach their maximum of
importance at the adolescent period.
An infection of tuberculosis in infancy will
run its course, as a rule, in several months.
Not infrequently it is a matter of two or three
years before the system is entirely free from the
infection, i. e., until the case is cured or the
lesion healed. During this period of time sev-
eral conditions are established that have a
marked influence in the life history of the indi-
vidual affected :
(a) In the first place the general health is
seriously involved; a lack of normal vigor is the
rule. The child faiU to gain in weight, the gen-
eral nervous reserves are .seriously affected and
a disturbance of function of all the organs leads
to a faulty nutrition of the brain and central
nervous system.
(b) A chlorotic type of anemia is the rule.
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ALTERED BLOOD PRESSURE— McCARTHY
809
This lowers the general resistance, disturbs the
metabolism and in turn aflfects the rapidly grow-
ing nervous system.
(c) As a result of this the reflexes are al-
tered. Not only are the tendon reflexes in-
creased and exaggerated, but the mental reac-
tions and visceral reflexes are likewise affected.
The visceral reflexes show the same hyper-
activity and this has an important bearing on
their function, not only during this period, but
through the life of the individual.
(d) The blood pressure is reduced far below
the normal and persists through childhood,
adolescence and adult life as such. Here again
we are dealing with a factor that interferes with
the general nutrition of the brain by an altera-
tion of its blood supply. It is likewise one of
the contributing factors to the altered reflex ac-
tivities of the organism.
(e) The constant, continuing strain of the
defenses of the body in the effort to throw off
an infection persisting for a long period of time
has an important influence on the life and vigor
of the endocrine system. There is a tendency
to accept the principle that a serious disturbance
of any one of the endocrine glands has a dis-
turbing if not a pathologic effect in the function-
ing of all of these structures. Primarily pul-
monary tuberculosis is essentially a disease of
lymphatic structures. Its effect on the thymus,
as a part of the lymphatic system, would tend to
derange the general endocrine functions. Sys-
temic tuberculosis has been shown to produce a
very decided effect directly on the thyroid and
my own studies of the pituitary have shown that
it is rare in terminal tuberculosis to find a pitui-
tary that does not show the same structural
change. It is not necessary to call attention to
the altered function of the adrenals, nor to call
attention to the influence of this organ on
general blood pressure states — more particu-
larly the depressed states. Apart from the di-
rect action of tuberculosis on the endocrine sys-
tem, the stress of continuous effort at defense
and the balancing of visceral function of a seri-
ously damaged organism lead to a change in
the nature of exhaustion that finds its secondary
reaction at the time of adolescence (the second
crucial period).
(f ) Finally the general loss of tone and vigor
leads to a general relaxation of tissue tone.
This may be specific or a part of a general loss
of tone. We find its manifestation in the re-
laxed chest, the relaxed abdomen, a visceropto-
sis, flat feet, and the lower relaxed blood pres-
sure above noted. When we sum up all of these
factors in the growing child, we have the mo-
rasmic or .semi-morasmic or hypo-normal child
physically, with flat chest and dropped abdo-
men, with increased mental and physical re-
flexes.
As the child grows to manhood, the increased
mental reflexes give a hypersensitive individual,
with a tendency to introspection to explain its
physical limitations and a tendency to dissocia-
tion of personality. A mental acuity as a rule
is the normal for the family and class type and
an ambition and drive far beyond the physical
stamina. In college these children are apt to
grow into the scholastic type, to take high places
in their class and college. Psychologically they
are apt to be suspicious on account of the rela-
tive cerebral anemia, unhappy, restless, with
nervous irritability and nervous imbalance — a
lessened degree of what is often seen as the
nervous and mental picture in Pott's disease.
One can readily see in these cases the possi-
bilities of trouble and unhappiness.
In cases where the brain tone is normal and
of vigorous inheritance the adolescent period
may be passed without difficulty. It is, how-
ever, a period of danger. If there should be no
recrudescence of active tuberculosis, there is
still considerable danger from the readjustment
of the endocrine mechanism. Not infrequently
we see in this group of cases the development
of adolescent insanity of the type of dementia-
praecox. I take it that we are here dealing with
a complex type of intoxication acting on a brain
and nervous system already damaged by the
constant stress of the factors already enumer-
ated. Transient mental states at the period of
adolescence are very common. The function of
growth of the mesoblastic tissues on the part of
the thyroids and pituitary having been termi-
nated, the new function of reproduction from
the sexual glands adds a new factor to an al-
ready complex situation. The added stress of
function on the entire endocrine system, already
damaged by the early infection, leads to perver-
sions of function of the glands and other vis-
ceral functions they activate. The arterial hj'po-
tension is accentuated, the thyroid is often en-
larged, there is a persistent tachycardia various
vasomotor manifestations, etc. This condition,
if not recognized in its etiologj', may follow the
usual course of a dementia praecox terminating
in dementia, with death from pulmonary tu-
berculosis.
In individuals, where the nervous resistance
to mental imbalance, inherent or acquired and
fixed through discipline, carries the individual
safely through this dangerous period, we usually
find in the matured adult a career of nervous
energy alternating with periods of ill health due
to exhaustion, the so-called neurasthenia. j
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THE PENNSYLVANIA MEDICAL JOURNAL
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Between forty and fifty, the critical involu-
tional period, when the sexual productive factor
declines and a new readjustment of the en-
docrine system is needed, new complications in
the life history, as a result of the partial or com-
plete failure, is likely to occur. This is the
period of what may be termed the depressive
psychoses. It usually begins with simple de-
pression associated with indigestion and irrita-
bility. This progresses slowly to a real melan-
cholia which, on account of the high reflex ex-
citability and nervous irritability, may be of the
agitated type. Not infrequently the following
.syndrome is presented :
(a) Healed or slightly active pulmonary tu-
berculosis; (b) arterial hypotension; (c) vis-
ceroptosis and flat feet; (d) hypo-nutrition;
(e) mucus colitis; (f) hypothyroidism.
When we arrive at the senile and presenile
periods we meet with conditions often very puz-
zling, such as uremic states, states with myo-
cardial changes, advanced arteriosclerosis, un-
questioned faulty action of the kidneys with
normal blood pressures. These are the cases
where, through the life history of the patient,
we were dealing with blood pressure varying
from 90 to no. In such cases a blood pressure
of 130 to 145 is the equivalent of 180 to 200 in
the non-tuberculous individual. The senile and
presenile mental states are not infrequently due
to faulty action of the cardiorenal system on
this basis.
So far I have simply followed out the sequel
or sequellae of a damage to the machine at the
first critical period. My time does not permit
me to outline the physical and mental conse-
quences of a continuing infection, like syphilis,
at the adolescent period. In addition to the
phy.sical changes we have here as a predominat-
ing factor the mfental shock, with the same evil
consequences of dissociation of the personality,
nervous exhaustion and drag, as in the tubercu-
losis groups.
The evil effects of physical and mental dam-
age at the involutional period are not so great as
at the first two critical periods. The life pro-
ductive work is largely finished. The evil con-
sequences of damage at this period are negligi-
ble from a biologic standpoint. They are often
liarbingers of old age. The decadent period
after all is the test of physical and mental fit-
ness, of proper adjustment or maladjustment,
of proper use or abuse of the machine. The de-
fects of the period of growth and of the pro-
ductive period are magnified in the decadent
period. If the defenses of the organism have
suffered from stress or accident or design at the
critical periods, the defenses are weakened.
The decadent 'period is the period of de-
veloping infectious processes — terminal proc-
esses. The resistance at this period being low,
any process, whether it be in the bronchial tree,
in the gall bladder area, or in the genito-urinary
tract, is likely to become active in its efifect on
the general organism, and increasingly so as the
exhausted or damaged endocrine system fails in
its adjustment on the one hand and in its de-
fense power on the other. Many cases of so-
called senile states are not as hopeless as they
seem if local infection can be removed and the
functional activity of the various viscera be
cared for by lessening the work thrown on
them, and the endocrine action compensated for
by substitution therapy. If the senile state is
due to brain damage by sclerotic areas second-
ary to cerebral arteriosclerosis, we are dealing
with a hopeless condition. The decadent period
is, as a rule, a period of intoxication either en-
dogenous and metabolic or by progressive in-
fections, either local with systemic effects or
general.
We return to the text. It is not so much a
question of the disease as of the individual who
has the disease, his life history and what has
happened to him and his family.
Therapeutics is an art, not a science. Diag-
nosis is the science of medicine. The treatment
of the case is an art that must be studied under
a master. The apprenticeship under masters
like Mitchell and Wood prepares men to treat
disease after the diagnosis is made. The rest
treatment of Mitchell has a much wider applica-
tion to-day in visceral disease than it had dur-
ing his life time, only, there are.no students
under masters who teach how rest is to be ap-
plied in the normal and pathologic lives of their
flock.
SELECTIONS
INFANTILISM IN CHILDREN*
J. D. LEEBRON, M.D.
PRILADeLPRIA
Instructor in Pediatrics, Gradtute School of Medicine of tbe
University of Pennsylvania.
Infantilism is a subject which has caused con-
siderable confusion, especially the infantilism in
children. This is due to the fact that in any
kind of inhibition of development, infantile fea-
tures may be retained so that unless a clear defi-
nition and a simple classification is set forfli,
there will always be possible a wide range of
opinion.
'Read l>efore the Northern Medical Association during tkc
meeting of February ii, 19*1 .
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INFANTILISM IN CHILDREN— LEEBRON
811
Griffith defines infantilism as a condition
where there is a persistence to a greater or
less extent of the bodily and often of the
psychic characteristics of infancy or child-
hood. While this definition applies to such in-
dividuals as attain adolescence or adult life, it is
found in infancy as well, when the condition is
comparatively a relative one, since there is a per-
sistence of characters, especially the somatic
ones, belonging to a time of life decidedly earlier
than the actual age of the patient.
Infantilism should be distinguished from
other disturbances of growth and nutrition in
the child. These occur as a result of either a
diseased state of one or more of the internal
glands or where there is interference with the
propei- function of the endocrine system. There
are several varieties of infantilism and while a
number of them develop as a result of disorders
of internal secretions, many of them are depend-
ent on other physical disturbances, as will be
pointed out later. It is interesting to mention
at this time that Falta condemns attempts to
blame infantilism as directly caused by diseases
of the glandular system. He includes this condi-
tion in his group of vegetative disturbances. It
is his belief that in true infantilism the organism
does not progress beyond the child stage of de-
velopment on account of damage in fetal or post-
fetal life. He further claims that the ductless
glands as well as the sexual glands functionate,
but only as in the child organism. Their com-
plete failure to functionate would result in the
genitalia, being eunuchoid.
The classification as modified by Gilford
seems to be the most logical one and is the least
confusing. He divides infantilism into two
main classes : A — the essential groups, which in-
cludes ateleiosis and progeria, both evidently be-
ing a freak of nature where the direct etiology
is unknown except that it is familial and heredi-
tary ; B — the symptomatic group, which includes
all the other forms in which the cause is known.
Here the infantilism is secondary to some dis-
turbance of function or other previous morbid
factors. There is also a less conspicuous arrest
of development and the persistence of child-like
somatic characters is not so pronounced. The
ateliosis group, also known as spontaneous, are
the most typical cases of infantilism, and in this
category are included many of the professional
dwarfs. This group may be divided into sexual
and asexual types, both of which possess an in-
herited and familial predisposition. In sexual
ateliosis, the infantile features persist until the
time of puberty, which as a rule is delayed. At
this time, there is a normal development of the
sexual organs and powers. The osseous changes
naturally corresponding to this process occur,
but there is an arrest of further growth of the
body, causing the individual to remain a minia-
ture human being with the size, physiognomy
and proportions of a child. In the asexual types
of ateliosis the entire body development is
markedly delayed, some parts more so than oth-
ers, especially the sexual organs. At puberty,
the sexual organs and powers do not develop and
many of the epiphyseal and body changes do not
occur. Growth advances very slowly, continu-
ing well into adult life. The other general
somatic characteristics persist. There is no in-
volvement of the intellectual powers. In some
of these cases the sexual organs eventually ma-
ture. These are not classified as asexual
ateliosis.
Progeria is very uncommon and signifies pre-
mature old age. Here there is a decided infan-
tilism with premature decay and is evidenced by
the early development of white hair or baldness,
arteriosclerosis, emaciation, and wrinkling of the
skin. The general carriage and appearance is
that of an old person, although in actual age the
patient is no more than an adolescent or young
adult.
Symptomatic infantilism, as mentioned in the
early part of this paper, is characterized by a
known etiology. Two types may be recognized
if a classification is formed on the clinical ap-
pearances of these cases : A — the Lorain, B — the
Brissaud. Classifying these cases from an eti-
ologic standpoint which is probably the better
way, the following types have been recognized:
A — intestinal, B — pituitary, C — pancreatic.
In the Lorain type the intellect may be normal
or its development retarded. The size of the
body remains stationary at puberty and the pro-
portions are that of a miniature adult. There is
a failure in development of the genitals and of
other sexual characteristics. These cases are
usually in poor health. Among the etiologic
factors there are : ( i ) any cause tending to pro-
duce malnutrition, such as malaria, tuberculosis,
defective hygiene, insufficient or improper food
(I have at present two cases of this type, both of
which are improving. One is a colored boy, age
7, who compares and measures physically with a
normal boy, age two and a half years. The sec-
ond case, a white boy, age 9, which I compared
with a normal boy, age 4, both being the same
size. He gained J^ inch and 3 pounds in four
months under thyroid treatment and physical
corrections) ; (2) heart disease congenital or
acquired in character; (3) arterial hypoplasia;
(4) chronic poisoning from within as in chronic
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THE PENNSYLVANIA MEDICAL JOURNAL
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autointoxication; (5) the lymphatic diathesis;
(6) the last but not the least important in eti-
ology, is congenital syphilis.
In the Brissaud type there is a tendency to
obesity. The body is small, the head large, the
abdomen prominent, the limbs short and
rounded, the trunk relatively large, the sexual
organs are undeveloped, the somatic proportions
are infantile and the intellectual development is
retarded. This condition has been attributed to
hypothyroidism in some, and to pituitary dis-
turbances in others. It is often referred to as
myxedematous infantilism. An example of this
type has been under my observation at the Poly-
clinic Hospital for nearly two years. He is. an
Italian boy and is doing remarkably well since
thyroid has been given him.
In the intestinal type of infantilism, there is
an arrest of growth with emaciation and anemia.
Fatigue is marked on slight exertion. The abdo-
men is distended and diarrhea is a frequent oc-
currence. There is a decided thirst with a vari-
able appetite more often excessive. The intel-
lect as a rule is normal, at times the child is pre-
cocious. These cases have an increased amount
of urine whose principle abnormality is an ex-
cess of ethereal sulphates. The feces are whitish
in color, gruel like in consistency, and of an of-
fensive odor. In the stools of these cases a large
amount of fat is formed, especially in the form
of fatty acids or soaps. The disease usually be-
gins when the child is about two or three years
old and may last several years with periods of
improvement followed by relapse. Herter,* who
made a special study of this variety of cases,
claims the presence in excess of g^am positive
organisms replacing the normal intestinal flora.
The bacillus coli and bacillus lactis aerogenes are
absent, while the bacillus bifidus, bacillus infan-
tilis and coccal forms characteristic of infancy
are still present. The condition here is a chronic
intestinal infection resulting in interference with
nutrition and in tissue starvation.
The pancreatic type of infantilism does not
differ from the intestinal one ; the general symp-
toms are similar. Bromwell,'' who described this
condition, claimed remarkable improvement fol-
lowing the administration of pancreatic extract.
The pituitary type of infantilism is often called
Frolich's syndrome, as it was first described by
him. Bartels called this type, dystrophia adiposo
genitalis in which the characteristic symptom is
the marked tendency to obesity. A typical ex-
ample of this form of infantilism was reported
by Griffith in the American Journal of Diseases
of Children. It was a male child with a tendency
to obesity ever since he was 11 months old. At
the age of 1 1 years, he measured 5 feet, i inch in
height and weighed 251 pounds. His genitals
and sella turcica were smaller than normal. His
sugar intolerance, which was increased, markedly
diminished after continued administration of
pituitary extract. The treatment had no effect
on the obesity. These cases are caused by hypo-
pituitarism which results from either a disturb-
ance of the pituitary body functions or the pres-
ence of a tumor. They lack hair in the axilla or
over the pubis. The sexual organs remain in-
fantile in character, and where this condition de-
velops in adult life there is a reversion to the in-
fantile state. There is a polyuria and an unusual
tolerance for carbohydrates but no glycosuria.
Drowsiness, asthenia, sluggishness and a sub-
normal temperature are characteristic.
Many of the other types have been mentioned
and named according to the disturbed organ
causing it, such as renal in chronic interstitial
nephritis, hepatic in cirrhosis of the liver, car-
diac, status lymphaticus, etc. There are many
conditions that stunt the growth. In most in-
stances of infantilism there is probably a dis-
turbed communication somewhere in the endo-
crine system. Infantilism differs from sporadic
cretinism, which is known by many other terms,
each designating a different degree of thyroid
insufficiency. A typical cretin is easily recog-
nized by the vacant expression of the face, the
large, thick, protruding tongue, the coarse hair
and fatty tumors. The hands are usually broad
and squat, with short shrimpy fingers. The
myxedematous skin is characteristic of cretinism
and absent in infantilism. It is harsh and dry
and thickened. It has creases and does not pit
on pressure, though it looks edematous.
Pfaundler and Schlossmann' recommended a
radiogram of the hand.as an absolutely sure diag-
nostic method. This will immediately differen-
tiate infantilism from dwarfism or nanism re-
sulting from premature ossification because of
severe rickets or achondroplasia.
The treatment of infantilism depends on the
determination of the cause. While the Brissaud
type responds to thyroid extract very readily, it
should be administered in all forms. Pfaundler
and Schlossmann claim thyroid to be particularly
recommended where the radiogram shows a back-
wardness in the appearance of the nuclei of the
carpal bones and epiphysio of the metecarpals
and phalanges. The pituitary types are aided by
taking pancreatic extract. In Herter's type the
intestinal condition must be corrected.
247 S. Thirteenth Street.
REFERENCES
t. Trans. Assoc. Amer. Phjrs., 1910, xxv, 528, Intestinal In-
fantilism, 1008.
2. Scottish Med. Journal. 1904, xlv. 321.
3. The Diseases of Children, edited by M. Phaundler and .\.
Schlossman. Vol. 11 1, page 540. i ' /-^r^t^lry
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PITTSBURGH ACADEMY OF MEDICINE
813
PITTSBURGH ACADEMY OF
MEDICINE
ABSTRACTS
DIAGNOSIS AND TREATMENT OF
CARCINOMA OF BLADDER
DR. C. H. AUFHAMMER
It appears that carcinoma of the bladder is
very often diagnosed, at too late a stage to in-
stitute radical treatment. The reason for this
late diagnosis is the lack of definite symptoms,
due to the noninvolvement of fixed portions of
the bladder and because often the chief symp-
tom— hemorrhage — is wanting. We have been
impressed with the frequency with which car-
cinoma is found involving the vault or lateral
walls without producing any symptoms refera-
ble to the bladder itself except, perhaps, mi-
croscopic blood.
The varieties of bladder carcinoma are: i.
Epithelioma. 2. Columnar celled Carcinoma
secondary to carcinoma of the uterus and rec-
tum. Epithelioma usually occurs after 40 and
begins in one of two ways: (a) As a benign
papilloma which subsequently becomes malig-
nant (by growing down into the submucous or
muscular tissues) or (b) as a typical malignant
ulcer infiltrating the deep tissues from the be-
ginning.
The symptoms present are usually hemor-
1 hage and cystitis. Hemorrhage is most marked
in a villous growth. Unfortunately this symp-
tom may be absent, except microscopically. The
cystitis is attended with very severe, vesicle ir-
ritability accompanied by pain in the hypogas-
trium and perineum.
The complications, presently, are found to be :
Hydronephrosis with pain in the kidney from
involvement of the ureter, followed by pye-
lonephrosis and septicemia; retention — ^al-
though rare — due to involvement of the urethra.
The physical signs found are: An indurated
mass felt in the bladder wall, through, the rec-
tum or vagina. Cystoscopy demonstrates a
characteristic sissile papilloma or an ulcer with
thickened margins, the center of which is a dark
red, bleeding slough.
The cystoscope definitely determines the diag-
nosis: (i) From stone in the bladder which
presents: pain after urination with spasm,
slight bleeding, click from the urethral sound,
x-ray. (2) From tuberculosis of the bladder:
In this disease pain and vesicle irritability are
very severe, bleeding is slight or absent, tubercle
bacilli may be demonstrated in the urine, cysto-
scopy which usually demonstrates the tubercu-
lar areas — at or near the ureteral meati.
It is in the early diagnosis of vesicle carci-
nomas (as in carcinoma anywhere) that the
most hope may be offered for cure. Later,
when the growth becomes extensively infiltrat-
ing and the pain continuous, there is no treat-
ment which will offer any hope at all.
It, therefore, behooves us to recognize the
early and precancerous bladder growth, espe-
cially by means of the cystoscope and vaginal
and rectal examination, in order that radical,
extensive and thorough treatment may be insti-
tuted.
This treatment should con.sist in: i. Supra-
bubic exposure of the interior of the bladder.
2. The resection of the growth through the
whole thickness of the wall, probably best done
with the cautery. 3. The application of suffi-
cient amounts of radium to that area. 4. The
suprapubic opening should be retained for
some days in order that radium, if thought ad-
visable, may be reapplied.
REMOVAL OF MEDAL TOP FROM LEFT
BRONCHUS
DR. J. H. McCREADY
Case — patient, Ann T., white, aged 11 years
— was referred to me in October, 1920, from
Youngstown, Ohio. While attending a party,
she and the other children were given small
medal animal charms as prizes. For safe keep-
ing she. placed the medal cat in her mouth and
inspirated it a few minutes later, after being
suddenly pushed from behind by another play-
mate. When she returned home she told her
parents about swallowing the cat but they
thought she would pass it in a few days and
dismissed the incident from their minds.
About three weeks later her mother noticed
that she had developed a slight cough but did
not pay much attention to it, until she noticed
that the child wheezed and seemed to have diffi-
culty in breathing at night. After consulting
her family doctor an x-ray examination was
made and the foreign body was found to be lo-
cated in the right bronchus. She was brought
to the Eye and Ear Hospital, October 10, 1920.
On admission the patient appeared quite sick,
with a heavy cough and a wheezing respiration.
Temperature 102, respiration 28. Both sides of
the chest showed many rales. No consolidation
was found. X-ray taken two weeks before en-
trance to hospital showed foreign body situated
in right bronchus about one inch below the
bifurcation.
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THE PENNSYLVANIA MEDICAL JOURNAL
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Operation : Under general anesthesia a
bronchoscope was passed into right bronchus.
The main bronchus and smaller bronchial tubes
were found to contain quite a large quantity of
thin pus. By means of suction and swabs most
of this secretion was removed, but no foreign
body could be seen. All branches of the bron-
chial tree that could be reach by the broncho-
scope were explored but still the foreign body
could not be located. Just a little below the
bifurcation of trachea a large mass of granula-
tion tissue was seen. Thinking that the foreign
body might have imbedded itself in the bron-
chial wall some of these granulations were re-
moved, but again the foreign body could not be
found.
The day following operation the chest exami-
nation showed marked signs of pneumothorax
on right side, broncho-vesicular breathing and
numerous rales on left side.
After allowing the child to rest for five days
a second operation was decided upon. Dr. Ray
examined the plates for us and verified the
previous report that the foreign body was lo-
cated on the right side. The bronchoscope was
again passed under the fluoroscope and instead
of the foreign body being located on the right
side, it was found just below the bifurcation on
the left side. Of course with the aid of the
fluoroscope for direction the metallic cat was
removed without much difficulty. Although the
post-operative reaction was quite severe she was
able to leave the hospital in twelve days. At
the time of discharge the pneumothorax had im-
proved to a very great extent.
The foreign body had evidently moved, dur-
ing a paroxysm of coughing, from the right
bronchus, over the bifurcation, into the left
bronchus, demonstrating the fact that a radio-
graph taken one week before operation should
not be depended upon in foreign body work.
Also that the fluoroscope is a great aid to
bronchoscopy, especially when dealing with me-
tallic substances.
When seen one month after discharge from
the hospital the child seemed well and strong,
there was no cough, no rales in the chest and
no signs of a pneumothorax remained.
TETANUS
DR. T. B. ECHARD
The tetanus bacillus has certain properties
which are of some importance to the treatment
of wounds likely to be infected with them. As
the name "anaerobe" implies, they cannot grow
in the presence of free oxygen. They have
some difficulty in establishing themselves on
healthy, but flourish freely on dead or devital-
i;;ed tissue. For the elaboration of their toxine
they require a medium which is neutral or alka-
line and tend to become avirulent when this be-
comes, or is made acid. Lastly from a practical
point of view, they have the faculty of entering
a resistant stage by spore formation, the spores
being particularly resistant to ordinary steriliza-
tion methods by heat or antiseptics.
With regard to the first of these characteris-
tics: the absence of free oxygen from the
depths of a gun shot or other penetrating wound
is insured by the presence of other microorgan-
isms which take up the oxygen, by the presence
of fresh tissue, and by the fact that communica-
tion with the outside air is frequently blocked
by a plug of prolapsed muscle or subcutaneous
tissue. The second condition of their growth is
insured partly by the destructive eflfect of the
penetrating object and partly by the action of
pyogenic microorganisms which not only act di-
rectly on the tissue but further devitalize them
by the vascular stasis resulting from the pres-
sure of inflammatory exudate which they cause.
Another property of these anaerobes is that they
elaborate their toxins locally, not entering the
blood stream until, at any rate, immediately be-
fore the death of the patient. The importance
of this lies in the fact that toxin production can
be stopped by efficient local treatment.'
Natural infection may and often does, occur
from an extremely trivial wound. The local
production of toxin may be very rapid and te-
tanus develop in a few days, or very slow so
that the attack comes on only after an interval
of weeks. This may explain the fact that, on
the whole, the prognosis is better the longer the
period of incubation.
In the treatment of tetanus I shall refer only
to antitoxin as I believe this to be the only line
of treatment on which there has been anything
like a general agreement.
The prophylactic value of injections of anti-
tetanic serum is beyond all question, but there
is strong evidence that in about ten days the
immunity conferred by the primary injection is
to a great extent lost. It is therefore the gen-
eral opinion that a second subcutaneous injec-
tion should be given in all cases of septic
wounds and, in order to anticipate the total dis-
appearance of the antitoxin from the body, the
second injection should follow the first at an in-
terval of several days. In case of long con-
tinued septic wounds, particularly those caused
by shell or bomb, or contaminated with filth or
dejecta, third and fourth injections at seven-
day intervals are recommended.
It may be definitely stated here that the dan-
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PITTSBURGH COLLEGE OF PHYSICIANS
815
ger of anaphylactic shock is negligible when
prophylactic doses of 500 units contained in
3 cc. of horse serum are given subcutaneously,
whatever the interval after the preceding injec-
tion. The primary injection should consist of
500 units and the second and following injec-
tions should be, for the present, of the same
amount. When operations are performed at
the site of wounds, for the removal of bullets
or shell fragments, even if they are healed, a
prophylactic injection of serum should invaria-
bly be given.
The relative merits of the subcutaneous, in-
tramuscular, intravenous and intrathecal
methods of administering tetanus antitoxin
practically cannot be determined by statistical
method. The primary object always being to
cure the patient, more than one route is em-
ployed, and wide variation occurs in the dosage.
It has been my misfortune to have seen four
cases of tetanus in the past six years and my
good fortune to have seen three recover. All
these cases were treated with the combined and
intensive intravenous and intrathecal method in
the early and severe stages of the disease and
supplemented with subcutaneous injections well
into convalescence. No anaphylactic reactions
occurred in any of the cases treated.
The cases differ widely in the severity of in-
fection and in accidental complications and the
more heroic method of injection is apt to be
chosen in the most desperate cases. Reliable
data is, however, available from animal experi-
mentation. Permin of Denmark showed that
antitoxin intrathecally prevented tetanus when
intravenous injection did not. Park and Nicoll
injected two minimal lethal doses of toxin into
guinea pigs, waited until spasm of the legs com-
menced, and then tried antitoxin by various
routes. In experiments on eighteen guinea pigs,
two controls and six treated by the intracardiac
and four by the intraneural routes, all died,
while of six receiving much smaller intrathecal
doses five recovered. Shorrington, * working
with monkeys, found that ten control monkeys
and those treated subcutaneously all died. Of
twelve treated intramuscularly all died. Of six-
teen treated by intravenous injection ten died,
62.5 per cent. Of eighteen treated by the in-
trathecal route five dfed, 27.7 per cent.
Watkins in the London Lancet, reports
twenty cases, sixteen of which were treated in-
trathecally, with two deaths. He believes there
is less danger of anaphylactic reaction by in-
trathecal than by intravenous injection and that
the danger of meningeal infection with ordinary
care .should be negligible. An insufficiently
treated case of local tetanus tends to become
general. The intrathecal rather than the sub-
cutaneous route should therefore be chosen in
all incipient cases.
Tests on rabbits and cats show an indubitable
superiority of the intravenous and intrathecal
route over the subcutaneous, possibly due to
the slower absorption by the latter route. The
whole problem of serum therapy seems to be to
cut off a fresh supply of toxin by bringing anti-
toxin into relation with the focus of infection.
The toxin apparently cannot be neutralized
after it has entered the central nervous system.
The toxin may remain localized or invade the
whole nervous system. It is therefore of
greater importance to use the more rapid in-
travenous or intrathecal methods in those not
having received prophylactic treatment, but the
more rapid method is also the safer in either
group. Frederick B. Utley, Reporter.
PITTSBURGH COLLEGE OF
PHYSICIANS
The Pittsburgh College of Physicians gave a
testimonial dinner held at the Pittsburgh Ath-
letic Club, on April 2, 1921, to Dr. Andre Crotti,
of Columbus, Ohio.
At the Speaker's table were Dr. R. J. Behan,
President of the Pittsburgh College of Physi-
cians ; Dr. J. C. Vaux, President of the Alle-
gheny County Medical Society ; Dr. R. R. Hug- '
gins, Dean of Medical School of University of
Pittsburgh ; Dr. C. R. Jones, Dr. H. H. Turner,
Dr. Joseph Barach, Dr. Lawrence Litchfield.
Covers were laid for fifty. An elegant din-
ner, with delightful music preceded the presen-
tation of Dr. Andre Crotti 's paper; the subject
of which in an abstract form is as follows:
The goiter problem has not only a humani-
tarian side, but has also economic and socio-
logic aspects which are of the utmost impor-
tance. Disregarding entirely the loss caused by
death from goiter, one well knows that the
goiter patient is no longer up to his 100 per cent,
efficiency, and that his impairment reaches all
the way from nothing up to the level of 100 pet
cent. If we let statistics speak for themselves
we shall find that, for instance, in Switzerland
the number of young men nineteen years old
discarded from military service in ten years
equals one-third of the entire Swiss army. This
number, of course does not include individuals
below nor above nineteen years, nor does it take
into consideration at all the female sex. Fur-
thermore, it is hardly necessary to mention that
cretins, feeble-minded, deaf and dumb, who are
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THE PENNSYLVANIA MEDICAL JOURNAL
August, 1921
often the direct result of endemic goiter, be-
come in one way or another a burden upon so-
ciety.
What is the cause of simple goiter? This
question is still an open and much debated one
and of the many theories advanced thus far,
none have stood the "acid test."
Goiter exists all over the world, high in the
mountains, down in the valleys, by the seashore,
on the plains, etc. McCarrison found it at ten
thousand feet in the Himalayas, and it has been
found at fifteen thousand^eet in India.
Goiter is present in certjiin regions and ab-
sent in others. In other words, it is endemic
very much in the same way that malaria used to
be observed. This fact is of great significance
because it suggests that there is a definite cause
inherent in certain regions alone, and not in
others.
So far, water seems to be the most probable
carrier of the goiter-producing agent. This
fact has been known since antiquity. In France,
Germany, Switzerland, and other countries,
there are sources of water supply which have an
immistakable goitrigenous effect. This goitri-
genous property can be destroyed by changing
the source of the water supply, by boiling the
water, or by adding iodine, bichloride of mer-
cury, etc., as shown by Marine and Gaylord.
Bircher found that such goitrigenous water,
when fed to dogs which had no goiter previous-
ly, would in almost every instance cause goiter.
Furthermore, he noticed that if the water were
passed through a Cumberland filter the goitri-
genoiis properties were almost suppressed,
whereas, if what remained on top of the Cum-
berland filter were fed to the dogs, most of them
would develop goiter. He furthermore ob-
served that boiling the water would render it
innocuous.
It was thought for a long time by some ob-
servers that this goitregenous property was ac-
quired by the water in passing through certain
geological strata, such as limestone, granite, etc.
If, however, one remembers that goiter is pres-
ent all over the world, and if one studies the
geological formations in the different countries
where goiter is endemic, one can soon come to
the conclusion that geological formations appar-
ently have nothing to do with the cause of
goiter.
One of the most recent theories advanced is
that simple goiter is caused by a lack of iodine.
This theory does not stand analysis because, as
we have seen, goiter is endemic in certain re-
gions just as malaria was. There is no appar-
ent reason why iodine should be plentiful in
certain regions and absent in certain others.
That goiter is found at the seashore, or its
neighborhood, militates against this theorj-.
The fact that iodine is able to cure certain forms
of goiter does not necessarily mean that goiter
is caused by the lack of iodine itself. We know
that iodine is an excellent remedy in syphilis
and that syphilitic gummata are apt to disappear
entirely if iodine treatment is instituted, yet no
one will claim that the syphilitic gumma is due
to the lack of iodine. The gumma disappears
because iodine seems to have a selective action
upon the treponema pallidum, and most likely
the same is true for goiter. Iodine very likely
acts as a germ destroyer. This is further cor-
. roborated by the fact that Gaylord was able to
obtain experimentally the same results by treat-
ing goiter in fish by u.sing iodine, bichloride of
mercury, etc.
Recently, Messerii and McCarrison have ad-
vanced the theory that goiter is of intestinal
origin and most likely caused by some form of
intestinal bacteria. Indeed, MtCarrison, after
making cultures of the feces of goiterous pa-
tients was able to reproduce in animals as well
as in human beings, and upon himself and his
collaborators, a definite thyroid hyperplasia;
hence his conclusion that goiter is caused by
some form of intestinal bacteria, which one, no
one knows.
There seems to be no doubt that simple goiter
is due to an infection of some sort, most likely
caused by a living organism carried through the
water. A strong argument in favor of this "in-
fection theory" is the fact that Chagas has ob-
served in Brazil a form of infection causing an
acute hyperthyroidism. This infection is con-
veyed to the human organism by the bite of a
fly, and the living organism causing the infec-
tion is known as the Schitzotrypanum Cruzi.
Chagas and Cruzi both observed that after the
bite of this insect the patient would undergo a
very acute clinical syndrome, characterized by
high fev?r and especially by mental and nerv-
ous symptoms such as delirium, headache,
tremor, nervousness, insanity ; and death would
often follow. If. however, the patient .so af-
fected recovered from this infection, a large
colloid goiter, similar in type to those found in
other patients, would develop. The injection
of the Schizotrypanum Cruzi into animals re-
produced the same .symptoms and effects.
Here, for the first time we have the proof of an
acute infection due to a known organism capa-
ble of causing goiter. It is consequently per-
missible to believe that the goiter which we ob-
serve all over the world may be due to the same
infection. The fact that epidemics of goiter
have been observed throughout the ages, not
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PITTSBURGH COLLEGE OF PHYSICIANS
817
unly in human beings but in animals also, is but
a further corroboration of the argument.
What is thyrotoxicosis? It is a thyro-neuro-
polyglandular disease, namely, a pathological
syndrome in which the thyroid, the nervous sys-
tem ; and the endocrine glands play their parts.
The first part of the proposition, namely, that
thyrotoxicosis is of thyrogenic origin, is very
generally accepted not only by the surgeon but
by the majority of internists. The second part
of the proposition, namely, of the nervous
origin, the matter stands as follows : Some au-
thors consider the central nervous system as the
cause of thyrotoxicosis; others believe that its
origin is primarily due to disturbance of the
sympathetic; again, others believe that it is a
disturbance of the vagus system. It is known
that puncture of the fourth verticle causes dia-
betes, that irritation of the subthalmic region
causes an increased function of the adrenals,
that the section of the restiform bodies causes a
hyperemia of the thyroid, exophthalmos, tachy-
cardia, etc. This shows that the nervous sys-
tem plays a very important part in the disturb-
ances of the endocrine glands. Whether this
influence is primary or secondary, is entirely an-
other matter. The weight of evidence, experi-
mentally as well as clinically, seems to go to
show that the nervous system is only second-
arily affected. Even in cases where thyrotoxi-
cosis seems to date its origin back to fear, phys-
ical shock, fright, etc., if one goes into the
analysis of these cases very carefully, trying to
ascertain the condition of the patient before the
accident, one will almost always find that prior
to the apparent cause of the disease, the nervous
system was already very unstable and in most
instances a certain form of thyrotoxicosis ex-
isted. The shock, fright, or accident just acted
as an exaggerating factor. Furthermore, many
causes of thyrotoxicosis are seen in which
iihock, fright, or accident, etc., never take place
and consequently cannot be incriminated. To
claim that these cases are primarily of nervous
origin is simply to make a statement founded
upon no proof.
Polyglandular Origin. If one studies the dis-
turbances of each one of the organs of internal
secretion separately, and compares them one
with another, aside from the typically charac-
teristic symptoms due to the pathology of the
gland itself, there is also a train of secondary
symptoms which occurs in almost every disturb-
ance of these organs. For instance, after com-
plete ovariectomy beside amenorrhea and loss
of sexual appetite, we shall observe hot flashes,
sweating, palpitation, moderate tachycardia,
nervousness, cutaneous eruptions, passive states.
and sometimes temporary insanity. Again, we
find in Addison's Disease, aside from the pro-
found myasthenia, symptoms characterized by
intense feelings of excessive fatigue, and be-
side the bronzing of the skin, there is a group
of more general symptoms such as complete
loss of appetite, vomiting, diarrhea, polydip.sia,
polyuria, headache, loss of sleep, states of de-
pression, flabby heart, irregularity of the men-
strual function, etc. The same is true in a gen-
eral way for the pathological disturbances of
all the glands of internal secretion. If one com-
pares these clinical symptoms with those found
in thyrotoxicosis, a number of those found in
the latter condition are seen to be common to
the diseases of the other organs of internal se-
cretion, although in every instance the organ
primarily involved is an entirely diflferent one.
This must mean, consequently, that there is be-
tween these organs a functional interrelation
and so it has been shown by pathology and ex-
perimentation. There is no one organ driving
the others exclusively, but rather the organs
drive each other reciprocally. The functional
solidarity of the thyroid, ovaries, adrenals, thy-
mus, and possibly the pancreas, is beyond doubt.
Summing up, we come to the conclusion that
thyrotoxicosis is a thyro-neuro-polyglandular
syndrome.
What starts the thyro-neuro-polyglandular
syndrome? We find, first, that the relation be-
tween infectious diseases and thyrotoxicosis is
more than merely accidental. If one studies
microscopically the thyroids of patients who
have died from the most varied acute diseases,
such as pneumonia, measles, typhoid, etc., in
almost every instance, we find thinning of the
colloid, slight cellular hyperplasia, increased
vascularity, and increased number of leukbcytes.
In some cases the condition is more marked
than in others. These findings are entirely sim-
ilar to those found in thyrotoxicosis, the only
difference being a matter of degree. The same
findings are discovered in iodine Basedow, or
acute intoxications. Finally, in all these cases
we find a more or less marked degree of toxic
thyroiditis. This microscopical picture corre-
sponds entirely to the one seen in thyrotocicosis,
consequently one is justified in concluding that
the process that occurs in thyrotoxicosis is simi-
lar to that occurring in infectious diseases, as
shown by the microscopical findings and also by
the clinical symptoms, such as nervousness,
tachycardia, tremor, so frequently observed in
acute infections. In the last analysis, we come
to the conclusion that thyrotoxicosis is a toxic
thyroiditis.
What causes the toxic thyroiditis with its
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THE PENNSYLVANIA MEDICAL JOURNAL
August, 1921
clinical syndrome is most likely dependent upon
various infections such as tonsillitis, cold,
gastro-intestinal disturbances, etc. It does not
necessarily mean that the strain of bacteria
alone is responsible for the condition, because
the syndrome is observed in all sorts of acute
infections, and caused by the most varied form
of bacteria.
So understood, the theory would explain the
pain to pressure, so often found in true toxic
goiters. It would explain the adhesions found
at the time of operation even when no external
treatment, as iodine or x-rays, had been used.
It would explain, too, why cervical lymphnodes
are so often hyperplastic, why there is leuko-
cytic infiltration throughout the parenchyma,
and would explain in part at least, the rise in
temperature sometimes observed in thyrotoxic
cases. Lester Hollander, Reporter.
DERMATOLOGICAL SOCIETY
The first meeting of the Pittsburgh Derma-
tological Society was called to order by the
temporary chairman. Dr. J. G. Burke, at 8: 50
.p.m. on May 6, 1921. The first order of busi-
ness was the consideration of the cases pre-
sented previous to the formal calling of the
meeting to order.
Case I. Pressented by Dr. Herbert G. Wert-
heimer. Diagnosis: Keratosis Pilaris. As
there was nothing unusual about the case no
discussion followed.
Case 2. Presented by Dr. Herbert G. Wert-
heimer. Patient presented typical lesion and
resultant scars on his face and scalp of acne
varioliformis. There was also a hyperpig-
mented hypertrophic area on the dorsum of his
left foot, the center of which was ulcerating.
The border of this ulcer was definitely defined
thick. X-ray examination of the underlying
bone was negative. His blood Wassermann and
tuberculin skin test was also negative. Consid-
ering the fact that the process on the face was a
tuberculid is the condition on the leg not a tu-
bercular process? Dr. L. L. Schwartz thought
of the possibility of one of three diagnosises:
syphilis, tuberculosis or foreign body. He
deemed it necessary to try out the patient on
antisyphilitic treatment in spite of the negative
findings. Dr. W. H. Guy agreed with the diag-
nosis of acne varioliformis relative to the lesions
on the face. The diagnosis of the process on
the leg should be decided after a biopsy and a
thorough study of the underlying bone changes.
Dr. Stanley Crawford did not accept the diag-
nosis of tuberculosis and thought, on accoun;
of the unilateral character, its chronicity and
the thickness of the margins of the ulcer the
lesion presented more the characteristic appear-
ance of a luetic process. Dr. Lester Hollander
called attention to the frequently occurring ul-
cerations on the more dependent portion of the
leg, due to changes in the lumen of blood-ves-
sels, as in the prepulse stage of thrombo angitis
. obliterans. A tubercular process would find a
very good soil on an area of the type. Dr. J. G.
Burke could not decide definitely between syph-
ilis or tuberculosis. In closing, the discussion
favored the diagnosis of tuberculosis.
Case 3. Presented by Dr. L. L. Schwartz, a
man 65 years old, a brass polisher by trade, who
presented himself to Dr. Schwartz about five
years ago, with a generalized desquamating
erythro dermia. He yielded to arsenical treat-
ment. Diagnosis of exfoliating dermatitis wa.s
made. One year ago he reappeared presenting
the same picture, with chills, rigor and intense
itching of the skin, loss of weight and marked
areas of thickening of the epidermis. An in-
tense appetite accompanied the recurrence of
the skin condition each time. Dr. Schwartz
thinks that this may be a case of pityriasis rubra
of the Hebra type. Dr. Herbert Wertheimer
agreed with this diagnosis. Dr. W. H. Guy
thought that on account of black follicular
papules on the back of fingers, which almost
constantly accompany this erythro dermia this
would make the diagnosis doubtful, and that
the progressive loss of hair and atrophy of the
scalp is not a part of the disease but consistent
with the man's age. An aleukemic type aleu-
kemia cutis of the Wilson-Broq. type should be
considered. Dr. Stanley Crawford considered
it a case of exfoliativa of the Wilson type, and
that the enlarged glands which this patient pre-
sents frequently accompanying this condition.
Dr. J. G. Burke thought that only for the rapid-
ly fatal type of these erythro dermias should the
Hebra name be reserved. In closing. Dr. L. L.
Schwartz hoped that at a future date he would
be able to decide definitely on this case.
Case 4. Presented by Drs. W. H. Guy and
Fred M. Jacob, a 21-year-old medical student
presenting a vesicular papular eruption on the
extensor surfaces of the arms, on the back, but-
tocks and posterior surfaces of the limbs.
Eruption is of one year's standing, intensely
itchy and clears spontaneously, leaving atrophic
scars and slight pigment. Patient is very nerv-
ous and both lobes of the tyroid gland are en-
larged. During the attacks patient shows
eosinophilia. Diagnosis: dermatitis herpeti-
formis. The treatment with x-ray locally and
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DERMATOLOGICAL SOCIETY
819
Fowler's solution internally seems to be con-
trolling the case. The association of hyper-
thyroidism may be of a great deal of impor-
tance and a study of his basal metabolism will
be done in the near future. Dr. L. L. Schwartz,
Dr. Stanley Crawford and Dr. H. G. Wert-
heimer agreed with the diagnosis. Dr. Lester
Hollander thought that x-ray treatment of the
tyroid gland, in conjunction with the adminis-
tration of suprarenal gland substance should be
attempted and its effect noted on the eruption.
In closing Dr. W. H. Guy thought to use either
one or the other for a systemic effect, and as the
case will be under his control for sometime to
come a thorough try-out of the measures as ad-
vised by Dr. Hollander will be given.
A report of a case that first resembled a
dermatitis then a pityriasis rubra Hebra in
which the fatal ending was due to a streptococ-
cus hemalyticus infection was presented by Dr.
John J. Burke. Most of the cases seen in der-
matological practice, with the exception of the
special hospitals and poor farms, are ambula-
tory and a death is unusual, so that when an
apparently healthy man with a simple eruption
walks into your office and then dies on your
hands within ten days it is of sufficient interest
to deserve a short study of the case.
A. F. K., age 29, applied for admission to the
South Side Hospital and, on account of having
an eruption on the face, admission was refused
by the hospital until they could be assured that
it was not a contagious disease, and ag I had
already been at the hospital that day he was ad-
vised to come to my office and see if I vvould
approve his admission.
On examining him I found a well nourished,
muscular man, 29 years old, a Spaniard by
birth but who had resided in the United States
for fifteen years. He stated that his boarding
mistress had told him he would have to leave
the house as the other boarders objected to his
appearance, so he has gone to the hospital. He
was employed as a rigger in the by-product
plant of the J. & L. Steel Co. Three weeks
previous he noticed red spots on his arms and
thighs which had become larger, and three days
before his face became red and swollen and his
eye lids were puffed so that he could hardly
open them. His chest, abdomen, back, arms,
neck and face were covered with a diffused
erythematous eruption, his upper lip and part
of the adjoining cheeks were covered by a light
golden crust as if a secretion had dried, al-
though there were no visible vescicles of pus-
tules to be found. With the exception of sev-
eral silver-dollar-sized areas of erythema on his
legs below the knees, the skin below the groin ;
was normal. He had a temperature of 102 and
showed enlarged papilla of the tongue, no sore
throat, headache, or any pain, and the skin did
not itch. I considered the question of scarlet
fever and the advisability of sending him to the
Municipal Hospital but, from the gradual onset,
lack of throat symptoms, and the legs being
free from the eruption, and his occupation in a
by-product plant, I concluded it was not a con-
tagious disease, and had him admitted to the
hospital. The eruption looked like a dermatitis
from an external irritant, and I made that my
provisional diagnosis, thinking that the tempera-
ture might be due to some incidental trouble
that would be found after admission. The
eruption gradually spread to include the whole
body and in three or four days the skin began
to peel in large flakes as large as the palm and
larger. The flakes were semitransparent and
had the appearance of oiled tissue paper. At
first his temperature gradually receded until it
was almost normal on the fourth day, but on
the fifth day it began to rise again and reached
105, and Dr. Palmer, the internist on service,
went over his and diagnosed a bronchial pneu-
monia. He never coughed and no sputum could
be obtained. His blood Wassermann was posi-
tive and a blood culture showed streptococcus
haemalyticus. The urine findings were nega-
tive, and a blood count gave haemaglovin 75,
R. B. C. 4,8000,000, W. B. 13,000, Fly. 85, L.
Lymp. I, S. Lymp. 14. The patient gradually
became worse and died on April i6th, having
been in the hospital ten days.
The treatment at first was small doses of
quinine which was increased to ten grains every
four hours, and later, when his pulse and res-
piration became rapid, he was put on digitalis
and given oxygen inhalations. The Wasser-
mann and blood culture reports were not re-
ceived until the day before he died and he was
then in so bad a condition that no .serum or
arsphenamine was given him. No autopsy was
permitted.
Summarizing this patient's symptoms as they
developed, we can divide them into three stages.
First. If he was seen the first or second day
after admission with an erthematous eruption
covering the face, arms, body, and upper legs,
with puffed eyelids, a diagnosis of dermatitis
would have been made if scarlet fever could be
excluded. If he was seen on the fourth or fifth
day when the eruption was universal and vivid
red, the skin desquamating in papery scales and
large sheets, the absence of itching and with the
serious impairment of health, Hebra's pityriasis
rubra would have been considered. While, if
seen on the eighth or ninth day, with the rapid
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THE PENNSYLVANIA MEDICAL JOURNAL
August, 1921
respiration, bronchial pneumonia, beginning
cardiac depression and the report of a blood
culture of streptococcus hemalyticus, the dis-
ease would have been considered as a virulent
blood infection and the skin eruption possibly
passed over as incidental by a clinician not in-
terested in dermatology.
A study of this case brings up a number of
interesting points for reflection, such as: Was
it originally a dermatitis or was it a streptococ-
cic infection from the beginning? Was the
skin eruption due to the blood stream infection
or was the streptococcic infection a secondary
one? That it is possible for an external irritant
to cause death is shown by the case reported by
Blocq of a fatal ending following the too vigor-
ous application of chrysarobin in a case of
psoriasis, also the fatalities during the late war
following the gas attacks. That the streptococ-
cus could cause a dermatitis is also possible, but
the usual streptococcic dermatitis is accom-
panied by edema, cellulitis and multiple ab-
scesses in addition to the redness that this pa-
tient showed.
It is also interesting to conjecture as to the
possible blood stream infection of the cases of
pityriasis rubra reported by the older writers —
take the twenty-one cases originally reported by
Hebra with fatal ending in twenty. . How many
would have shown a streptococcus hemalyticus
infection if the technique of blood culture had
been available at that time, and what change
would it have made in the description of the
etiology and nomenclature of this disease.
I regret that the W^assermann and blood cul-
ture report were rtot received while this patient
was in condition to tolerate arsphen?imine.
While none of his symptoms or eruption sug-
gested syphilis, the arsphenamine might have
had some action on his blood stream infection.
I realize that there are a number of features
about this case that I would have preferred to
have more data on, but the patient was under
observation for so short a period that more
could not be obtained.
The regular business meeting of the organi-
zation was now taken up and the following
charter members were decided on : Dr. Walter
J. Highman, of New York City; Dr. Howard
Fox, of New York City; Dr. John G. Burke.
Dr. Russell H. Hoggs, Dr. Stanley Crawford,
Dr. W. H. Guy, Dr. Lester Hollander, Dr. Fred
M. Jacobs. Dr. L. L. Schwartz, Dr. Herbert G.
Wertheimer.
Nomination of officers was the next order of
business. The following officers were elected
unanimously : Honorary president, Dr. L. L.
Schwartz; president. Dr. J. G. Burke; secre-
tary. Dr. W. H. Guy. Dr. l^ester Hollander
moved that meeting should be held once a month
from September to June, both months inclusive.
Seconded by Dr. Stanley Crawford. This mo-
tion was carried. On motion by Dr. W. H. Guy
that meeting should be held at 8 p. m. on the
last Thursday of each month, which was sec-
onded by Dr. Lester Hollander, a considerable
amount of discussion followed. On the call of
question motion was carried. Moved by Dr.
Lester Hollander that the society meet in the
various offices of the members of the society in
an alphabetic order, except when it would be
inconvenient to the man, in which case the
meeting should be held in the office of the mem-
ber whose name appears next in alphabetic
order. Seconded by Dr. Stanley Crawford and
carried. Moved by Dr. Herbert G. Wertheimer
that ca.ses should be presented with their his-
tories in writing after which .they should be
regularly discussed. It was moved by Dr. Stan-
Icy Crawford that the candidates to the society
should be considered in the light of an active or
an associate member. An active member was
defined as one who limits his work entirely to
the field of dermatology and is actively engaged
in the work of this society, presenting and dis-
cussing cases; an associate member being one
who, though interested in the field of derma-
tology, does not necessarily confine himself to
its limited practice. It was also moved that be-
fore members are acted on they should be intro-
duced toi the society. This motion was seconded
by Dr. Fred M. Jacob, and carried. Moved by
Dr. Fred M. Jacob that Dr. Rimer, of Pitts-
burgh, and Dr. Barr, of Johnstown, be invited
to the next meeting. Seconded by Dr. I^ester
Hollander and carried. It was moved by Dr.
Lester Hollander that members who attended
the first organization meefing at the dinner
given by Dr. G. H. Giiy at the University Club
on March 25, 1921, should be named as charter
members of this society; all others who may
follow shall become either active or associate
members. Seconded by Dr. Fred M. Jacob and
carried. It was moved by Dr. W. H. Guy that
Dr. H. M. Snitzer be elected an associate mem-
ber of this society; seconded by Dr. Stanley
Crawford, carried.
Meeting adjourned at up. m.
Lester Holmnder, Reporter.
THE HARRISBURG ACADEMY OF
MEDICINE
At the June meeting of the Academy the ad-
dress was' by Dr. Joseph McFarland, Professor
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HARRISBURG ACADEMY OF MEDICINE
821
of Pathology, University of Pennsylvania,
Philadelphia. He discussed "Some Problems
of Tuberculosis." He stated that recent knowl-
edge of the tubercle bacillus compels us to re-
vise current ideas of infectious diseases. It is
not true that normal blood is free from bacteria.
To the habit of drawing but a few drops for
experimental purposes has been due this mis-
conception. With the use of larger amounts the
presence of bacteria is found. It is not strange
that from the swarms of micro-organisms in the
alimentary canal a few should struggle through
the barrier and be taken up by the blood stream.
Crypts of the tonsils, with their deeper parts
relatively unprotected by a lining membrane, are
admirable gates of entry for some micro-organ-
isms, particularly streptococcus viridans and
.••treptococcus hemolyticus. Thence they pass
to the lymphatics of the neck, gain entrance
eventually to the blood stream and, by predilec-
tion, find lodgment in the heart, joints and
lungs, so prevalent is the tubercle bacillus that
is habitually present in practically every one.
Dr. Opie, of George Washington University,
St. Louis, has devised a method of x-ray pic-
turing of the postmortem lung which enables
one to locate nodules of the bacillus in 95 per
cent, of the cases, and further refinements of
technic will probably expose them in the other
five per cent. Should we say. therefore, that
everyone has tuberculosis? The answer is no.
The distressing thing about such tubercle bacilli
is the constant increase of their presence.
Sooner or later bodily resistance may break
down, with such increase in numbers or viru-
lence of bacilli as to cause active infection. One
modern theory has been that the few tubercle
bacilli habitually present in the body are vac-
cinative in effect. Another recent view is that
the presence of the bacilli sensitizes the organ-
i.sm so that each subsequent attack is more seri-
ous. This view is presented, not as a dogmatic
assertion, but as a modern and promising con-
cept.
As for treatment of tuberculosis, the speaker
was positive in his declaration that there is no
treatment. In referring to the treatments of
the past, which had been vague enough to be
called fads, he mentioned cod liver oil, from
which some pharmacists derived the curative
element they called "Morrhua." Later creosote
became the favorite remedy, wherefrom pa-
tients smelled like a smoke house instead of a
fish factory. Hydrogen sulphide was, within
the memory of old practitioners, the advanced
treatment. The gas was passed from a rubber
bag through the rectum, until the victim tasted
it. The theory probably was that an odor so
horrible would prove too much for the bacillus.
No attention was paid at these times to the fact
that the patients died under all these treatments
the same as before. The latest fad is the sani-
torium, where it must be admitted, consump-
tives usually get better.
Our business is to sit down seriously and
meditate upon the good we can do. We cannot
treat the tubercle bacillus, but we can treat the
patient. What such a man needs is to have his
mind and body at rest. A sanitorium does all
this for a time, and attempts to create an atmos-
phere of encouragement. Good food and quar-
ters are products of civilization. To expose a
patient to inclement weather is to deny him
some of the benefits of civilization. The
-speaker is unable to see any treatment for tu-
berculosis in this, as one treats only the mind
and the body of the patient. Of utmost urgency
is it to control the spread of the bacillus, both
human and bovine, if we are to reduce infection
and re-infection in both adult and child.
During the discussion which followed several
speakers gave expression to the conviction that,
although no treatment for tuberculosis exists,
we are on the threshold of the discovery of such
treatment. J. B. Hileman, Secretary.
WASHINGTON SOCIETY OF
CLINICAL MEDICINE
On the evening of June seventeenth at the
Hotel East on. Dr. Paul Correll had as his guests
the Washington Society of Clinical Medicine as
well as a number of physicians from Easton,
numbering about sixty in all. The meeting
opened with a full course dinner which was
heartily and gastronomically enjoyed by all.
Following the dinner a symposium was held
on "The Urinary Bladder and Genitalia." The
anatomy of this tract was handled very ably by
Dr. Stanley Krebs while Dr. B. M. Hance care-
fully covered the diagnosis and nonsurgical
treatment. Dr. Paul Correll closing the subject
with the surgical con.sideration. Following the
papers the subject was thrown open for discus-
sion which lasted long after the midnight hour
and proved very helpful and interesting.
The meeting adjourned with a hearty vote of
thanks to Dr. Correll, each individual inviting
himself to be present at the next meeting.
W. Gilbert Tillman, Reporter.
The scratch of the lion's claw is almost as deadly as his bite,
for he never cleans his nails, and he always carries under them
rotten meat that is rank with deadly germs. Plies and water
bugs do the same thing on a smaller scale; and: ''don't for-
get," says the U. S. Public Health Service, "that they never
wipe their feet."
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THE PENNSYLVANIA MEDICAL JOURNAL
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ABSTRACTS FROM GAZETTE DES
HOPITAUX
THE PSYCHIC DIFFICULTIES OF
EPIDEMIC ENCEPHALITIS
M. LE DOCTEUR J. EUZIERE
MONTPELLIER, FRANCE
Translated by Hugh Hamilton, M.D., Harrisburg
Our information concerning epidemic en-
cephalitis is progressing toward completeness;
all has not been observed in the disease ; that is
one of the reasons for its present prominence.
Many of the symptoms are too indefinite to de-
pend upon. As time goes on we get less and
less new facts, but each case presents peculiar
symptoms given in the descriptions of the new
ones seen. It is to be noted that the cause of
this complaint is due to disturbance of the cere-
brospinal axis with a marked predeliction for
the meseocephalic region of the brain. It fol-
lows that the symptomatology shows congestion
of the nerve axes. At present the descriptions
from the sequelae number many and all are very
serious, which before had been unnoticed. Our
desire is to study the succession of the psychic
signs of epidemic encephalitis, when they have
value in the acute condition, and of the compli-
cations of convalescence.
In the acute period the psychic difficulties
present a great variety of form and also of in-
tensity. In truth it is exceptional enough in
those that show points that are characteristic of
a clinical form which we may call delirious
(Mm. Briand et Rouquier, Bosc). This is
nearly always a delerium of excitement with
mental confusion and visual hallucinations. A
characteristic frequently follows on the part of
the patient to be in a state of fear, with impul-
sive resistance approaching agression from his
terror of you. The agitation sometimes be-
comes so violent that it might be called acute
delirium. In many cases, following motor dis-
turbance, it is insufficient to form a disease by
itself. Usually the delirious manifestations re-
main positive only a very short time. At the
same time the paralysis of the eyes is fleeting
with some myoclonic shakings and reflexes of
the radial and cubito-pronator. From the ob-
servations of Salniont, in three cases recognized
as epidemic encephalitis, the patients became
calm after a few days and shortly gave the com-
plete diagnosis of it. Here it may be said that
all forms take on a delirium before the lethargic
kind which is much more rarely recognized.
On the contrary, we see a myoclonic convulsion
succeed the choreic which we have seen as a
Parkinson affectibn (thesis by M. Gignout).
It is exceptional that mental abberations of
the epidemic encephalitis may resemble a case
of dementia in its complete clinical demonstra-
tions, so that as we continue to see the case it
assists one to make a very different diagnosis.
In a report by Ardin, Delteil, M. Raymond and
Derrien, patients at first showed delirium, in-
coherency, pains in the joints, disturbances of
memory and motor difficulties. These symp-
toms are noticed in the beginning of a general
paralysis. Still more recently Widal, E. May
and Chevalery have reported the history of a
patieilt having catatonic convulsions with iden-
tical movements, dullness and indifference, yet
retaining his intellectual faculties. Upon the
question of the reports on epidemic encephalitis
and of dementia prsecox, Lougnel, Levastine
and Logre have each published cases of this
kind. Following the difficulties of the physical
manifestations of the disease, Netter occupied
a place in clinical history of little importance,
so that the danger of a wrong diagnosis is to
let it lose its significance.
We have studied each of the usual indica-
tions of this disease. In the lethargic kind,
sleepiness is a characteristic s3rmptom, a real
psychic difficulty. It depends upon how much
the sleejMness of epidemic encephalitis compares
with the intellectual functions, as in types of the
infectious diseases which are not without a cer-
tain degree of mental confusion. The analogous
remark of R. Benard in this respect is of much
importance: "It is natural to think that this
clinical difference has a dissimilar pathol(^.
The types of the infectious diseases show a gen-
eral infection of all the nervous system; the
dullness of encephalitis is due to a local lesion
of the centers of sleep." The clinical difference
that we see of value, is that it is agreed that in
the serious cases the sleepiness is accompanied
by decided asthenia. This professed asthenia
and the attached psychic difficulties we find now
in the so-called after-effects of the acute attack.
The presence of sleepiness should be considered
in the examination of patients, in our effort to
find out by questioning and answers whether it
is true confusion. In the choreic type the
psychic phenomena in their behavior arc ex-
cited deliriums. Yet make this distinction. .AH
the occurrences of chorea arising from epidemic
encephalitis are not usually to be expected. The
very acute and intense symptoms, such as high
fever and very serious results are apparent in
the acute choreas when mortal, as has been de-
scribed by Dieulajoy; the other chronic and
much weaker cases are of a symptomatolc^
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ABSTRACTS FROM MENTAL HYGIENE
823
along the great series of Sydenham in his
studies of chorea. In the first group the de-
lirium is nearly always the delirium of agitation
and hallucination and very violent; these cases
are being discussed at the present time. At
other times the patient's excited state, with
psychic phenomena such as babbling and over-
sensitiveness, would lead one to think him a
maniac; but this is not so. Often enough from
these conditions we may strictly predict the
sequelae in the same patient. Here is the case
of a young girl whose history of an epidemic
encephalitis shows such symptoms as come very
near those of the chorea of Sydenham. We
find very often sleepiness with mental confusion
between crises of hallucination. This condition
is evidenced often in the evening and at night,
and is charafteristic.
The division we discuss is not that of abso-
lute quiet, but all sorts of maniac furor in the
course of the strong and fatal chorea. When
the convulsions are far apart it is favorable.
For this reason, the confused cases found in
epidemic encephalitis are known as myoclonic
or catatoniac types.
II
It is very important to have a history of the
mental condition of the epidemic encephalitis
patient, in order that we may not give treatment
unnecessarily for the acute phase of the disease.
In the course of convalescence we find that the
patients are often less preoccupied and less te-
nacious of ideas. We are still unable to give a
definite prognosis. Two difficulties may be pre-
sented : First, with few exceptions the patients
revert to false insane conditions (Briand and
Rouquier of the Society of Physicians for the
Insane, and Bremer of the Society of Psychia-
try). One child of nine years suffered from an
attack of epidemic encephalitis in June, and the
following February had periods of hypomania-
cal excitement in the night. Second, we find on
the contrary the cases of depression. Now and
then we find that the patient does not complain,
but shows symptoms of profound asthenia. It
is remarkable that the tendency to be much pre-
occupied, and to have all the marks of a neu-
rasthenic, is singularly the fact in those cases
which secondarily develop the infection of Net-
ter, a syndrome of Parkinson's disease.
But we may see cases of deep depression and
psychic disturbances of a mixed character. In
a case which is of my personal knowledge (pub-
lished in the Thesis of Ponjade of Montpellier,
1920) there followed after a case of epidemic
encephalitis a gradual sleepiness, then melan-
choly. This seemed to be a melancholy delirium
with notions of incurability and sensations of
approaching death in times of anginas. The
patient was, nevertheless, pretty healthy in De-
cember, 1919.
ABSTRACTS FROM MENTAL
HYGIENE
Vol. 5, No. 2, April, 1921
BY EDWARD M. GREEN, M.D.
HARSISBURG
MAL-BEHAVIOR VIEWED AS AN OUT-
PATIENT MENTAL AND NERVOUS
CLINIC PROBLEM
EDWARD A. STRECKER
PHUADEI.PHIA
A broad interpretation of the term "mal-
behavior" includes all departures from "aver-
age behavior." Its relation to the conduct of
the individual as well as its effect upon the fam-
ily and the community is discussed. Two prin-
ciples are enumerated as the result of investiga-
tion of a series of fifteen cases reported in ab-
stract : first, that the activities of the clinic must
be concerned with the study of mal-behavior,
its causes and correction; second, that advan-
tage should be taken of every agency which can
be enlisted, to the end that the clinic should not
be highly specialized but on the contrary highly
generalized.
The cases reported illustrate the various
problems brought to the clinic, some of which
are physical, some psychogenic in character,
while others present a combination of these two
factors. In addition the mal-behavior may be
the outcome of economic or environmental situ-
ations, psychotic influences, or be developed
upon a basis of constitutional psychopathic in-
feriority.
The complexity of the problem of mal-be-
havior is stressed, as is the importance of view-
ing such cases from a broad stand])oint rather
than attempting to solve them according to the
rules of a single system.
AN EMOTION.M. CRISIS
EDITH R. SPAULDINC.
BEtlFORD HIIXS
An emotional outbreak occurring among a
group of psychopathic delinquent women at the
Bedford Reformatory. A brief psychological
analysis of each member of the group concerned
precede^ .\\\t actual narrative.
Ther^v ee"''^ *^ ^^^'^ ^^^" * general feeling
of uux- t atv^o^S ^^'^^^ young women in ad-
'^S\
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THE PENXSYLVANIA MEDICAL JOURNAL
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vance of the outbreak, in which the prominent
factors were, the excitement resulting from a
play which they had given, resentment over the
fact that the play leader was about to leave the
service of the reformatory, a mutinous spirit
engendered especially by one of the number,
and a growing antagonism toward her shared by
all members of the group. The emotional riot
was manifested by screaming, oratory, profan-
ity, abuse, and threats and extended over a
period of five and a half hours.
The factors responsible for the outbreal: are
enumerated as follows: first, "The emotional
instability of the group as a whole plus the ab-
normal mental trends and the exaggerated traits
of character"; second. "The extreme immatur-
ity of the entire group" ; third, "The strong ele-
mental instincts that seek unhampered expres-
sion in the lives of these women" ; fourth, "The
expression of the herd in.stinct"; fifth, "The
physical elements that played their part in tlie
scene" (Irritability and nervousness in connec-
tion with menstruation) ; sixth, "The individual
complexes that were aroused.
The article concludes with the suggestion tiiat
therapy, education, self-government and disci-
pline must all be utilized in dealing with such
l)atients as those concerned in the incident re-
lated.
MENTAL HYGIENE AND THE COLLEGE
STUDENT
FRANKWOOD E. WILLIAMS . .
NEW yoRK
By most institutions of learning the factors
lying at the base of failure to take one's place
as an efficient member of the organization re-
ceive little if any attention, for such failures
are looked upon as evidences of intellectual de-
fects rather than as emotional disturbances and
faulty adjustments which, if not corrected, may
lead to serious consequences. Mental hygiene,
on the other hand, is concerned in great part
with social and economic problems responsible
for a body of helpless sufferers, with "the men-
tal health, the happiness, and the efficiency of
the average normal per.son."
The immediate problems of the college stu-
dent are discussed, his ideals, the discrepancies
between these ideals and the actual situations,
his hopes, his fears, his ambitions and disap-
pointments, and the feelings of inferiority which
may be fleeting or become a part of his person-
ality as a result of discouragement and intro-
spection. His equipment for handling these
problems is also reviewed, as are the solutions,
adequate or faulty, at which he arrives and the
new attitudes which he may assume toward
persons and environment. The emotional fac-
tor in the distorted outlook upon the situation
and in the development of neuroses and psy-
coses having their beginnings during the period
of college life are stressed.
Restoration to a normal outlook upon life
might be gained for many of these students
overwhelmed by the complexities of the situa-
tions first experienced during their college years
if some agency was maintained for investigating
the causes of failures and rendered accessible at
all times to those in need of advice and help in
adjusting their emotional lives and habits.
"Emotions as well as intellect and mental
health as well as physical health must be made a
part of the program" if the student body is to
be con.served, failure be forestalled, f>artial fail-
ure minimized and larger individual usefulness
made possible.
EXPERIMENT TO DETERMINE THE
POSSIBILITIES OF SUBNORMAL
GIRLS IN FACTORY WORK
ELIZABETH B. BIGLOW
NEW HAVEN
Because of a shortage of help and the conse-
c|uent necessity of employing inefficient work-
ers, a large rubber company undertook to find
out what could be done with a group of sub-
normal girls by giving them .special training in
the simpler varieties of work. The experiment
was conducted throughout a period of eight
months during the year 1920 and the classes
varied in membership from 3 to 14. In all 2,^
girls were under observation. At the outset a
complete case history of each pupil was taken,
supplemented by a record of work, Stanford
Revision and other .special tests, both imbecile
and moron types being included in the experi-
ment.
It was proved that, if given sufficient train-
ing in some simple work, the subnormal girl can
be relied upon to carry on this work indefinitely,
for she is more satisfied with a monotonous job
than are normal persons and is more faithful in
its performance. The girls concerned in the ex-
periment were happy, contented, and their be-
havior both at the factor)' and at home improved
during the period of their employment. In the
management of such cases it is of especial im-
portance that their training should be carried on
apart from other workers and over a longer
period than is required of normal persons, that
the teacher should be possessed of tact and pa-
tience and be able to recognize the limitations
of his pupils. In dealing with them every in-
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ABSTRACTS FROM MENTAL HYGIENF:
825
centive should be niade use of, such as rivalry
with other workers of the same type, stimulation
of interest in the progress of work by means of
charts and other devices, fear of losing the job,
and commendation for effort and accomplish-
nient. Being so easily influenced by example
and by suggestion strict discipline must be main-
tained and a who^esonle respect for authority
engendered.
Suggestions are also made looking to the rec-
ognition of this class by those who frame the
labor laws in order that they may not be de-
prived of employment because incapable of the
intellectual progress required of normals. As
many borderline cases will not be cared for in
institutions every effort should be made to ren-
der them self-respecting and useful members of
the community by means of training, fir.st in the
sjiecial classes of the public schools and later in
some form of occupation under direct guidance.
\^OCATIOKAL PROBATION FOR SUB-
NORMAL YOUTH
ARXOLD (RESELL
NEW HAVEN
It is gradually becoming recognized that the
subnormal individual has a real place in the eco-
nomic system of the country and that the segre-
gation of every such case in institutions is im-
practicable. Experiments which have been
made in several quarters show that the morcn
and the high grade imbecile may find a useful
field for the employment of their limited capa-
bilities. The special class of the public school
has provided for such instruction as is best
suited to these defective classes so that the legal
requirement of attendance up to a certain age i ?
no longer productive of mortification and dis-
couragement only. The question then arises,
"what can further be done for these handi-
capped children"? In order to find a solution
of this problem the Governor of Connecticut in
IQIQ appointed a Commission on Child Welfare.
This Commission reported in favor of a "su-
pervisory state bureau of child welfare, a divi-
sion of special education and standards, as a
department of the state board of education to
guide and encourage provisions for all types of
exceptional school children, and a state-wide
system of juvenile courts with well-trained pro-
bation officers."
It is the object of the courts and the schools
to forestall the necessity of institutional treat-
ment and, in the case of defectives, to provide
vocational training by means of which they may
be usefully employed. The law proposed by the
Commission on Child Welfare provides that
upon proper application to the judge of the
juvenile court he may establish the status of
vocational probation for each of several classes
enumerated in lieu of commitment to an insti-
tution if he is satisfied that the child is defective
and that employment is preferable in his case
to continuance in school. The further duties of
the courts and probation officers are also out-
lined.
The article concludes with mention of the
general tendency of welfare work toward local
community control.
OBSERVATIONS ON MAL-ADJUSTED
CHILDREN
LEON.'XRD BLUM(iART ,,
NEW YORK
Mental diseases dependent upon structural
changes were the first to be intensively studied
and understood, while in recent years the dis-
orders resulting from functional derangements,
disturbances of the ductless glands, and dis-
ea.ses of metabolism have received greater at-
tention. Study of functional ner\'ous disea.ses
is at present being pursued from what may be
called the dynamic viewpoint and is concerned
with the manifestations of improper functioning
of apparently normal qualities, treatment being
directed to the establishment of efficient func-
tional habits.
Since it is recognized that such disorders in
adults exhibit symptoms which are frequently
but exaggerations of their behavior in child-
hood, it is apparent that correction of this be-
havior in the mal-adjusted child is of the high-
est importance in the prevention of such condi-
tions. With these facts in mind the author un-
dertook, at the Cornell Medical College Psy-
chiatric Clinic, fhe examination of mal-adju.sted
children who presented problems not under-
stood by their parents and the social agencies
having control of them. All social agencies
were freely employed in the reeducation of these
children but the teachel- or worker in close con-
tact with the patient was chiefly depended upon
for the anticipated improvement. Those chil-
dren who presented especially difficult problems
were sent to Hartley House Farm. During a
period of seven months, 44 patients, whose ages
ranged from 6 to 18 years, were intensively
studied. It was found that difficulties and bad
home conditions were responsible for the ap-
pearance of most of them, while in the re-
mainder various other factors were present. A
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826
THE PENNSYLVANIA MEDICAL JOURNAL
August, 1921
record of improvement was noted in nine of the
12 farm cases and in i6 of the others.
The average teacher fails to understand such
children and is apt to maintain an attitude to-
ward them rather antagonistic than sympathetic,
which in itself is sufficient to negative any pos-
sibility of good being derived from the associa-
tion. One is warned against classing a child
as "feeble-minded" upon the intelligence test
alone, for many other factors may enter into
failure to satisfactorily respond to these tests.
The need for such a clinic is demonstrated by
the wide variety of symptoms that can be un-
derstood and satisfactorily treated only after an
intensive study of each child and its home en-
vironment. To insure good results there must
be a change of attitude of the home to the child.
When home conditions cannot be remedied farm
schools sliould be utilized, as it was in such
schools that the largest percentage of improve-
ment was made.
THE POSSIBILITIES OF A STATE SO-
CIETY FOR IVTENTAL HYGIENE
H. DOUGLAS SlNCiER
DUNNING
The failure of certain State Societies for
Mental Hygiene to actively pursue the aims of
such organizations is not due to a lack of con-
structive work but to a failure to grasp the pos-
sibilities and to formulate a plan of procedure.
Education and propaganda are among the chief
activities of these societies, but they must also
give attention to the prevention, early diagnosis
and treatment of many conditions which render
the individual a liability rather than an asset to
the community. The publicity already given to
the evil results of alcoholi.sm and syphilis has
heen a prominent factor in the passage of the
prohibition amendment and in the nation-wide
efforts expended in the prevention and control
of .syphilis. The same measures, applied to the
relation existing between physical and mental
diseases, to the mental stresses producing in-
tolerable situations which may lead to mental
disorders, and to the recognition of the early
evidences of mental breakdown, may be equally
productive of good results.
The Society for Mental Hygiene should co-
operate with every agency already in the field
of welfare work and should emphasize the psy-
chiatric problems involved. The .state hospitals
may be especially helpful in contributing statis-
tics and facts in regard to mental disorders and
their treatment. The establishment of mental
health clinics and dispensaries in all commimi-
ties is one of the most important functions of
the society. These should be maintained
through some local agency and adapted to con-
ditions which exist in the community. The need
for regional clinics, traveling clinics, and psy-
chopathic hospitals should be demonstrated and
every assistance offered in organizing them and
placing them upon a permanent footing.
The qujdifications of the "executive head of
the society, its personnel, the items of expen.se
and provisions for the maintenance are briefly
outlined by the author.
MENTAL DISEASES IN TWELVE
STATES, 1919
HORATIO M. POLLACK
ALB.\NY
and
EDITH M. FURBUSH
NEW YORK
A study based upon statistical data supplied
by the 46 hospitals of twelve states for the year
1919, these being the only states from which
could be obtained complete returns in the form
recommended by the National Committee for
Mental Hygiene.
There were carried on the books of these
state hospitals at the beginning of the fiscal year
the names of 79,039 patients. During the fol-
lowing twelve months 22,312 were received, of
whom 16,176 were first admissions, 4,476 were
readmissions, and 1,660 were transfers from
other institutions. Within the same period
there were discharged 12,022 patients, 3,325 as
recovered, 4,025 as improved, 2,041 as unim-
proved, and 886 as without psychosis, while
1,745 were transferred to other hospitals. The
deaths during the year numbered 9.309. At the
close of the fiscal year the records showed an
increase of 1.2 per cent, in the population of the
46 hospitals.
The rates of first admissions per 100.000 of
the general population is given in table Ko. 4-
This rate is highest in Massachusetts and lowest
in Iowa, reaching in the former state 98.5 and
in the latter 37.1. The southern and western
slates show a lower rate than do the New Eng-
land and eastern states, except for Arizona
which stands next to Massachusetts in this re-
spect. The factors chiefly influencing these
rates are given as accessibility of hospitals, en-
vironment and the race and age distribution of
the population.
Reports from the various sources are studied
collectively, with the result that data derived
from so large a number of cases becomes qnite
impressive and variations due to local conditions
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August, 1921
COMMUNICATIONS
827
are minimized. The study demonstrates the de-
sirability of securing uniform statistics from
every state for the purpose of comparison.
COMMUNICATIONS
TO THE REUNION EXECUTIVE COMMITTEE
OF THE EIGHT COUNTIES OF SOUTH-
EASTERN PENNSYLVANIA, AND
OTHERS INTERESTED
Greetings. — On account of the Medical Society of
the State of Pennsylvania meeting in Philadelphia the
early part of October there will not be a reunion held
this summer. The reunions have been popular and
profitable, and many of us will much regret the op-
portunity of meeting our co-workers, but so much
work must be done to make the meeting of our State
Society a success and there will, in this great meeting,
be so many opportunities for entertainment and mar-
shalling of our forces to combat the lowering of the
standards of medical education and practice, and the
uplift of medicine as found in the three fully qualified
and legally recognized schools of practice, it seems to
your secretary, treasurer and chairman better to omit
our reunion this year, and to throw our energies into
the success of our State Society meeting.
Please bear in mind it is well for our eight counties
to keep well organized so that we can effectively con-
test with those who for mercenary, greedy and avari-
cious reasons would degrade and lower our medical
standards, thereby working injury to the sick and
afliicted. Do not forget that the battles we have lost
were due to want of organization, and those gained,
through a well organized opposition. The one great
object in our reunions has been to effect a well quali-
fied force to accomplish that which is good for those
under our care, to protect them from those unqualified
to practice medicine.
I wish to thank those who worked so hard to make
our reunions a success, and to announce that there is
in the hands of the treasurer a balance of $53.00, after
all expenses of the 1920 reunion were paid, a good
"starter" for the 1922 reunion.
Fraternally yours,
J. B. Carrell, Chairman.
AN EFFICIENT AND CHEAP SIGNAL OR CALL
SYSTEM FOR HOSPITALS AND OTHER
INSTITUTIONS
A great many institutions that have been built for
a number of years find some sort of signal system
very desirable. The installation of electric light sys-
tem or dictaphone is very expensive. We have found
the system of installation as described below not only
very efficient and fool proof, but also extremely cheap
in the installation and maintenance.
The apparatus consists of telegraph receiving
sounder and sending key. The sounders are placed at
convenient locations over the institution. The key is
placed on the telephone central table or at ofTice. The
sounders and keys are connected in series with about
six dry cells or storage battery. Each officer and
member of the staff of the institution has a number.
When his number is sounded he immediately calls the
office on the phone. He, of course, pays attention only
to his own number.
The working instructions arc as follows: "Learn
your own number only. The signal will be. given three
times with an interval of about five seconds between
signals. In a compound number the taps will be close
together, the short interval in number not to be con-
fused with the interval between signals. When you
hear your signal go to the nearest phone and call of-
fice. Please cooperate in installing this system."
This has been installed with twelve instruments and
a sounder at a cost of about $75.00, and has been ex-
tremely efficient and preferable in every way to call-
bells, lights, etc.
It has now been nmning two months on six dry
cells with no sign of diminution of current.
A. R. Mathknv, M.D.
Pittsburgh.
Fellow Secretaries. — EHd you ever receive any com-
pensation for replying to the questionnaire sent you by
life insurance companies, concerning the fitness and
ability of physicians willing to serve them as examin-
ing physicians? To certify as to their capability, skill
and sobriety? To assure the company as to their non-
use of narcotics and intoxicants? A dozen questions
to be answered.
The secretary doing such work must make more
notations than a notary public or justice of the peace
requires of a physician when making an affidavit for
which the physician must pay fifty cents — the regular
fee. Insurance companies do not pay one cent for
such information yet it is the means of making much
money for them. Certifying to the qualifications of a
physician should be paid for the same as anything else.
Insurance companies claim, however, that we should
do it for the good and ethical reason of helping the
neighboring physician or member of the society who,
in turn, provides the means whereby the company
makes its money. It takes more than ethical courtesy
to buy raiment for the body; extending valuable in-
formation for nothing to the money-earning company
does not buy sustenance for the secretary. Financial
corporations don't thrive on ethical courtesy, either.
That kind of blarney talk handed out by insurance
companies at this day is all bosh — only one of the
many taffy replies of the companies, and in the past
we have swallowed it all — hook, line and sinker.
The matter could easily be adjusted in a manner
fair to both. Let the insurance company inclose
twenty-five cents in postage in the letter of inquiry to
the secretary. That would be something. If the life
insurance companies want incompetent examiners, let
them seek elsewhere for them. If a company insists
that the reply to the questionnaire is not worth a quar-
ter to them, then you can quickly conclude that the
company is not ^orth a nickel to you for placing in-
surance risks.
Fellow Secretaries: Let us demand something for
our information or stop giving it; it takes time and
concern, and if it is not worth something to the com-
pany, why ask us for it. Plain talk but true I In my
twenty-five years as secretary of a country society. I
have filled out over a hundred such questionnaires and
never received a cent reward. Let us demand remu-
neration and stop swallowing their fool talk. Secure
some sort of a reasonable compensation or stop it ; it
is equally fair to both.
Anthony F. Myers, M.D,
Blooming Glen, Bucks Co., Pa.
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THE PENNSYLVANIA MEDICAL JOURNAL
August, 1921
THE PHILADELPHIA SESSION.
OCTOBER 3-4-5-6, 1921
In this issue of the Journal appears the program
for the Philadelphia Session of the State Medical So-
ciety, October 3-6, 1921. The Committee on Scientific
Work urgently requests each member of the society
carefully to scan the pages of the program of the
sections and general sessions and see, after reading
them, if he can afford to miss this session of the State
Society. The Committee on Scientific Work has ar-
ranged for the presentation of ninety-six papers on
diversified subjects, that can not fail to appeal to all
doctors, no matter in what special line of \york they
are most interested. The committee after consulta-
tion with a large number of our members decided to
present a program that would prove of intense prac-
tical interest to the profession, and be of help to them
in their daily work. In this hope we have in a modest
way succeeded. A wealth of material in the form of
papers was volunteered and the committee was sorry
that all could not be accepted. Only those papers that
fitted in with the skeleton program, as outlined by the
full Committee on Scientific Work at its first meeting
at Harrisburg in January could be considered. We
are sorry for the disappointments that we may have
caused, but rejection of a paper does not mean that
the paper was not of sufficient value, but that the sub-
jects could not be used in this year's program.
In' all the sections and general sessions two or more
men of prominence in their line will read and discuss
papers. Can you afford to miss the papers in the
Medical Section by Dr. Llewellyn Barker, of Balti-
more, on The Classical Endocrines? and Dr. J. J. R.
McCleod. of Toronto, Canada, on The Chemical Con-
trol of Respiration? No, of course you can't. Do
you mean to say you are going to pass up the papers
in the Surgical Section on the treatment of fractures
of the femur, including Dr. M. S. Henderson's
(Rochester, Minn.) paper on "Non-Union in Fractures
of the Neck of the Femur"? Are you going to let Dr.
George W. Crile return to Cleveland without hearing
what he has to say on "(he "Treatment of Cancer of
the Large Intestine"? Your patients demand your
presence at these meetings. What are you going to
tell your associates when they ask you "Did you hear
Dr. John Lovetts Morse, of Boston, Mass., in the
Pediatric Section on 'Discussion of the Recent Ten-
dencies in Infant Feeding'?" What do you think they
will say when you add, "I did not hear Dr. Charles
Kerly's (New York) paper on 'Effort Syndrome'?"
More than likely yoiu- reply will be 1 had a blowout
on the way to the meeting.
Come and sit down at the medical feast prepared by
the Eye, Ear. Nose and . Throat section and enjoy
what Dr. P. H. Friedenburg, New York City, has to
say on the "Endocrine System in Its Relation to the
Eye, Ear and Nose," and hear Dr. Robert Scott, of
Washington, D. C, open the discussion, while Prof.
J. Van der Hoeve (Lyden) discusses the paper on
"Vitreous Loss." Do you, yourself, know what these
men will tell you? If you do, stay at home.
In the General Sessions you will hear discussed the
"Treatment of Syphilis in the Primary. Secondary,
and Early Tertiary Stages," by Dr. Jay Schamburg ;
Visceral Syphilis, by Dr. Thomas McCrea, and Neuro-
Syphtlis, by Dr. Harry C. Solomon, of Boston, Mass.
Dr. Elliott Joslin, of Boston, Mass., and Dr. Frederick
Allen, of Morristown, N. J., will give you points on
the management of your diabetic patients. Come and
receive a set of Dr. Joslin's cards which you will not
procure by staying at home. Dr. Lexvis Ziegler, of
Philadelphia, will present a paper on "Wood Alcohol
Toxemia and the Remedy." The first patient you may
be called to see when you return home may complain
of the symptoms he describes.
These are but a few of the many so interesting and
practical subjects to be discussed that you can not af-
ford to remain away from the Philadelphia Session
of the State Society this year. Remember the date—
October 3-4-5-6, 19^1. Write at once for hotel ac-
commodations. Thomas G. Simonton, Chairman.
Committee on Scientific Work.
LEGISLATION RELATING TO MEDICINE
The time in which effective influence may be ex-
erted on legislative action relating to medical practice
and public health has passed for this session.
The reactions of the legislature to many measures
presented by physicians has been adverse. This win-
ter's experience has been very much like that of pre-
ceding years. The legislature of Massachusetts has
acquired the reputation of being conservative in its
treatment of bills, directly or remotely, relating to the
efficiency of physicians and standards of medical edu-
cation. Although freak bills, such as those applied to
the regulation of the heels of women's shoes, have
been quickly disposed of, serious recommendations
designed to raise the standards of medical practice
have, with one exception, received adverse action.
Matters which have led to disputes among physicians,
as the maternity bills, are not referred to, because it
was to be expected that a body of laymen would
shrink from enacting into law, bills which have caused
dissension in the ranks of the profession. But when
a bill is presented which represents the trend of events
and is supported by reputable physicians and recog-
nized experts, and which is rejected, one may be par-
doned for failure to understand the working of a legis-
lator's mind.
In order to profit by experience, those who have the
responsibility of representing the profession should
study the conditions which influence the attitude of
members of the General Court toward the recommen-
dations of physicians. It is possible that the medical
profession is loosely organized in its campaign for
constructive legislation. It is true that the Massachu-
setts Medical Society and the Massachusetts Homeo-
pathic Medical Society have a joint legislative com-
mittee. This committee meets in the autumn and cre-
ates an auxiliary committee representing the senatorial
and representative district throughout the state. These
committees are called together and such proposed leg-
islation as has been formulated is discussed and ap-
proved or opposed, as the case may be. Afterward it
has been found that there is difficulty in securing at-
tendance at meetings, the probable reason being that
most of the men living at a distance feel that the presi-
dents of the societies and their immediate associates
will attend hearings and give such advice as the sub-
ject under discussion warrants. It is true that the cen-
tral committees send circulars of information to the
members of the auxiliary committee but there has
seemed to be little evidence of effective work.
Everybody concedes that the great body of lawmak-
ers are honest men, actuated by a firm sense of duty,
and a determination to enact laws which will meet the
approval of the masses; and right here the great ele-
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August, 1921
TRUTH ABOUT MEDICINES
829
ment of chance comes in, for the legislature is be-
sieged by people who are sincere, but who are not al-
ways able to determine what is good and what is bad,
but whose evident honesty, together with support of
associates equally illogical confuse the minds of legis-
lators, and when arguments of proponents seem to off-
set those of proponents, endorsement of a good meas-
ure is denied.
One should put himself in the place of the legislator
in order to understand his reactions. His mind is bur-
dened with a multitude of somewhat complex ques-
tions with opposing forces contending for his support.
He cannot take time to ascertain the attitude of his
constituents and hence he sometimes drifts with the
current set in motion by some forceful person.
Like most people, he is vulnerable to the malign sug-
gestion of trust, to abuse of power, or a desire to
crush out weak organizations, and is unconsciously
swayed by such claims.
The unpleasant and often unproductive attempt to
influence legislation, has led some men to propose that °
medical organizations should retire from the field and
let the people act unguided and uninspired. It is
argued that physicians know how to protect them-
selves and that effort to secure public health measures
is a thankless task unless the people ask for protec-
tion. On the other hand, can physicians with under-
standing remain quiet, when there is danger to public
health, or possibility of fraud?
H anything is to be accomplished there must be or-
ganization and intensive effort. We can profitably
learn from politicians that the time to inaugurate a
movement is in advance of conflict, and if future mem-
bers of the legislature are to know the wishes of their
constituents, there should be laid a foundation of
knowledge. Every well qualified physician should be
engaged in securing the support of his community for
those measures which lead up to more efficient prac-
tice and the discard of pernicious or selfish ambitions.
The time to act is now. The disappointments of this
legislative session are fresh in mind. The people will
demand support of progressive medical legislation, if
informed. Let the legislative committees enter upon a
campaign of education in every community, taking, for
example, the benefits of vaccination, the need of well
educated and trained practitioners, and such other
questions as have met the unanimous approval of the
profession. — Editorial, Boston Medical and Surgical
Journal, May 5, 1921.
TRUTH ABOUT MEDICINES
ToNA-ViN. — To those familiar with nostrum adver-
tising, the advertisements which have appeared in
newspapers for "Tona-Vin" made it fairly easy to
classify the product as probably belonging to the class
of alcoholic nostrums that are being born over night
in order to meet — or beat — the exigencies of the pro-
hibition law. According to the label the preparation
contains "soluble iron and quinin, fluid extract of
senna leaves, wild cherry and aromatics." The A. M.
A. Chemical Laboratory analyzed Tona-Vin and re-
ported that it is a dark-brownish liquid, having an
odor like wild cherry and wine and a slightly bitter,
somewhat sour taste. The presence of 18 per cent, of
alcohol is declared on the label. The analysis demon-
strated that the amount of quinin was so small that,
to obtain a single tonic dose of quinin, it would be
necessary to drink the contents of about 14 bottles of
the preparation. The chemists further found that, to
obtain an average dose of iron, the individual would
be obliged to drink the contents of an entire bottle of
Tona-Vin. When one ounce was dealcoholized and
swallowed by a healthy man, no effect except a doubt-
fully laxative action was noted. Evidently Tona-Vin
is not sufficiently medicated to prevent its use in mod-
erate amounts as beverages. There is, of course, no
legitimate reason for administering such drugs as iron
and quinine and senna, in ridiculously small doses, in
a menstruum containing 18 per cent, of alcohol (Jour.
A. M. A., Jan. 15, 1921, p. 193).
Glover's Cancer Serum. — In an envelope bearing
the name "T. J. Glover, Research Laboratory, Toronto,
Canada," but mailed, apparently from New York, phy-
'sicians are receiving "literature" about Dr. Glover's
Cancer Serum. This is stated to be a serum from im-
munized horses "between the ages of seven and nine
years, of the roan type," and is claimed to have a
specific action on every known type of cancer. The
advertising offers to send the serum on receipt of
price. While this would indicate that the Glover Re-
search Laboratory had received a permit from the U.
S. Public Health Service licensing the interstate sale
of the sertim in the United States, no such license has
been issued (Jour. A. M. A., Jan. i, 1921, p. 52).
Polyvalent Vaccines for Colds. — At least five com-
mercial manufacturers of biologic products make and
push the sale of vaccines to prevent colds. Of these
at least two, from time to time, have added new strains
of bacteria to the formulae with which they originally
introduced their products, so that seventy-five or eighty
different types of bacteria are now included. Every
year different types, varieties and species of bacteria
have been associated with colds in different parts of
the country. Presuming — although it has never been
proved — that any vaccine has value in preventing colds,
the logical thing to do is to prepare a specific vaccine
for each form of cold in each part of the country.
Commercially it is much more profitable to mix all the
bacteria together, to prepare a vaccine and to inject
this into the patient in the hope that some organism
will produce antigens which will find their mates. The
present-day shotgun biologic mixture is more ridicu-
lous than the old shotgun proprietary — and a greater
menace to public health and to scientific medicine
(Jour. A. M. A., Jan. 15, 1921, p. 182).
More Misbranded Nostrums. — The following prep-
arations have been the subject of prosecution by the
federal authorities charged with the enforcement of
the Food and Drugs Act: Benetol Suppositories
(Benetol Co.), misbranded in that unwarranted
therapeutic claims were made for them. Vinol (F,
Stearns & Co.), misbranded in that false and fraudu-
lent claims for curative effects were made for it. •
Mir-A-Co (Mir-A-Co Co.), sold with false and mis-
leading statements regarding its composition and with
fraudulent therapeutic claims. Novita Globules;
Novita Capsules; Novita Salve, Stainless; Novita
Salve, Brown (Novita Co.), misbranded in that the
therapeutic claims were false and fraudulent. Pepso-
Laxatone (Burlingame Chemical Co.), adulterated in
that it did not contain diastase or pancreatin as
claimed and that the therapeutic claims made for it
were false and fraudulent. Alkano (Alkano Remedy
Co.), offered under false and fraudulent therapeutic
claims (Jour. A. M. A., Jan. 29, 1921, p. 326!. .
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830 THE PENNSYLVANIA MEDICAL JOURNAL August, 1921
THE PENNSYLVANIA Defense." After discussing the problem of
medical defense and the need of additional pro-
1^ l?r> ir^AI 10ITI?\rAT tection for New York state physicians it gives
X^KiliLJlV^^Li J\J\JI\rSt\l^ the following preamble and resolution :
"„.,... ~ ' : ~. , ^ „ . ,. .. "Whereas, It is desirable to continue the
Published montnlr under the »uj>ervi8ion of the Publication , r • <• i • t c
Committee of the TruMees of the Medical Society of the Sute benefit to our members of malpractice defense
ennsy vania. work to prevent the profession from being sub-
zditor ject to unjust attack ; and
FREDERICK L. VAN SICKLE. M.D Harriaburg "Whereas, Through the defense plan of the
FRANK F. D. RECKi^!*".*. ."".*". Harriaburg Medical Society of the State of New York, the
Aaaocuto Editor* members have had the cooperation of their fel-
josirR McFamjimd, M.D Philadelphia low members and the defense of l^al counsel of
GloaGB E. ?FARijn, M.D Philadelphia , ..... ... r ,t ■ • ,■
LAwaiMd tiTCHMBLo, M.D Pittsburgh the socicty in the protection of their reputation
r~s«wSi/°Ro"'jAM; ^-.S:: ••.•.V.-.-.V.V.-.V.V.V.V.Pwi&'S- and interest against unjust attack; and
feS*.*,; J* M««"'^°-: . : : : : : ; : : : : -.^LZ'^tli "Whereas, a large number of members of the
PubUottion Committee Society desire, in addition to the protection af-
iRA G. Shobmakm, M.p^ Chairman ..Reading forded bv the malpractice defense, indemnity
TuiosoxK B. Appel, M.D Lancaster . ■' , . , .• , .
Framk c. Hahiiohd, M.D Philadelphia against judgment Or Claim for which they may
... ~ ~ 7 ~ ! '. be answerable in law despite the use on their
All communications relative to exchanges, books for review, f , , , .„ , . ,
manuscripts, news, advertising and subscriptions are to be ad- part of the best Skul, Care and judgment ; and
dressed to Frederick L. Van Sickle, M.D., Editor, aia N. ' ,,,,,, r. . . j -i f ^ .
Third St., Harrisburg, Pa. Whereas, Such an indemnity feature can be
The Society does not hold itself responsible for opinion, ex- ^dded to the benefit of the malpractice defense
pressed in original papers, discussions, communications or ad- work of the Said SOcicty through proper arrange-
ments with an insurance company at a reasonable
Subscription Price— $3.00 per year, in advance. rate and under conditions which will make avail-
. _ ,„^, able to the said society's malpractice defense
August, 1921 ■ , ^ r ^ "Lu • lu
^ many elements of strength in the arrangement
of the said insurance company, particularly in
the investigation of claims and the separation of
cases; and
MEDICAL DEFENSE IN ALLEGED "Whereas, The members who procure such
MALPRACTICE SUITS indemnity will not thereby lose any of their
The Medical Society of the State of Pennsyl- "^^^t^ °^ participation in the malpractice defense
vania has for some years been fortunate in the °* *f society, but will receive all of the benefits
conduct of its Medical Defense Fund, in that it ^'j^'"^'" ""^ .^"""^ members as well as the benefits
has been exceedingly successful in the defense of ^* indemnity; and
State Society members and because of the few "Whereas, The operation of this plan will af-
judgments which have been rendered. Recently, ^ o^d increased protection to the members and de-
in various states the question has arisen, and is crease the cost to the society for the maintenance
probably being discussed in this state, as to why of this malpractice defense department ; there-
physicians should be obliged to carry insurance fore, be it
tc cover suits against them for alleged malprac- "Resolved, That the Medical Society of the
tice in addition to the expense of the conduct of State of New York, through its House of Dele-
the State Fund. gates now as-sembled, upon the recommendation
It is quite logical for us to reason that, inas- of the legal counsel of the State Society, hereby
much as the State Society does not pay judg- endorses the .said plan and approves of the same
ments, the fear of judgments being rendered and authorizes that the council, officers, 1^
against members compels them to carry other counsel of the society and the county medical
insurance protection, especially those who prac- societies take such action with respect thereto as
tice surgery or other branches of medicine which shall be fit and proper to carry the same indem-
render them more liable to this source of annoy- nity feature, provided that nothing herein con-
ance. For the purpose of bringing this matter tained shall require any member of this society
to the attention of the profession, and of show- to release his rights now existing to participate
ing the trend of work which is being done in in the benefits of the malpractice defense or
other states, we will quote from an editorial in compel him to subscribe to malpractice defense
the May issue of the Nczv York State Journal of insurance except as he shall so elect."
Medicine, under the caption of "Malpractice From this, it is evident that the profession of
Digitized by VjOOQIC
August, 1921
EDITORIALS
831
the state of New York realizes that additional
protection, other than a mere defense, is desira-
ble. This matter has also been discussed by the
AmericanMedical Association in the light of en-
deavoring to establish an insurance fund within
the ranks of the profession. Might we not seri-
ously consider for Pennsylvania some means
either of adding to the Medical Defense Fund
as it now stands a judgment clause or, better
still, some means of creating an insurance de-
partment which would give the members an op-
portunity to purchase insurance by the group
plan through some reliable agency ?
"WHERE DO WE GO FROM HERE?"
The doughboy made famous the above caption
during the late war, and we use it to point to the
trend of affairs as they apparently exist in the
present-day scheme in the United States. By
this we mean that the agitation existing in our
country, which is affecting the profession of
medicine and its associate sciences and arts, must
lead us to infer that something is happening be-
tween the people and those who are practicing
the healing art.
There is an adage which says: "Where there
is smoke, there must be fire." And smoke is now
arising from the printed statements in every
medical journal of this country to the effect that
medical practice is being assailed from many
different angles.
In the July issue of the Illinois Medical Jour-
nal an editorial states: "The Illinois medical
practice act, as revised in 191 7, was found un-
constitutional in the State Supreme Court on
July 22d." Another editorial in the same journal
states: "There was recently introduced in the'
Illinois Legislature a bill which would limit the
price a doctor could charge for an alcoholic pre-
scription to $1.00." Further on it states: "We
are reliably informed that a member of the House
of Representatives at the recent session of the
Illinois Legislature, in speaking of the bill alluded
to, remarked : "Gentlemen, this bill is the enter-
ing wedge. We propose to fix it in the future
so tliat doctors can do no prescribing at all. In
oiher words, if people are to be treated in the fu-
ture it will be by some method of drugless
therapy."
There is real legislative smoke, there is real
legislative danger existing in many parts of our
great country, as pertains to the type of legisla-
tion which you might call state vocational fads,
or pseudo reforms. It is of course apparent
from what source comes this agitation. We do
not purpose to call "Wolf" when there is no
wolf, nor yet to be artlessly innocent of real dan-
ger when danger concerns us. Laymen in the
legislative halls do not sense the dam^^e that can
be done the healing art, established upon the ex-
perience of centuries, by. the passing of a few
laws which will so twist the public mind as to
create a serious breach of faith between the pub-
lic and those who have its best interest at heart
— ^and this caused largely by those who have only
the desire to financially fleece their victims.
The time to prepare for war is when peace
reigns, and we must continually agitate the ques-
tion within our ranks so that when the legislative
session is again called we may know that there
will be business to transact. Let us not be in a
position to say, "Where do we go from here?"
when apparently there is no place to go, should
legislation affect the profession as it has in Illi-
nois, Missouri and some other states.
"SOCRATES REDUX"
THE MODERN PAGANISM
"I have to be very careful, these days, what
I say. I find what Sir Walter Scott says is
true, "There is a cheild amang ye takin notes,
faith he'll prent it."
But as he uttered these words we noticed that
the eyes behind the thick glass spectacles were
beaming, and the crow's feet at the corners
were wrinkling in harmony with the elevated
outer angles of his mouth, so we inferred that
he was pleased rather than otherwise. He took
his accustomed place, wiping the perspiration
from his forehead with a spotless handkerchief,
but sat upon the edge of his chair, making a pre-
tense of being in a hurry, until he should find
out whether we were too busy to listen to him
talk or not.
As the day was warm and things pretty well
under way, we tilted back in the editorial chair,
relaxing in a pleasant breeze that wafted the
sweet perfume of honeysuckle, and the sweeter
notes of a song sparrow through the open win-
dow, and waited to hear what might follow.
"One of my friends has just let me read a
letter in which the writer said, 'Old Socrates is
still with us and his articles are well worth the
time that it takes to read them' — old Socrates,
indeed !"
"Ah," we said, "We had an idea that unpop-
ularity compelled him to drink hemlock two
thousand years ago."
"So it did, and it probably served him right.
But what worries me is that .somebody is now
•calling me Socrates, and may sooner or later
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832
THE PENNSYLVANIA MEDICAL JOURNAL
August, 1921
force Hie into a position in which I will have to
drink something bitter too."
"Don't worry," we said, "At present the
critics seem to like what you say."
"In Kings — I mean the Book of Kings in the
Bible — it tells that during the reign of Ahab,
king of Israel, there used to be schools and col-
leges of prophets. There were hundreds of
those young prophets, and when the king said
'Prophesy,' they prophesied. The system
seemed perfect : they first found out what the
king was determined to do, then they advised
him to do it. But now and then it happened
that a real prophet got into the school, and
started to do some original work — if you want
to know more about it read the twenty-second
chapter of Kings and see what happened to
Micaiah when he tried it: they 'put him in
prison and fed him upon the bread of affliction
and water of affliction.' "
"You must have been to church last Sunday,"
we suggested, "and got religion."
"Don't worry, I have no more religion than
you or any other man ought to have ; most of
us have little enough in these times! But I
wonder what became of the writing of those
prophets. Where was it published ? What was
the matter with it that it did not live ? It was
a great system of subsidizing the prophets and
getting the best, and ought to have worked.
Do you suppose that if they had subsidized
Isaiah, given him a staff of assistants and ste-
nographers that he would have done more and
better work? Suppose that you were selected
as a promising writer, as of course every editor
must be, and placed in a hcmdsome new insti-
tute with assistants and stenographers, and told
to prophesy, could you do it?"
As we had never thought about such a thing,
we were obliged to express some doubt, but
really did not commit ourselves.
"A publisher once arranged with Thomas
Moore, that he should write the greatest poem
in the world, and agreed to pay him the greatest
price ever paid for a poem when it was finished.
The result was 'Lalla Rookh.' No, it is not the
greatest poem in the world, and though it is
very pretty as a story and the little poems are
entertaining, there are plenty of people like
yourself, for example, who have not read' it.
and even some who like and know a lot of
poems who have not heard of it. You see
poems cannot be written that way. They never
can be written to order or for pay. They have
to bubble up out of the full heart of the poet,
and they seem to find their greatest inspiration
in adversity. Imagine yourself given a sum of
money and then ordered to write poetrj' or
music. Could you do it ?"
"How about cutting out the religion and
poetry and telling us what you really have in
your system?"
"I am coming to it. It has become the fash-
ion of the day to fit up comfortable workshops,
equip them with the very best of tools, employ
a couple of first class clerks and a stenographer
for each, provide each with card indexes and all
of the latest furbelows, and then select some
well educated and promising young fellow for
each, pay him a good salary, and then say to
him, 'now that we have fixed you up, go ahead
and invent something.' "
"We never heard of such a thing. Where is
it done?"
"Where? Why everywhere. It is quite the
style."
"Surely no sane business man would be so
foolish."
"Right! No business man would. My son-
in-law has just gone into business with a big
corporation. He is a graduate of a great insti-
tution of learning, and is an engineer, but that
did not help him. He began at the bottom and
spent a month filling oil barrels, painting bar-
rels, then was moved up to selling oil and is still
on the road in hope that in the course of time
he will really get a chance to be something."
"Well, we began with religion, moved on to
poetry, and now have reached business, and still
we have come to nothing in particular."
"How obtuse you are. There are to-day
dozens, perhaps even hundreds, of elaborately
fitted up workshops, called laboratories, all over
the country, some supported by private sub-
scription, some supported by 'Foundations' and
some endowed, upon which no expense has been
spared, in each of which there are promising
young men and women, usually well paid, who
do a little towards the routine work of the in-
stitution with which they are connected, but to
whom some one is saying 'prophesy,' 'write a
great poem,' 'invent something' or at least 'dis-
cover something' — in other words, 'RE-
SEARCH.' Scarcely one of them ever has dis-
covered anything, or can discover anjrthing,
because discoveries are not made that way.
The poor kids don't know what to discover and
are most miserable because they are expected
every year to send out a bundle of nicely bound
reprints containing what they have, but proba-
bly should not have written. These are rarely
read by those who receive them, and are judged
rather by their appearance and quantity rather
than by their contents and quality, which is a
shame in these days of paper shortage. Would
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August, 1921
EDITORIALS
833
any business man stand for anything like that ?
Of course not. What a business man demands
is results. He must first have the results, and
then he is willing to furnish additional oppor-
tunity. In these workshops the opportunities
are offered in the hope of results, and so the
money is wasted and no results come.
"Don't I believe in laboratories and in scien-
tific research? Of course I do or I wouldn't
have a private laboratory of my own. What I
object to is the waste of money and opportunity
where there is no hope of achievement. If a
man has an idea, he usually finds the way to test
it out, and if a man has none, no amount of op-
portunity will give him any. You can't make a
silk purse out of a sow's ear, and you can't
squeeze discoveries out of any empty head.
The great discoveries have never been made by
those of whom discovery was expected. It is
always some other fellow who, according to all
the books ought not to have done it, who suc-
ceeds."
"Then you do not believe in scientific re-
search ?" •
"Scientific research is a kind of modem pa-
ganism. It is the cult of a false god whose tem-
ples are being erected at enormous expense all
over the country, and whose priesthood of well
meaning men is being supported at the financial
sacrifice of those led to believe that fire will be
called down from heaven. But like the priests
of Baal on Mount Carmel, the researchers cry
aloud to their god, dance and work themselves
into a frenzy, declaring that only through their
eflforts can knowledge come, when unexpected-
ly, from nowhere, without the prestige of any
foundation, without any authority, some young
Elijah steps forth, and behold, the heavenly fire
appears."
FABLES FOR THE KANSAS DOCTOR
Once upon a time there was a Kansas doctor who
did not belong to his State or County Medical Society.
He could give no reason for this except that a physi-
cian he did not like, belonged. Another reason he se-
cretly held was, a man is not so likely to betray his
ignorance if he keeps strictly to himself.
He managed to get by for some time until one un-
fortunate day a.ilivver derailed itself and put a body
scissors on Hank Jones on the side hill south of town.
"Doc" was called and made a diagnosis of a fracture
of both bones of the leg above the knees. This he
certified to in Hank's accident policy blank. Three
months later Hank got around with four inches of
shortening and a leg so crooked he usually took the
milk bucket when he started for the mail box, as it
was very uncertain what direction his leg would take
him.
In due course of time Doc was sued for $5,000 dam-
ages, in spite of the fact men of Hank's calibre were
quoted at about ninety-eight cents per dozen on the
local exchange.
Then the doctor looked around for something to
lean upon. No powerful organization was at his call.
No professional brethren rushed in to help carry the
burden. No skilled counsel versed in this line of liti-
gation was free for the asking. Instead he was com-
pelled to employ an attorney who didn't know the os
femur from the os cervix, and after a lengthy, expen-
sive trial, a jury of twelve bovine-eyed individuals,
who had given their oath they didn't know anything
and never expected to, brought in a verdict for the
plaintiff in full. — Jour. Kan. Med. Soc.
TAKE SAFE WATER FOR PICNIC LUNCHES
Motorists, hikers and campers take grave chances
when they drink water from unknown sources, accord-
ing to officials of the State Department of Health.
Wayside brooks and springs are often badly pol-
luted and may be capable of causing typhoid fever or
other serious intestinal disorders. Even farm wells
should be looked on with suspicion, for convenience
rather than safety usually governs the location of such
wells, which results in their being placed too close to
privies, sink drains, and other sources of contamina-
tion.
Only springs in sandy soil remote from roads and
human habitations, should be considered as safe for
drinking purposes. The better course is to carry an
adequate supply from a source known to be pure or
to boil all drinking water. — N. Y. State Dept. of
Health.
Spirocide Not Admittbd to N. N. R. — The Council
on Pharmacy and Chemistry reports that Spirocide is
advertised as a new and successful treatment of syphi-
lis by fumigation and inhalation. The product is fur-
nished in the form of tablets which are stated to be
composed of metallic mercury, copper sulphate, cypress
cones, henna, nutgali and dried pomegranate. Experi-
ments in the A. M. A. Chemical laboratory showed
that when the tablets are ignited the organic constit-
uents are consumed, the mercury is volatilized and
most, if not all, of the copper remains behind. For
use, the patient sits on a chair, the tablet is ignited, and
the patient is covered with a sheet so that he will in-
hale the mercury vapors produced. The Council ob-
tained the opinion of syphilographers with regard to
the evidence submitted by the Spirocide Corporation,
which markets the product, and as to the advisability
of giving recognition to a method for the administra-
tion of mercury by inhalation. In consideration of
the opinions expressed by its consultants, the Council
declared Spirocide inadmissible to New and Non-
official Remedies because, first, the claims made for it
are unproved and unwarranted ; secondly, the routine
use of an inexact method for the administration of
mercury is detrimental to sound therapy ; and thirdly,
the name is not descriptive of the composition, thus
failing to remind the physician who uses the pastils
that he is administering metallic mercury (Jour. .\, M.
A., Jan. 22, 1921, p. 259).
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The Medical Society of the State of Pennsylvania
OFFICERS' DEPARTMENT
WALTER F. DONALDSON, M.D.
Secretary
8014 Jenkins Arcade BIdg.
Pittsburgh, Pa.
MEDICAL DEFENSE
Applications for medical defense against suits
for alleged malpractice continue to be filed, the
latest being founded on the result obtained in the
treatment of a fractured elbow. The physician
making application was in charge of the case but
three days during the absence of the plaintiff's
regular physician. Immediately after applying
temporary dressing, the patient was referred for
x-ray examination and was within the first four
days examined by five other physicians. This
experience would indicate that the mere fact that
the attending physician is well fortified by con-
sultants, 'does not lessen his liability to the an-
noyance of defense against suit for alleged mal-
practice.
POSTGRADUATE PROGRAM
The Medical Society of the State of Pennsyl-
vania presented the following schedule at Somer-
set on Tuesday, July 19, 1921 :
10:30 A. M. (Eastern Standard Time)
Chairman, Charles B. Korns, M.D., President,
Somerset County Medical Society
"Immunity in Diphtheria," Henry J. Cartin,
M.D., Johnstown.
"Cancer," Edward A. Weiss, M.D., Pitts-
burgh.
"Obstetrics and the General Practitioner,"
Thomas E. Mendenhall, M.D., Johnstown.
"The Clinical Aspects of Nephritis and Its
Treatment, with Special Reference to the Diet,"
R. R. Snowden, M.D., Pittsburgh.
"The New-Era as it Affects Medical Practice,"
Walter F. Donaldson, M.D., Pittsburgh.
1 : 30 p. M.
Chairman, I. J. Moyer, M.D.. Trustee, The Medi-
cal Society of the State of Pennsylvania
"Pneumonia," W. W. G. MacLachlan, M.D.,
Pittsburgh.
"Pain as a Warning of Oncoming Spinal Cord
Disease," George J. Wright, M.D., Pittsburgh.
"Ano-Rectal Diseases as Seen by the General
Practitioner," Curtis C. Mechling, M.D., Pitts-
burgh.
"Diagnosis of Surgical Conditions in Abdo-
men," Evan W. Meredith, M.D., Pittsburgh.
"Non-Operative Treatment of Fractures,"
Clarence B. Millhoff, M.D., Johnstown.
There were ninety-two (92) physicians regis-
tered and the attendance and interest was main-
tained at the highest possible average from the
opening to the closing paper. All essayists were
present. The latter expressed themselves as be-
ing delighted with the reception received. The
local Committee on Arrangements provided
Court Room No. 2 in the handsome new Somer-
set County Courthouse and a good dinner was
served promptly at i p. m.
It is believed that as a result of this meeting,
the morbidity and mortality from diphtheria and
cancer will be favorably affected throughout the
wide area served by the physicians in attend-
ance and there is no doubt that many of the
teachings of twenty years ago and the practice*
of to-day in obstetrics and in the treatment of
nephritis will be modified to the benefit of the
people of southwestern Pennsylvania; the rec-
ognition of certain spinal cord diseases and of
the mixed types of infection involved in latter
day pneumonias will, no doubt, be evolved earlier
than heretofore by the physicians who were
present at this meeting; surgical conditions in
the abdomen will be recognized earlier and the
treatment of anorectal diseases approached more
skillfully ; fractures that can be treated without
operative interference will hereafter be treated
in such a way as to obtain better results.
It is our hope that the following physicians
participating in this conference will be mission-
aries spreading propaganda for the gradual but
endless development of postgraduate work by
county, state and national medical societies :
SOMERSET COUNTY (32)
Irwin C. Miller, William P. Shaw, Berlin; Frank E.
Sass, Boswell ; 'M. V. Brant, Caimbrook ; Samuel E.
Lyon, Central City; W. Rov McClellan, Garrett;
George C. Grazier, Henry A. Zimmerman, Hollsopple : -
Henry Hertzler, Mosheim W. Kuhlman, Jenners;
William W Keim, Jerome; George A. Noon, Listie:
George B. Masters, Macdonaldton ; Bradley H. Hokt
Charles P. Large, Bruce Lichty, H. Clay McKinley.
William T. Rowe, Meversdale; Charles L Shaffer,
Ralphton; Charles J. Hemminger, Clinton T. Savior,
Rockwood; Charles B. Korns, Sipcsville; A. M. Up-
house, *S. Slabotsky, Henry L Marsden, Henr>- Wil-
son, Henry S. Kimmell, Fred B. Shaffer, J. Earl Dull.
J. Ross Hemminger, Somerset; *J. H. Gardner,
Albert F. Keim, Stoyestown.
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August, 1921
OFFICERS' DEPARTMENT
835
WESTMORELAND COUNTY (i8)
Benjamin M. Watkins, Derry; Domer S. Newill,
Donegal; *Janies F. Trimble, Wilder J. Walker,
Greensburg; Charles E. Taylor, *Charles J. Kelly,
Irwin ; Joseph H. Watson, N. Ney Prothero, Urban
H. Reidt, Jeannette ; Thomas W. Moran, *J. W. Blair,
Latrobe; Effie B. Dunlap, Ligonier; Albert A. Bea-
com, Mammoth; Myers W. Horner, John L. Burk-
holder. Mount Pleasant; Carroll B. Rugh, New Alex-
andria; Samuel S. Wright, Pleasant Unity; D. Alli-
son Walker, Southwest.
FAYETTE COUNTY (i6)
Elliott B. Edie, Louis P. McCormick, Andrew J.
Colbum, Hugh J. Coll, Earl C. Sherrick, Don D.
Brooks, . Edg^r A. McCombs, Connellsville ; Harry J.
Bell, Dawson; Robert E. Heath, Fairchance; Chester
B. Johnson, Mount Braddock; William H. Means,
Percy; Robert H. Jeffrey, James E. Van Gilder, Clyde
W. Conn, William S. Kimmell, Uniontown; Jesse H.
Hazlett, Vanderbilt.
CAMBRIA COUNTY (9)
Henry J. Cartin, Calvin G. Rush, Thomas E. Men-
denhail, Joseph J. Meyer, William E. Matthews, John
L. Sagerson, John B. McAneny, Clarence B. Millhoff,
William O. Lubken, Johnstown.
ALLEGHENY COUNTY (8)
Walter F. Donaldson, Evan W. Meredith, W. W. G.
MacLachlan, George J. Wright, R. R. Snowden, Curtis
C. Mechling, Irwin J. Moyer, Edward A. Weiss, Pitts-
burgh.
INDIANA COUNTY (3)
H. Boydston Smith, Blairsville; H. DeV. Hotham,
William B. Ansley, Saltsburg.
WASHINGTON COUNTY (2)
Orville G. Lewis, J. Frank Donahoo, Washington.
BEDFORD COUNTY (i)
Walter F. Enfield, Bedford.
OUTSIDE OF STATE (2)
S. S. DeVaux, Cincinnati, Ohio ; H. S. Hickok, Kan-
sas City, Mo.
'Nonmember.
CHANGES IN MEMBERSHIP OF COUNTY
SOCIETIES
The following changes have been reported to July
19:
Adams : Transfer — Donald B. Coover, Spring
Grove, to York County.
Allegheny : New A/^mfcerj^— William H. Chambers,
133. Fifth Ave., McKeesport; R. W. Ebe, 135 W.
Swissvale Ave., Swissvale (Edgewood P. O.) ; Jesse B
Griffith, 618 McKee Ave., Monessen; August Saska, 519
Eights St., Homestead ; Paul P. Doyle, 2006 Beaver St.
N. S., Pittsburgh; Charles N. Silman, 992 Lilac St.;
Richard C. M. Stewart, 6101 Broad St., Pittsburgh.
Reinstated Members — Aaron Jacobwitz, 8084 Jenkins
Arcade; Clarence R. Welfer, 820 Hiland Bldg.;
George W. Beane, Jenkins Arcade; Walter H. Cas-
key, 305 Shady Ave.; Robert K. McConeghy, 4200
Butler St., Pittsburgh ; Harry S. Lake, Willock ; Fred
H. Harrison, 20 N. Lee St., Cumberland, Md. ; Samuel
Itscovitz, 123 Fifth Ave., McKeesport; Ira C. Duncan,
Broadway, East McKeesport; Arthur P. Schaefer,
821 Lockhart St., N. S., Pittsburgh.
Bedford: Reinstated Member— T. Sheldon Taylor,
Schellburg.
Berks: New Members — Lawrence H. Fitzgerald,
Temple; Wellington A. Lebkicker, 25 S. Fifth St.;
William S. Long, 208 N. Sixth St., Reading.
Bucks : New Members — Edmund R Everetts, Lang-
horne; Linford B. Roberts, Wycombe.
Cambria: Removal — ^John W. Barr from Nanty
Glo to 236 Market St., Johnstown.
Chester: Death — George R. Spratt (Univ. of
Penna., '64), of Coatesville, recently, aged 82.
Clearfield: New Member— W\\\\& A. Houck, Du
Bois.
Crawford: D^oiA— Margaret B. Best (Trinity Med.
Coll., Toronto, '99), of Meadville, May, 26, aged 56.
Delaware: Reinstated Member — Peter M. Keating,
Wawa.
Franklin: New Member— Rohtri B. Brown,
Waynesboro.
Indiana : New Member — ^James M. Torrence, In-
diana.
Juniata: New Member — Penrose H. Shelley, Port
Royal.
Lancaster: Z)ea//i— Albert S. Blough (Medico-
Chirurg. Coll., Phila., '04), May 26, in Lancaster Hos-
pital, fctllowing an operation.
Lackawanna : New Members — Albert J. Colcord,
Port Allegheny; Helen M. Houser, 306 Wyoming
Ave. ; Lucius M. Elsinger, Council Bldg. ; Joseph F.
Saltry, Capouse Ave.; William J. L. Davis, Board of
Trade Bldg.; Samuel P. Longstreet, 511 N. Washing-
ton Ave. ; Llewellyn D. Griffith, 722 So. Main St. ;
James R. Skeoch, 1000 Webster Ave., Scranton.
Luzerne: Reinstated Member — Austin L. Haus-
lohner, 32 N. Washington St., Wilkes-Barre.
Lycoming: New Member — Leo M. Knauber, 821
Diamond St., Williamsport.
Lawrence: New Member — William G. Evans, Ell-
wood City.
McKean : New Member— Edward J. Phillips, Rix-
ford.
Mercer: New Member — Frederick C. Potter, Mer-
cer Sanitarium, Mercer.
Mifflin : New Member — Raymond M. Krepps,
Lewistown.
Montgomery : New Member — George Cordonna,
Norristown.
Montour: New Member — Carl E. Erwin, Geissinger
Hospital, Danville.
Northampton: Reinstated Member— Damd F.
Bachman, Bethlehem. Death — Henry J. Laciar (Coll.
Phys. & Surg., Baltimore, '81), of Bethlehem, June 13,
aged 64.
Northumberland: Death — John S. Mengel (Jeff.
Med. Coll., '87), of Trevorton, aged 52.
Philadelphia : New Members — Leonard F. Bender,
4321 Frankford Ave., Archibald M. Cook, 1421 Arch
St. ; Samuel Finley (jordon, 1326 Rockland St. ; Den-
nis Alexis Myers, 1831 Chestnut St. ; Russell Richard-
son, 320 S. Sixteenth St.; Arthur R. Vaughn, 3651 N.
Fifth St., Philadelphia. Transfer— Harry A. Britton,
35 1 N. Fifth St., Reading, to Berks Co. Deaths-
John H. Hartwell (Med. Chirurg. Coll., Phila., '10),
June 21, aged 48; Edward S. Vanderslice (Univ. of
Penna., '64), ^of Philadelphia, June 28, aged 78.
Snyder: Death — William W. Longacre (Coll. of
Phys. & Surg., Baltimore, '93), of Mt. Pleasant Mills,
June 10, aged 56.
Susquehanna: Reinstated Member — William E.
Park, New Milford.
PAYMENT OF PER CAPITA ASSESSMENT
The following payment of per capita assessment has
been received since June i6th. Figures in the first
column indicate county society numbers; second col-
umn, state society numbers :
June 17 Lackawanna 19S-198 7131-7134 $20.00
Montgomery 148 7135 5.00
18 Butler 46,49 7136-7137 10.00
Lycoming 105 7138 5.00
20 Schuylkill 104 7139 5.00
Lawrence 60 7140
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THE PENNSYLVANIA MEDICAL JOURNAL
August, 1921
21 Luzenie
226-228
7141-7143
1500
Perry
17
7144
500
22 Mifflin
26
7145
5.00
Clinton
25
7146
5.00
Warren
45-48
7147-7150
20.00
23 Lackawanna 199-204 7151-7156 30.00
25 Juniata 13 7i57 5oo
2:j Ivackawanna 205-206 7158-7159 10.00
Clearfield 60 7160 5.00
28 Adams 26 7161 5.00
July I Northampton 130 7162 5.00
Erie 123 7163 5.00
2 Indiana 62 7164 5.00
5 Clinton 26 7165 5.00
7 Washington 126 7166 5.00
Lackawanna 207 7167 5.00
Delaware 87 7168 5.00
8 McKean 44 7169. 5.00
10 Luzerne 229 7170 5.00
Allegheny 1 148-1 166,
1168-1169 7171-7191 105.00
13 Franklin 55 7192 500
Philadelphia 2028-2029 7193-7194 10.00
18 Susquehanna 21 7204 5.00
19 Northampton 131 7205 5.00
Bedford 17 7206 5.00
Per capita assessment for remainder of year 1921
for new members uniting with component societies
subsequent to June 30:
July 12 Philadelphia 2030-2035 7195-7200 $15.00
13 Montour 22 7201 2.50
Bucks 83-84 7202-7203 5.00
19 Mercer 75 7207 2.50
FREDERICK L. VAN SICKLE, M.D.
Executive Secretary
212 N. Third St., Harrisburg. Pa.
AMENDMENTS TO BY-LAWS
The Board of Trustees at its meeting May 2,
1 92 1 recommended to the House of Delegate.;
the following amendments to the By-Laws of
the Medical Society of the State of I'cnn.syl-
vania. Change Chapter V, Section 5 of the By-
Laws on page 20, to read :
"The Executive Secretary shall he appointed
annually hy the Board of Trustees at its first
meeting after the annual session of this Society.
Adequate salary and other expenses of his office,
shall be provided. He shall aid in the upbuild-
ing of medical organization in this State, and
.>;hould visit each Councilor District of this So-
ciety once a year, .subject to the direction of the
Board of Trustees. , He shall be a member ex-
<>11icio of the Committee on Public Health Leg-
islation, and shall keep the medical profession
informed on proposed or pending legislation of
interest to the general public and the medical
profes.«ion. He shall organize the machinery
for obtaining evidence against illegal practition-
ers, and present such evidence to the Bureau of
Medical Education and Licensure for action as
provided by laws of the Commonwealth of
Pennsylvania. He shall be ex-officio a member
of the Committee on Scientific Work. He shall
be Editor and General Manager of the Journal.
He shall be Manager of Sessions and Exhibits
for the annual session of this Society. The
combined offices of the Executive Secretary'.
Editor and General Manager of the Journal,
Manager of Sessions and Exhibits shall be
known under one title as Executive Secretary."
"Change Chapter VI, Section 2, of the By-
Laws on page 26 by striking out the words Edi-
tor, Manager of Sessions and Exhibits, and in-
sert in lieu thereof, the words 'Executive Secre-
tary.' "
"Change Chapter VL Section 7, of the By-
Laws on page 28, by striking out the words
Manager of Sessions and Exhibits, and insert
in lieu thereof the words, 'Executive Secre-
tary.' "
"Change Chapter VI, Section 8, of the By-
I^aws on page 28, by striking out the words
Manager of Sessions and Exhibits, and insert
in lieu thereof the words, 'Executive Secre-
tary.' "
IN MEMORIAM
Whereas, Our beloved friend and colleague. Dr.
William H. Mcllhaney, has paid the debt of nature,
and joined the innumberablc host in the Great Beyond,
we, the members of the Northampton County Medical
Society, beg leave to express our deep sense of per-
sonal loss, and extend to his life long friend and
helpmeet, Mrs. Mcllhaney, and the near relatives, our
heartfelt sympathy in this their hour of bereavement;
therefore, be it
Resolved, That these, our sentiments of sympathy
and condolence, be spread upon the minutes of the
Society, and a copy of same be sent to the bereaved
family.
Committee,
Dr. J. H. Hunt,
Dr. E. W. Richarbs.
Dr. W. p. Thomason.
Northampton County Medical Society.
The U. S. Public Health Service calls attention to
the fact that only twenty-three states have efficient
birth registration laws; eighteen have imperfect ones;
and five have none at all. Inability to prove age may
cause all sorts of legal troubles later in life — in prov-
ing citizenship, in voting, and in inheriting, for in-
stance. Don't forget to make sure that the new ar-
rival in your home has been registered.
Don't give the baby patent medicine. If you feci
you must use advertised remedies try them on your-
self, or better still, on the dog. Let your family doc-
tor attend to the baby.
Digitized by VjOOQIC
County Medical Societies
REPORTERS OF COUNTY SOCIETIES:
Adams — Henry Stewart, M.D., Gettysburg.
Alueghenv — l.cster Hollander, M.D., Pittsburgh.
Armstrong — Jay B. F, Wyant, M.D., Kittanning.
Beaver — Fred B. Wilson, M.D., Beaver.
Bedford — N. A. Timmins, M.D., Bedford.
Berks — Clara Shetter-Keiser. M.D., Reading.
Bt.AiR — James S. Taylor, M.D., Altoona.
Bkadpord — C. L. Stevens, M.D.. Athens.
Bucks — Anthony F. Myers, M.D., Blooming Glen.
EuTLER-'L. I.eo Doane, M.D., Butler.
Caubria — John W. Bancroft, M.D.. Johnstown.
Carbon — Jacob A. Trexler, M.D., Lehighton.
Center — James L. Seibert, M.D., Bellefonte.
CiiE.'TER — Henry Pleasants, Jr., M.D., West Chester.
Ci-ARioN — Sylvester J. Lackey, M.D., Clarion.
Clearfield — J. Hayes Woolridge, M.D., Clearfield.
Clinton — R. B. Watson. M.D., I.ock Haven.
Columbia — Luther B. Kline. M.D.. Catawissa.
Crawford — Cornelius C. Laffer, M.D., Meadville.
Cumberland — Calvin R. Rickenbaugb, M.D., Carlisle.
Dauphin — F. F. D, Reckord, M.D., Harrisburg.
Delaware — Gebrge B. Sickel, M.D., Chester.
Elk — Samuel G. Logan, M.D., Ridgway.
Erie— Fred E. Ross, M.D., Erie.
Favette — George H. Hess, M.D.. Uniontown.
Franklin — John J. Coffman. M.D.. Scotland.
f'.nEENE — Thomas B. Hill. M.D., Waynesburg.
Huntingdon — John M. Keichline. Jr., M.D., Petersburg.
Indiana — C. P. Reed, M.D., Indiana.
Jefferson— W. J. Hill. M.D., Reynoldsville.
Juniata — Benjamin H. Ritter, M.D., McCoysville.
Lackawanna — Harry W. Albertson, M.D., Scranton.
LilNCASTn — Walter D. Blankaaship, M.D., Lancaster.
Lawrebci — William A. Womcr. M.D., New Castle,
Lbbanon— John C. Bucher, M.D., Lebanon.
LrriQh — Frederck R. Bauscb, M.D., Allentown.
Luzerne — Walter L. Lynn, M.D., Wilkes-Barre.
Lycouihc — Wesley F. Kunkle, M.D.. Williamsport.
McKean— Fred Wade Paton, M.D., Bradford.
MCRCSR — M. Edith MacBride. M.D., Sharon.
Mifflin — O. M. Weaver, M.D., Lewistown.
MoKROE — Charles S. Flagler, M.D., Stroudsburg.
MoNTcoUEav — Benjamin F. Hubley, M.D.. Norristown.
Montour — John H. Sandel, M.D., Danville.
Northamfton — W. Gilbert Tillman, M.D., Easton.
NoRTHUKBxaLAND — Charles H. Swenk, M.D., Sunbury.
I'ERRV — Maurice I. Stein, M.D.. New Bloomfield.
PiiiLADELPHiA — John J. Repp, M.D., Philadelphia.
roTTEB — Robert B. Knight, M.D., Coudersport
Schuylkill — George O. O. Santee, M.D., Cressona.
Snyder — Percy E. Whiffen, M.D.. McClure.
Somerset — H. Clay McKinley, M.D.. Merersdale.
Sullivan — Martin E. Herrmann, M.D., Dusfaore.
Susquehanna — H. D. Washburn, M.D., Susquehanna.
Tioga — ^John H. Doane, M.D., Mansfield.
Union— Oliver W. H. Glover, M.D., Laurelton.
Vehanco — John F. Davis. M.D., Oil City.
WarrEK— M. V. Ball, M.D., Warren.
Washington — Homer P. Prowitt, M.D., Washington.
Wayne — Edward O. Bang, M.D.. South Canaan.
Westuoreland — J. F. Trimble, M.D., Greensburg.
Wyoiiikc. — Herbert L. McKown. M.D., Tunkbannock.
York— Gibson Smith, M.D., York.
August, 1921
COUNTY SOCIETY REPORTS
ALLEGHENY— MAY
The reg^uiar monthly scientific meeting of the Al-
legheny County Medical Society was held on May 17,
1921, 8:30 p.m., at the Pittsburgh Free Dispensary
Building, 43 Fernando Street, Pittsburgh, Pa., with
the president, Dr. Carey J. Vaux, in the chair. At-
tendance : 159.
"Primary Face Presentation in a Normal Pelvis
(Its Etiology and Termination)" by Dr. C. J. Baron,
was illustrated with a manikin. In this case the first
diagnosis was that of a R. O. P. presentation. The
fetal circulation was greatly distressed and for that
reason a version was performed, after which both
mother and child made an uneventful recovery. The
length of the cord was 118 cm., that is 68 cm. more
than normal, and was looped around the neck five
times. The high mortality rate in face presentations
was mentioned by the speaker and the importance of
rectal examinations instead of vaginals was empha-
sized.
Dr. D. L. Simon, in his presentation "Acute Ure-
thritis Neisseria" emphasized the use of the micro-
scope in the diagnosis. The treatment was taken up
in a methodical way, calling attention to plenty of
rest, liberal diet, observation of sexual hygiene, and
physical cleanliness. Internal medication in this con-
dition is used only to alkalinize the urine and in the
administration of sedatives. A detailed description
was given of his technic of hand injection with a
smooth conical pointed, quarter of an ounce capacity
urethral syringe, using argyrol from 5% to 20%, pro-
targal from ^% to 2%, albargin from 14% to 1%
freshly distilled water, three times a day. This to be
continued until discharge is present, an astringent
lotion to be prescribed, with a massage of the organ on
a sound. After taking up the argument against the
irrigation method of treatment, which he thought was
more dangerous and productive of more cases of
posterior urethritis, which he classified in two varieties,
first the insidious, second the hyperacute, he closed his
paper.
"The Satus of the Antemortem Blood Culture in
Diagnosis. An Analysis of 1,600 Examinations" was
presented by Dr. DeWayne (i. Richey. The analysis
was based on 1,692 blood cultures from 1,505 different
individuals with the following technic : 10 cc. of blood
was removed by needle and syringe, which was
planted arobically in 1% Dextros broth, was watched
from 5 to 6 days, then steril cultures were discarded.
Twenty-six per cent, showed a growth, 74% yielded
no organism, 14% of deposited cultures comprised the
pneamococcus group, 30% of deposited cultures con-
stituted the streptococcus group, 20% of deposited
cultures showed the staphylococcus areas. All the
cases of staphylococcus albus were regarded as con-
taminators. In 22% of deposited cultures bacillus
typhosus was obtained, while the other grade negative
bacilli constituted 6% of the positive findings. Two
instances are worthy of special mention, one where
bacillus influenza was found in the blood stream, the
other has to do with the isolation of gonococcus from
three blood cultures. All were fatal. In the resume
Dr. Richey called attention to the importance of early
and frequent repetition of this procedure. I>r. J. I.
Johnston took up the discussion from the standpoint
of an internist. Dr. Jos. McMeans called attention
to the fact, that the importance in blood stream infec-
tion centers about virulence of organism, and the
dosage of the invasion. Dr. (Irover Weil emphasized
the importance of blood cultures in following surgical
procedure.
"Prostatism Without Prostatic Enlargement. Lan-
tern slides." Presented by Dr. Theodore Baker. In
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THE PENNSYLVANIA MEDICAL JOURNAL
August, 1921
demonstrating this condition with lantern slides the
author spoke of the method, which is used for the
deviation of this condition. Demonstrating the in-
strument and its use. Particular attention was called
to the importance of the differential diagnosis from
types of condition which may produce obstruction. In
the discussion of this paper, Dr. E. J. McCague and
Dr. D. L. Simon, agreed with the presentation of the
suhject.
The next was the "Presentation of a Case of Ele-
phantiasis," of the leg, presented by Dr. R. E. Bren-
neman. An amputation of the leg was advised and
carried out, which resulted in the patient's death.
In a very interesting and exhaustive paper Dr. H.
H. Donaldson took up the subject of "Acute Intes-
tinal Obstruction" and, after reviewing the literature,
spoke on the necessity of early diagnosis, with early
surgical interference, to obtain the best possible re-
sults. He called attention to the necessity of obtaining
a good history and eliciting, if possible, information as
to previous operations for a possibility of adhesions.
A visible peristalsis, vomiting,' abdominal distension,
the passage of blood and the presence of acute pain
are all points of importance. He recommended the
following procedure: Rectal examination should be
made, purgatives should be abstained from, the ad-
ministration of sedatives, gastrical lavage, with an
early laparotomy. The median incision should be
performed, search should be begun at the colon, then
a radical operation performed. Dr. J. J. Rectenwald
reported a case of chronic intestinal obstruction, in
di.scussing this paper. Dr. H. E. McGuire spoke on
the urgency of getting these cases into the hospital
early. Dr. J. P. Griffith emphasized the importance
of toximia in these cases. Dr. John W. Boyce said
that occasional symptoms of an acute obstruction may
occur from a malignant disease in the cecum. In clos-
ing the discussion Dr. Donaldson called attention to
the possibility of peritonitis, which should be watched
carefully.
"Treatment of Perforation and Gangrene of the
Appendix with Spreading Peritonitis," presented by
Dr. J. P. Kerr, laid particular stress on the importance
of drainage in these cases. Both at the opening and
above the symphysis pubis, drainage to be efficient
must be thorough, Fowler position, a Murphy drip and
morphine are the adjuvants to this treatment. Dr. R.
J. Behan agreed with the previous paper in its en-
tirety and illustrated the chemical principles. involved
in this method of treatment. Dr. Kerr, in closing,
thought that this should only be used -in cases where
there does not seem to be any walling of the peri-
tonitis.
"Plates Illustrating Elementary Diagnosis of Heart
Disease by X-Ray." Dr. John W. Boyce called this
his family album of heart diseases, showing a number
of normal and abnormal hearts, presenting his subject
in the most interesting manner. The discussion by Dr.
J. I. Johnston and Dr. Andrew P. D'Zmura was of
the clinical value of roentgenology in cardiac condi-
tions. Discussion was closed by Dr. J. W. Boyce,who
emphatically stated that none of the procedures of
laboratory nature are of more importance than a good
history, and physical findings.
"Relation of Seborrhoea to Skin EHseases," Dr. Stan-
ley Crawford, analyzed the dermatological conditions
occurring at different periods of a patient's life,, who
suffered from an increase of the function of the
sebaceous glands, carrying this scheme from early
childhood to the appearance of acne, oily and greasy
skins, to the formation of acne rosacea in middle life,
and the appearance of rodent ulcers and senil kera-
tosis towards the terminal period of life. Discussion
was opened by Dr. Lester Hollander, who called at-
tention to the intimate relation of the endocrine sys-
tem to the skin, and the utilization of this knowledge
in internal medicine. Dr. John G. Burke spoke of the
tendency of these cases of seborrhoea to skin infec-
tions.
Meeting adjourned at ii : 30 p. m.
Lester Hollander, Reporter.
ARMSTRONG^JUNE
This society is ioo% in membership and holds
monthly meetings and for the scientific meetings has
taken the Dental Association in.
Tuesday, June 7, 1921, was the regular monthly
meeting, and we had a good attendance. The paper
on "Pyorrhoea" was given by Dentisf Rudolph and a
talk on "Hydrophobia" was given by Dr. Bierer.
These were very interesting cases and brought out a
good discussion.
It is a lamentable fact that the members of a society
like the medical society do not take more interest in
the meetings for it means much to the man who has
been in practice for a number of years and who does
not feel that he can take the time to take a post-
graduate course, the papers, the clinics and the dis-
cussions give a mighty good post course and will pull a
"feller" out of his well worn "rut."
In reviewing the transactions of our county medical
society we find that some members were always active
in the society. Among them is our good friend Dr.
C. J. Jessop, who located in Kittanning, Pa., in 1875,
and was a charter member of the organization in 1876.
Dr. Jessop enjoyed a large practice and was often
called in consultation in the surrounding counties.
The Kittanning Hospital was founded by him in 1898
and he was the chief surgeon from that time. Ht
always manifested a great interest in his home town
and county, one well qualified to shape public opinion
and inspire men to look forward to better conditions
for mankind. He has always been a close student and
was acknowledged to be the best anatomist in this
part of the state. He has satisfied his own mind and
proved to the satisfaction of his many patients that
he has completed a treatment for sciatica. He has
always been generous to the poor, kind and sympa-
thetic to the suffering and commands the esteem and
respect of his profession. He took great pleasure in
collecting relics and souveniers. Among them was a
collection of Indian relics which he presented to the
Elks Home. And before the advent of automobiles
he kept a fine string of horses of high blood. In
March of this year, while enjoying the beauties of the
sunny southlands of Florida, he was stricken with
apoplexy. He is able to be out in his car but does not
practice. He is the only surviving charter member of
the Medical Society of Armstrong County. He has
made large contributions to the library of the hos-
pital. J. B. F. Wyant, Reporter.
BLAIR— APRIL, MAY, JUNE
The Blair County Medical Society met in regular
session on April 26, 1921, with a live attendance to
listen to a most highly intelligent essay presented by
Dr. H. O. Jones, of Altoona, on Syphilis. The main
points he brought out were : better no treatment, than
Digitized by
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August, 1921
COUNTY SOCIETY REPORTS
839
inadequate treatment; first stage of syphilis is curea-
ble under intensive arsphenamine therapy; a clinical
and serological cure should be sought in early sec-
ondary syphilis; the heart should be watched in sec-
ondary syphilis, just as it is in rheumatic arthritis;
nitritoid crises are produced exclusively by toxic
arsphenamie. Very few have been the papers read
before the society that were as thorough, up to date,
and masterful as this essay of Dr. Jones.
The May meeting was held in Community Hall,
with Dr. C. E. Snyder, of Altoona, an essayist on the
"Significance of Bleeding from the Vagina." This
topic is one of the many which is always of major
importance to all practitioners, whether specialists or
not. As Dr. Snyder said "vaginal bleeding is sig-
nificant of an underlying cause, and is a danger sig-
nal ; don't treat this sign, for it is not a disease, with-
out determining the cause." There was a very free
discussion of this paper, and I feel sure that all in at-
tendance went away, having learned anew to watch
out for irregrular, unnatural vaginal bleeding.
Our last or June meeting was held June 28th in
Community Hall and the society was honored with the
presence of our district censor. Dr. Frontz, of Hunt-
ingdon. He gave us the once over and also enlight-
ened the members on some of the state society doings,
especially as regards the Medical Defense Fund, the
Legislative Committee accomplishments, etc. His
visit with us was thoroughly enjoyed and we trust his
calls will be more frequent. Dr. James S. Taylor pre-
sented an essay on Prenatal and Obstetric Care, show-
ing the necessity of care of the expectant mother, the
necessity of blood pressure readings, of pelvic meas-
urements, of use of rubber gloves, etc. A free dis-
cussion was aroused by the paper.
The annual outing will be held July 26th, taking the
place of our July meeting. An out-of-doors picnic
will be our outing this year and all the members are
looking forward to a grand time.
Dr. A. S. Kech spent the month of June in post-
graduate work at Harvard. Dr. Galbraith was in at-
tendance at the American Orthopedic Society's ses-
sions in Boston last month.
All the doctors say that Blair County is "discourag-
ingly healthy," but it is noticeable that none of the
practitioners are kicking about our comparatively
healthy surroundings.
James S. Taylor, M.D., Corresponding Secretary.
BRADFORD— MAY
The regular monthly meeting of the Bradford Coun-
ty Medical Society was held at the Van Dyne Civic
Building, Troy, May loth, with seventeen members
and two visitors present. Dr. Carlyle N. Haines,
Sayre, read the following paper :
SALVARSAN IN SYPHILIS
Since Eriich announced the discovery of salvarsan
eleven years ago, much has been written concerning
its therapeutic applications and limitations in syphilis.
We all appreciate . the failure of the single dose cure,
as was first advocated by him. We are beginning to
realize as our experience with it increases, that it is
but one of the factors in the course of the disease.
What it accomplishes in one case may be no guide to
its efficacy in another.
Salvarsan is spirillicidal in its action, it suppresses
contagion, it clears up lesions, but its effects are only
transient, and must always be followed by or given in
conjunction with mercury. Mercury will not suppress
contagion, but it is a better builder of immunity.
The phrase "protected with mercury" discloses the
cardinal weakness of salvarsan. We know that pa-
tients treated with salvarsan alone do not make the
recoveries that patients treated jointly with salvarsan
and mercury do. While patients with primary and
secondary lesions treated with salvarsan alone appear
to get along very well, the lesions disappearing like
magic, they are, nevertheless, more prone to recur-
rence in the form of late and neurosjrphilis. Patients
who have had nothing but salvarsan therapy are in
great danger, because their immunity or tissue resist-
ance has been sacrificed at the expense of the spiril-
licidal action of the salvarsan. Without immunity or
tissue resistance we wage a hopeless fight against the
spirochete. Our aim in treating syphilis should be to
keep the tissue resistance or immunity at the highest
point possible, while the spirillicidal action of sal-
varsan is going on.
It is now believed by many syphilographers that
there are different strains of the spirochete, and that
these different strains have a certain selective action
for certain tissues. If our tissue resistance is lowered
and we are infected by a strain with a certain selective
action for that tissue, then we have a more severe in-
fection and one that calls for more protection with
mercury than we would have provided our tissue re-
sistance were at par. This apparently explains why
almost anything cures some cases; while nothing
avails in others. While mercury is a great builder of
immunity it is, nevertheless, a drug that should not be
used indiscriminately. It is highly toxic and irritat-
ing to the kidneys. The urine should be examined
frequently for any evidence of renal impairment.
Chemical analysis alone is worthless. We consider
two or three casts per field as a warning to "watch
our step." Salvarsan on the other hand has practically
no effect on the kidneys, and can be given with almost
perfect safety in a case with advanced nephritis.
Broadly speaking, salvarsan is contra-indicated in
cases with marked vascular changes, mercury in cases
with renal impairment. If used cautiously salvarsan
and mercury can be given together in almost every
case. Many times we wonder why the patients are
not wrecked by the massive mercuralization that we
see in some cases. Salvarsan in these cases seems to
exert a stimulating action following prolonged mer-
curalization. It is in these cases of massive mercural-
ization combined with salvarsan that we obtain our
best results in late and neuro syphilis.
In the treatment of syphilis we follow as closely as
possible the plan as advocated by Dr. John H. Stokes
of the Mayo Clinic. To him and his associates I am
deeply indebted for many favors and courtesies. In
the treatment of syphilis we give no medication by
mouth except occasionally the iodides in late and
neuro syphilis. Mercury is given in the form of rubs
or inunctions, each rub containing thirty grains of
metallic mercury, or the succinimide, a soluble salt,
grains one-fifth to one-third given intramuscularly.
The amount of mercury given varies according to the
age, and tolerance of the individual. We do not use
any of the insoluble salts.
Salvarsan is given intravenously by the gravity
method, 20 c.c. of freshly boiled distilled water per
decigram. We use old salvarsan in preference to
neo salvarsan. We believe we get better results from
its use. Treatments are given in a series or course,
each course consisting of six or eight injections. Dur-
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THE PENNSYLVANIA MEDICAL JOURNAL
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ing the past few months we have used a new product
in selected cases — new in this country, but old abroad,
called silver salvarsan. The results so far have been
very gratifying. We have had no reactions following
its use, the lesions have cleared up quickly and as a
whole we are very well pleased with its action.
We restrict the diet, eliminatny all fruits and acids
during the course of treatment. We examine care-
fully for focal infections. Each patient is given
printed instriictions for taking rubs, and the caro of
their mouth and teeth. The care of the gums and
teeth is very important, as their involvement will very
often compel us to stop treatment, especially with
mercury.
Intensive antisyphilitic therapy is indicated only in
the early stages of the disease, while the spirochetes
are free in the blood and tissues. In late syphilis
when the spirochetes are walled off by fibroses and
infiltration it is not only dangerous but useless to em-
ploy the intensive treatment. Much more is to be
gained by taking the more leisurely course.
Our method of treating early syphilis, provided
there are no contraindications, is to mass the sal-
varsan rather heavily in the first course. An intra-
venous injection of three to six decigrams of sal-
varsan every third day until three injections have been
given, then every week until three more are given.
Mercury is given in the form of rubs, one rub each
day for six days, a bath and change of underwear the
seventh day in place of a rub. This is continued until
forty are taken. Then a rest from all treatment for
a month or six weeks. At the end of the rest period
the whole procedure is repeated, except that the sal-
varsan is given once each week. We pay no attention
to the result of the Wassermann. After the- first
course, as a rule it is negative, but if the patient is
allowed to go without further treatment it usually
again becomes positive. This same procedure is again
repeated at the end of three to six months, and in fact
until the Wassermann remains repeatedly negative, the
spinal fluid negative, and the clinical examination is
negative. The patient is then instructed to report for
examination twice each year for at least two years.
If there is no evidence of recurrence he is told that
he is probably cured.
In late syphilis we have an entirely diflferent disease
to combat. Here we do not find the usual good health,
the patients are older, there has been more or less
damage to the vascular system and nervous system,
and the patients do not have the resistance, or im-
munity that we find in early syphilis. The therapy of
late syphilis must, therefore, strike a balance between
the gravity of the disease and the physical handicaps
of the patient. Only after a most careful examination
should a person with late syphilis be placed upon treat-
ment. Many a case of neuro syphilis has been over-
looked by the over optimistic therapist who sees but
one thing in the disease. Because a patient has an
osseous or cutaneous condition, it doesn't mean that
he has no involvement of his eyes, ears, vascular, or
central nervous system. We see many patients who
say that they had syphilis five or ten years ago and
were given one dose of salvarsan and were "cured,"
but now they have an aortitis, iritis, early optic
atrophy, beginning tabes, with its accompanying light-
ning pains, or almost any condition. We find they
have sometimes a positive Wassermann, but more
often it is negative, especially if of several years'
standing. The spinal fluid will in the majority of
these cases show some deviation from normal, if not
strictly positive. Salvarsan is capable of doing im-
mense harm when its employment is intrusted to Aose
who are over optimistic in its action. Little salvarsan
is worse than no salvarsan. It is, though, a most
wonderful drug when properly used.
In early syphilis with no contraindications we mass
the salvarsan and reinforce with mercury. In late
syphilis we reverse so to speak — mercury first and
salvarsan later — constantly watching the patient's con-
dition. In neuro syphilis each case is a case unto it-
self. Salvarsan, if given without a preparatory course
of mercury, will do immense harm in nearly every
case. The length of the preparatory treatment varies
with the severity of the disease. The more the nerv-
ous system is damaged the longer should the prepara-
tory treatment be. The succinimide, a soluble salt of
mercury, grains one-fifth to one-third given intra-
muscularly three to five times a week is our choice of
mercury. This treatment varies from ten days to two
or three months before salvarsan is given, and when
given it never should exceed four decigrams to the
dose. It is in this class of cases that we give the
iodides, if at all. We never give the iodides in early
syphilis. In late syphilis and in neuro syphilis, espe-
cially the latter, we occasionally see very good re-
sults, if combined with mercury. Given alone they
will not reverse a positive Wassermann or hold the
disease in check. We do not hope to cure the patient
with neuro syphilis, but in the majority of cases the
disease can be checked and held under control by pro-
longed treatment, atrd the patient lead a useful life.
It is wonderful how some of these cases improve and
remain apparently well.
We do not employ intraspinal therapy. So far as
our experience with it goes, and the experience of
many others, the results are not a bit better, and pos-
sibly not so good as with the combined prolonged
treatment with mercury and salvarsan. Very few of
these cases have a positive Wassermann. A few have
negative spinal fluid, but the majority show some
deviation from normal. It doesn't mean the patient's
hasn't syphilis because both are negative. When one
•sees a patient's condition improve under active treat-
ment, the headaches cease, the lightning pains and
"rheumatism" disappears, and in one case a persistent
high blood pressure drop to normal and remain nor-
mal, then one feels at times the fallacy of always
being guided by the laboratory reports at the expense
of the clinical picture. Too many of us place too
much reliance upon the Wassermann test. A negative
Wassermann means nothing unless repeatedly nega-
tive, and the clinical examination is negative. The
Wassermann test is one of our best aids in the diag-
nosis and treatment of syphilis if we only interpret it
correctly.
1. Never give salvarsan, unless protected with mer-
cury.
2. In primary and secondary syphilis, unless there
are contraindications, such as tuberculosis in the ac-
tive stages, vascular or renal changes, or any acute
condition from some other cause, the combined inten-
sive treatment is the treatment of choice.
3. In late syphilis nothing is to be gained by inten-
sive therapy. Here we find as a rule the patients are
older, they have less resistance, and frequently vascu-
lar, renal, or central nervous system lesions, or a com-
bination of all. Here, the less intensive treatment is
the treatment of choice.
4. The value of a complete physical examination,
including the reflexes and eyegrounds cannot be over-
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COUNTY SOCIETY REPORTS
841
estimated. The diagnosis of syphilis has been repeat-
edly made in otherwise obscure cases.
5. Never discharge a patient as cured simply because
the blood is negative. The blood should be repeatedly
negative, the spinal fluid negative, and the physical
examination negative, and then not until the patient
has been under observation for at least two years.
6. Never tell a patient that so many "shots" will
cure him.
7. Mercury should be given cautiously in patients
with renal conditions, salvarsan in vascular conditions.
Frequently examine the urine microscopically. Watch
for cumulative effects of mercury and salvarsan in
every case.
8. Be constantly on the lookout for arsenical in-
juries, such as a dermatitis, itching of the skin, jaun-
dice, nausea and vomiting, etc. I saw a patient die
from an exfoliative dermatitis which developed three
weeks after completion of her treatment. Arsenic is
especially stored in the liver, spleen, and skin.
9. Occasionally there is a therapeutic shock, Herx-
heimer reaction, which is dangerous in proportion to
the structures involved by the infection. This has
special reference to the meninges, brain, myocardium,
and other vital structures.
10. An empty stomach usually prevents early reac-
tion. In acute reaction occurring on the table, adre-
nalin solution 5 to 15 minims, i to 1,000, should be
given subcutaneously.
11. A well compensated heart is not a contraindica-
tion for salvarsan in small doses.
12. The average case of syphilis can be treated only
to the point that the kidneys will stand.
Dr. Charles H. DeWan, Sayre, read the following
paper :
TRANSFUSION
By transfusion we mean the transfer of blood from
one individual to another. This transfer of blood was
first attempted in 1492 in Rome, but not until the mid-
dle of the seventeenth century did it take its place in
surgery. The indications for transfusing a patient
are numerous but can be summed up in two : namely,
deficiency in the quantity or quality of the blood. In
the former I wish to include all forms of severe or
prolonged hemorrhage, as in cases of hemorrhage
after injury or operation, melena in the infant, hemo-
philia, etc. In the latter indication I wish to include
all forms of anemia, acute and chronic suppuration,
etc.
In cases of hemorrhage, especially the capillary type,
we have learned that no therapeutic measure for stop-
ping it is quite as good as a transfusion of blood.
When blood is lost from the circulatory system the
blood pressure is lowered and the heart beats rapidly
because of lack of fluid and resistance. This fluid
must be replaced. Nature attempts to do this by catl-
ing on the other fluids of the body but by the time
she accomplishes this it may be too late. Intravenous
injections of saline solution will raise the blood pres-
sure only temporarily as it soon escapes from the
blood vessels. Solution of g:um acacia, etc., will raise
the blood pressure and continue it so but adds nothing
to the blood but bulk. In other words we have no
more red cells to carry on- the work than when we
started. On the other hand if blood be transfused
into the blood vessels of a patient after hemorrhage
it not only stops bleeding by increasing the clotting
power of the blood but also raises and maintains the
blood pressure. The blood used is not an inert sub-
stance like the other solutions but becomes part of
the body and carries on all functions known to it
In pernicious anemia we know that there is as yet
no known cure, but by means of transfusion such a
patient's life may be extended from six months to
two years. If a few transfusions would give a man a
lease of life from one to two years it is well worth
the trouble because those few years may be of untold
value to his family or business. Also in acute sup-
puration, as in ruptured appendix, the patient is pro-
foundly toxic; his blood is laden with poisons, his
red cells are being used up. On account of his toxic
condition the bone marrow is not able to produce
cells as in health. If such a patient be transfused
from a healthy donor he not only receives new blood
cells into his veins to replace those that are fast de-
generating but also receives protecting agents in the
serum in the form of antibodies which may be just
enough to tide him over his crisis. In chronic sup-
puration we always have an associated secondary
anemia and the patient is unable to cope with the in-
fection because of this anemia. If this secondary
anemia is overcome by transfusion the patient obtains
increased powers of resistance to overcome the infec-
tion. In shock after operation or due to injury the
blood vessels dilate. The patient bleeds into his own
vessels thereby taking the blood from the vital cen-
ters, and the heart has nothing to work against. By
means of transfusion the blood pressure is raised, and
more blood is passed through the brain and other
organs.
There is no good thing that cannot do equally as
much harm. This is- true of transfusion. In the
hands of the inexperienced it is capable of doing un-
told harm. The greatest danger lies in the injection
of blood clots or large quantities of air into the blood
stream. I have seen air injected several times in
small amounts (1-2 c.c.) at a time without any symp-
toms. Before a transfusion can be performed the
blood of the donor and recipient must be typed out.
If the blood did not mix the recipient would, likely
succumb due to showers of emboli. We know that all
blood falls into one of four types. If a person wishes
to be a donor he may have his blood typed out and be
held in reserve until needed. Since some blood con-
tains isoagglutins it is much safer to match donor's
and recipient's blood together first before transfusing.
This can be done safely within one-half hour's time
and may avoid a marked reaction. Since hTHolvsis
occurs only when agglutionation is present it . vmly
necessary to determine the latter. This can bo easily
and quickly done by bringing into contact a J.-.-p of
citrated blood of donor and recipient in salt solution
and waiting twenty minutes for agglutination to take
place.
Transfusion of blood may be done by the direct or
indirect method. In the indirect or citrate method
blood is drawn under strict asepsis into a sterile flask
which contains 10 c.c. of 2^% sodium citrate in phy-
siological salt solution for every 100 c.c. of blood
drawn. The blood must be agitated continually to
keep from clotting. The blood while still warm is
placed in a large burette and allowed to flow into the
vein of the recipient by means of gravity.
By the direct or whole blood method both patients
lie side by side with a small table between. The veins
of both donor and recipient are pierced with a fifteen-
gage needle and these needles in turn are connected
with a three way valve by means of two short rubber
tubes. The blood is drawn out of the donor by means^
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THE PENNSYLVANIA MEDICAL JOURNAL
August, 1921
of a record syringe. The valve is turned and the
syringe full injected into the recipient. An assistant
by means of another syringe filled with physiological
salt solution keeps the tube that is not in use from
clotting by passing saline through it.
I prefer the latter method to the former because it
can be done more quickly and with less reaction after.
By the direct method I have transfused 700 c.c. in
six minutes with no symptoms whatever during or
after the transfusion shown by donor or recipient. It
can be done at the bed-side or in private homes equally
as well as the citrate method. I have seen no' case
where it has disturbed the patient mentally by the
operation, but on the other hand helps to quiet them
because as a rule the donor is a relative and this in
turn helps to quiet the patient. Chills and rise in
temperature are not as frequent after transfusion by
the direct method as by the citrate method. The re-
actions after transfusion by the direct method aver-
age about six per cent., while that of the citrate
method is much higher, blood being typed by the same
method in both cases and by the same technician. Be-
cause of the small percentage of reaction we believe
this method to be far superior to the citrate method in
cases of sepsis and profoundly toxic patients. For
here we do not wish to add any more toxic substance
to the blood.
I also wish to say a word concerning transfusion
in children and infants. In children whose veins of
the arm are too small to admit a needle of sufficient
size we have had to resort to the anterior jugular vein
of the neck with good results. In infants under twelve
months of age blood by the direct method may be
transfused into the longitudinal sinus at the posterior
angle of the anterior fontanelle. A needle is thrust
through the scalp into the sinus. Blood is drawn from
the arm of the honor into a syringe by an assistant
The syringe when full is handed to the operator who
slowly injects it into the sinus.
Dr. George W. Hawk, Sayre, gave an interesting
talk on the Cardinal Symptoms of Duodinal Ulcer,
outlinmg the history of the typical case running over
a period of years with periodic attacks of pain coming
on an hour or so after meals and relieved by the tak-
ing of food and alkalies. On an average it is about
nine years before food and alkalies fail to benefit the
patient, and probably some cases are really "cured."
After the patient becomes emaciated from the more
frequent attacks and a more restricted diet he is likely
to consult the surgeon. At this time he should be put
to bed and given alkalies and milk, the latter every
few hours. If this medical treatment fails to give de-
cided benefit then it is a case for the surgeon. In
about ten per cent, of the cases of acute perforation
of a peptic ulcer there is no history of previous gastric
symptoms. Cases of ulcer complicated with gall blad-
der trouble, or gall badder trouble without ulcer, are
accompanied with much belching of gas in addition to
the pain similar to that due to gastric or duodinal
ulcer. In chronic appendicitis we have gastric dis-
turbances and tenderness. The taking of food does
not give relief in either appendicitis or gall bladder
trouble. C. L. Stevens, Reporter.
CENTER— MAY, JUNE
The forty-fifth anniversary of the organization of
the Center County Medical Society was celebrated by
holding its meeting at the club house of the Nittany
Rod and Gun Club, at Hecla Park in Nittany Valley,
in the afternoon of the 25th day of May, 1921. This
club house is located seven miles east of Bellefonte
upon a most beautiful broad piece of table-land to the
south of which, at a pleasing distance, rises the ma-
jestic Nittany Mountain which is now covered with a
vegetation which the recent rains and warm weather
have stimulated with an unusual degree of greenness;
thus making it a place picturesquely ideal for the
meeting at this season.
The meeting was called to order at 4 o'clock, when
the following responded to the roll call: Drs. J. P.
Ritenour, William Glen, Jr., Grover Glen, h. C Kid-
der, J. V. Foster, C. S. Musser, H.. S. Braucht, H. H.
Longwell, J. R. Barlett, W. O. McEntire, Melvin
Loche, David Dale, M. W. Reed and J. L. Seibert. As
invited guests there were present Drs. J. S. McOhee,
D. W. Thomas and W. E. Welliver, of Lock Haven,
and A. B. Painter, of Mill Hall.
Following the adoption of a motion that the regular
order of business should be omitted, the president of
the society. Dr. J. P. Ritenour, introduced the speaker
for this special meeting. Dr. Thomas G. Simonton.
Associate Professor of Medicine of the University of
Pittsburgh, who for more than an hour entertained
the society with one of the most practical addresses
it ever has had the pleasure of listening to. He
treated his subject, "Pneumonia, Referred Pain, Diag-
nosis, Treatment and Complications" with such mas-
terful acquaintance with it, from each and every view-
point, that all present were unanimous in declaring
their pleasure and profit in hearing this address.
At the close of the meeting all repaired to the din-
ing room where a banquet awaited them. During this
hour and while choice viands were being served. Dr.
McEntire contributed a recitation which added much
pleasure to the occasion.
The regular June meeting convened in official ses-
sion in the court House in Bellefonte on June isth at
10 o'clock a. m. In the absence of the president Dr.
George H. Woods, of Pine Grove Mills, was elected
to preside temporarily. The following members re-
sponded to roll call: Drs. George H. Woods. G. I.
Yearick, O. W. McEntire, H. H. Longwell, Melvin
Locke, J. C. Rogers, M. W. Reed, W. U. Irwin,
J. V. Foster, J. P. Ritenour and J. L. Seibert Fol-
lowing the transaction of the usual business of the
society and no special business presented to engage
its attention, a paper was read by Dr. J. L. Seibert on
the subject of Pulmonary Tuberculosis from the
Viewpoint of the General Practitioner. This paper
was discussed with much interest. A general regret
was expressed at the absence of Dr. C. S. Musser
whose name was on the roster of the society for a
paper on the subject of Mitral Stenosis for this meet-
ing, since his contributions are always interestingly
received. J. L. Seibert, Reporter.
CHESTER— MAY
A very enjoyable meeting of the Chester County
Medical Society was held at the home of Dr. Howard
Mellor at Sconneltown on Tuesday, May 17th. As
the weather conditions were ideal, the members as-
sembled on the lawn and were called to order by
President Willis N. Smith, of Phoenixville.
Following the regular order of business Dr. Mellor
read a most interesting and instructive paper on Eye
Symptoms and Eye Diseases in Relation to Organic
Diseases of the Brain and Spinal Cord. While not
dealing with too many supertechnical points in oph-
thalmology, Dr. Mellor showed clearly the value of
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August, 1921
COUNTY SOCIETY REPORTS
843
careful and repeated occular examinations in the
routine study of cases of suspected organic brain and
spinal cord disease. Changes in -the appearance of the
retina, the blood vessels and the optic nerve often
give the earliest clue to obscure diseases. These
changes may come on suddenly, and if too much de-
pendence be placed upon previous examinations the
important symptoms may be missed. Dr. Mellor also
laid much emphasis upon the charting of the visual
fields in order to determine hemianopsia, as in cases
of brain tumor, or inversion of the color fields in
cases of hysteria. Dr. Mellor urged closer coordina-
tion of the work of the ophthalmologist and internist
and surgeon.
Dr. Mellor's paper was discussed at some length by
Drs. Gifford, Sharpless, Klevan, Kerr, Hammers and
others.
A vote of sympathy was extended by the society to
Dr. Ehinger on the occasion of his recent illness.
Upon the adjournment of the meeting the society
was entertained at luncheon by Mrs. Mellor and her
associates. A few of the more fortunate members
were honored by the privilege of sitting at the famous
table which has been the object of envy and despair
of most of the archaeologists as well as the million-
aires of the country. We hope that Dr. Mellor will
favor the Reporter with an authentic history of this
table for it is a marvellously preserved relic of the
ages when woodcraft was in the nth power of per-
fection. The inlaid work representing scenes in Eng-
land and elsewhere is worth a long journey to see.
At the close of the collation a rousing vote of
thanks was extended to Dr. and Mrs. Mellor for their
splendid hospitality. Henrv Pleasants, Reporter.
CLINTON— MAY
The Clinton County Medical Society held its May
meeting at the Lock Haven Hospital at 8 p. m. on the
22d with Dr. J. E. Blackburn, Dr. Thomas, Dr. Mc-
Ghee, Dr. Shoemaker, Dr. M. D. Campbell and Dr.
Critchfield present
In the absence of the Secretary, Dr. McGhee was
elected secretary pro tem. No business of any impor-
tance was transacted. Dr. D. W. Thomas read a very
interesting and instructive paper on the Differential
Diagnosis of Gall Bladder Diseases, Appendicitis and
Tubal Diseases. It was fully discussed by all the
members present.
The secretary was unavoidably absent for the first
time in ten years, as he was a patient in the hospital
with a severe, attack of herpes zosters, the most dis-
agreeable disease in existence and the best place to
have it is, as Mark Twain says "on the other fellow
and heaven help him." The secretary wishes to ex-
press his appreciation to the Medical Society for the
beautiful roses which they so thoughtfully sent him.
He also wishes to say, just here, that the hospital is
the most beautifully situated one in the state and that
the service, including diet, the attention of the super-
intendent and all the faithful attention of the nurses
is not surpassed by any hospital.
On June 5th Drs. Thomas, Critchfield, McGhee and
Welliver started by automobile for Boston to attend
the American Medical Association, which was being
held there, they expected to be absent about ten days.
Doctor Joseph M. Corson, although still a member
of our society, has removed from Chathams Run,
Clinton County, to Hughesville, Lycoming County.
Our next meeting will be held at Renovo at 3 p. m.
on June 24th. R. B. Watson, Reporter.
COLUMBIA— JUNE
The regular monthly meeting of the Columbia
County Medical Society was held at Hotel Magee,
Bloomsburg, on June 9th. In accordance with our
usual custom, dinner was served at the noon hour,
following which the society convened in business and
scientific session, with Dr. C. B. Yost, the president, in
the chair. Fifteen members were present.
After disposing of the ordinary routine business,
the scientific program was taken up. The first subject,
"Gastric Surgery," was presented by Dr. John W.
Bruner, in which he ably considered the symptoms and
diagnosis, together with a description of the different
gastric maladies for which surgical procedure may be
required, especially naming ulcer of the stomach,
neoplasms, carcinoma, gall stones and other diseases
of the gall bladder and ducts. He also enlarged upon
the methods of operation, etc It was a very instruc-
tive and practical presentation of the subject. The
general discussion was opened by Dr. Willet P.
Hughes, with several of the members participating.
Quarantine was the next subject and was presented
by Dr. James R. Montgomery. He considered the
subject from a legal, hygienic and sanitary viewpoint,
dwelling also upon the period of incubation for the
varied infectious diseases, also urging prompt and
strict compliance with the requirements of the law
and the interpretations and demands of the health au-
thorities of the state. The paper was one of great
interest and was much appreciated. General discus-
sion was ably opened by Dr. S. B. Arment, for many
years a most efficient and fearless county medical di-
rector. The discussion was quite general, most of the
members taking part and giving evidence of general
interest in the subject.
Luther B. Kline, Reporter.
DAUPHIN— MAY
At the regular monthly meeting of the Dauphin
County Medical Society — Dr. C. R. Phillips, presiding
— Dr. Thomas B. Fuchter, Associate Professor of
Medicine at John Hopkins University, Baltimore, de-
livered a most instructive lecture on the "Etiology
and Modem Treatment of Diabetes Mellitus." Dr.
Fuchter said in abstract:
During the digestive process of carbohydrate meta-
bolism sugar is converted into gliKose or grape sugar.
This is furnished by the foodstuffs, sugar in the food,
canesug^r and saccharose and the starches or carbo-
hydrates in the diet. About 50 to 55% of the protein
molecule is converted into glucose. Fats and hydro-
carbons do not give sugar. Therefore the carbohy-
drates and proteids in the food are modified and
changed by the ferments of the salivary glands and
pancreas and completely converted in the intestinal
tract. Eventually it is carried through the portal sys-
tem to the liver and stored there as glycogen. The
liver is capable of storing away as excess 300 gms. of
this material. The muscles of the body are able to
store away an equal amount. The normal amount
within the circulating blood is from 0.75 to 0.15%.
Hyperglycemia is an excessive amount of sugar in the
blood. The kidneys act as filters. Renal diabetes is
questioned. Fluoridizin, an alkaloid manufactured
from the bark of peach trees, if injected into an ani-
mal, produces 6 to 10% of excess sugar in the blood.
The function of the kidneys is thus impaired.
The endocrine glands — the pancreas, thyroid, pitui-
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THE PENNSYLVANIA MEDICAL JOURNAL
August, 1921
tary and adrenals — play the most important part in
diabetes, and the posterior lobe of the pituitary has a
direct bearing upon carbohydrate metabolism. In
acromegaly — particularly the early stage — there is
glycosuria. Tumors of the anterior lobe produce
functional disturbance of the posterior lobe. In the
late stage of the disease there is no glycosuria, as
there is an increased tolerance for carbohydrates, with
thickening of the skin and other symptoms. . The
adrenals influence corbohydrate metabolism potentially.
In exopthalmic goiter cases there is frequently found
a trace of sugar in the urine, as there is a lowered
tolerance. There is a correlation between the thyroid,
adrenals and pancreas. In the pancreas there are is-
lands of cells that are independent of the other acini
of the gland. These groups of cells are called the
islands of Langerhans, and their secretion finds its
way directly into the circulation. The hormone thus
produced has an intimate relation with corbohydrate
metabolism and its absence or reduction produces
hyperglycemia and glycosuria. If nine-tenths of the
pancreas is removed fatal diabetes results in a few
days. There are two types of interstitial pancreatitis
— intralobular and intra-acinous. Three out of four
cases of the latter have diabetes mellitus. The islands
of Langerhans undergo degenerative changes and the
hormone necessary for the warehousing of sugar be-
comes diminished.
Bronze diabetes : a condition in which there is an
enlargement of the liver, sclerotic pancreas, pigmen-
tation of the skin and glycosuria. The liver changes
are secondary. This disease depends upon the de-
struction of blood substances of the body, including
the sebaceous glands of the skin. This explains the
pigmentation. The pancreas gradually becomes scle-
rosed, and there are often ascites. Glycosuria is the
terminal event.
Puncture of Fourth Ventricle and Glycosuria: If
the left abdominal sympathetic nerve, supplying the
adrenal gland is cut, glycosuria idoes not occur when
the floor of the fourth ventricle is punctured ; other-
wise the adrenals oversecrete their hormone, which
causes the liver to give up its glycogen more readily,
as ordinarily the hormones of the adrenals and pan-
creas balance each other. The pancreas retards, while
that of the adrenals increases the output of glycogen.
Treatment: No two cases can be handled alike. It
is important to find, if possible, the cause of the glyco-
suria. The urine should be properly examined and
the patient should save the urine for the 24-hour pe-
riod. This should be measured and the amount re-
corded and the examination made from a sample of
this quantity. If this is impossible, then a sample
three hours after a meal should be used. It is very
important to examine for acetone bodies — namely,
acetone and diacetic acid. These are derived from
beta-oxybutyric acid, which in turn is derived from
the breaking down of fats in the tissues. If these are
found you can ward off coma by the proper treatment,
as these may be present for a long time in the urine
without producing coma. If the patient has acetone
in the urine and develops an acute infection, he is
much more likely to go into coma than if free from
acetone.
Prophylactic Treatment: Investigate if there is a
family history of obesity, and in suspects find if there
is a lowered tolerance for carbohydrates. Give the pa-
tient 100 gms. of glucose upon an empty stomach, and
test the specimen of urine. If sugar is found, then
the person should be urged to pull the weight down.
and not to overindulge in starches and carbohydrates.
Hygienic Measures: These cases are subject to in-
fections of the skin, and they should be urged to take
warm baths and occasionally a Turkish bath.
Exercise: If no acetone bodies are found in the
urine, exercise is very helpful and tends to bum up
the carbohydrate in the muscles.
Diabetic: Professor Fuchter reviewed the old
method of dieting these cases but spoke particularly
upon the Allen treatment, or the starvation method.
Individual cases must be considered. In moderately
severe, over-fat cases which are physically weak, with
acetone and diacetic acid in the urine, the fats should
be cut down first, followed by the removal of the pro-
teids from the diet. Then quarter the carbohydrates
and in four to five days all may be cut off. In the
less severe cases, where there is no diacetic acid in the
urine, put on a starvation diet in one or two days.
This comprises two cupfuls of coffee without sugar
and three cupfuls of bullion in 24 hours. If the urine
still shows sugar, then allow starch for two days and
then try the starvation diet again. The blood sugar
should be tested every day. Dr. Allen has starved his
patients from seven to ten days. After the urine is
free, allow one day of 5% vegetables which have been
thrice cooked and then starve a day, if necessary.
Thus the diet may be gradually increased and tolerance
worked up. Three hundred and fifty to 400 gms. of
5% green vegetables may be added and then the 10%
vegetables, etc. If the urine remains free, then add
one egg daily, or two eggs in two to three days. Al-
ways add the fats last, such as butter or fat meat.
Other carbohydrates may be added, watching the urine
and the sugar content of the blood.
Patients should be taught to test their own urine
and should be given a book on the subject so that they
may learn all about their disease, for without their
full cooperation nothing will be accomplished. In
cases where coma is threatened use alkalies, such as
sodium bicarbonate, so as to neutralize the effect of
the oxybutyric acid in the blood. If the patient is in
actual coma there is not much that can be done.
Whiskey may be given by the mouth, sodium bicar-
bonate by the rectum, or 2 to 5% solution (800 c.c)
intravenously. Gangrene, pruritus and neuritis are
very troublesome complications of the disease.
Frank F. D. Reckoro, Reporter.
DAUPHIN— HARRISBURG ACADEMY— MAY
On Memorial Day, May 30, 1921, at a joint meeting
of the members of the Harrisburg Academy of Medi-
cine and the Dauphin County Medical Society, a com-
plimentary dinner was tendered to their fellow mem-
bers who were in the service of the United States
Government as medical officers during the World War.
1917-1919. In order to gather historical data every
guest was requested to prepare a short narrative of
his service from the time of leaving home until his
return, under his own official signature. This was read
by him as a part of the program and is to be bound
in book form and preserved as a valuable addition to
the Academy library. The doctors of the two organi-
zations who were active members of the local ex-
amining boards and medical advisory board were in-
vited to act with the appointed committee, in arrang-
ing details, with the idea of making this meeting a
memorable historical gathering. In addition there
was a large daylight group picture taken of all the
members present, with the guests in uniform.
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COUNTY SOCIETY REPORTS
845
The medical chairman of the various examining
boards and medical advisory board rendered state-
ments covering registrants examined by them mider
the authority of the commissions received by them
from the United States Government which added ma-
terially in completing the history of the professional
services rendered by the members of the two societies
during the war.
The physicians who served on active duty were as
follows: J. Loy Arnold, ist Lieut.; Robert E. Barto,
1st Lieut.; F. W. Byrod, ist Lieut.; Carson Coover,
Captain; John L. Gulp, Major; Gilbert L. Dai ley,
1st Lieut.; Gustave A. Dapp, ist Lieut.; Percy E.
Deckard, Major; John M. Dickson, ist Lieut.; John
Wesley Ellenberger, Contract Surgeon; William P.
Evans; Edgar S. Everhart, Major; Constantino P.
Faller, Captain; Lester W Frasier, Senior LieuK, U.
S. N.; George F. Gracey, Major; Andrew J. Greist,
1st Lieut. ; John L. Good, ist Lieut. ; Charles V. Hart,
1st Lieut.; J. W. Horn, Captain; Robt. M. Hursh, ist
Lieut.; Frank D. Kilgore, Senior Lieut., U. S. N. ;
J. H. Kreider, ist Lieut.; George B. Kunkel, ist
Lieut.; George L. Laverty, ist Lieut.; Jesse L.
Lenker, ist Lieut.; John W. MacMullen, ist Lieut.;
Richard J. Miller, ist Lieut.; George R. Moffit,
Major; Peter B. Mulligan, Captain; Edwin A. Nico-
demus. Major; Roscoe L. Perkins, Major; Jacob M.
Peters, Major; Edward Roberts Plank, Major;
Charles S. Rebuck, Captain; Sylvia J. Roberts, ist
Lieut.; Frank F. D. Reckord, ist Lieut; Josiah F.
Reed, ist Lieut.; Floyd L. Romberger, Captain; Wil-
liam S. Ruch, Captain; Frank L. Shenk, Captain;
Fred C. Smith ; H. Albert Smith, Major ; Charles R.
Snyder. Captain; Geo. A. Trieman, ist Lieut.; Charles
L Trullinger, ist Lieut.; James- L. Wagenseller, ist
Lieut.; Louis W. Wright, ist Lieut.; Geo. A. Zim-
merman, 1st Lieut.; J. Landis Zimmerman, ist Lieut.
MEMBERS OF DRAFT BOARDS
V. Hummel Eager, Charles C. Cocklin, J. Edward
Dickinson, John H. Eager, Jr., George B. Kunkel,
Jesse L. Lenker, C. A. Rahter, Thomas E. Bowman,
H. H. West, Clarence R. Phillips, Emerson E. Dar-
lington, Martin L. Nissley, Samuel N. Traver, Byard^
T. Dickinson, John R. Plank, Harvey B. Bashore, D.'
£. Hottenstine.
SPECIAL scaw>.K
Hugh Hamilton, Examining Surfjeon, Regular U. S.
Army Recruiting Station, Harrisburg, Pa.; Hiram
McGowan, Member Penna. Medical Defense Commit-
tee; Thomas S. Blair, Assistant Surgeon, U. S. Pub-
lic Health Service; C. E. L. Keene, Special Investi-
gation Work.
MEDICAL ADVISORY BOARD
F. W. Coover, David S. Funk, John B. McAllister,
Park A. Deckard, Henry R. Douglas, J. Walter Park,
Charles S. Rebuck, George B. Stull, Harry B. Walter,
M. L. Wolford, William E. Wright, H. Hershey
Famsler, William J. Middleton, Earle R. Whipple.
Frank F. D. Reckord, M.D., Reporter.
DELAWARE— MAY
The May meeting of the Delaware County Medical
Society was held at the home of Dr. G. Victor Janvier,
Lansdowne, on May 12th, Dr. George H. Cross pre-
siding. After the transaction of business Dr. John C.
Hirst, of Philadelphia, presented a paper on "Prolapse
of the Uterus — Its Prevention and Treatment, Pallia-
tive and Curative."
As causative factors in the production of prolapsus
uteri. Dr. Hirst mentioned the improper use of forceps,
particularly before the os is fully dilated. The dam-
age to the perineum and anterior vaginal wall due to
this procedure weakens the natural support of the
uterus. Relaxation of the vaginal walls may also oc-
cur from other causes, such as excessive hard work,
etc. Pressure from above the uterus may also cause
its decent, as in cases of large ovarian cysts. Preven-
tive treatment consists in the proper use of forceps
and at the proper time repair of lacerations and the
judicious use of episiotomy where severe lacerations
are inevitable. Palliative treatment aims to keep the
patient comfortable and this is best accomplished by
use of the Menge pessary. Proper care of the pessary
was emphasized. In discussing the operative treat-
ment. Dr. Hirst first performs a circular amputation
of the cervix, after which it is dilated to prevent
stenosis. The cystocele, which is often very marked,
is next repaired by the Hirst modification of the Wat-
kins interposition operation. In this modification the
uterus, through an opening in the peritoneum, is su-
tured beneath the bladder. The first sutures, however,
are placed anteriorly to the fundus so that the bladder
rests on the fundus rather than on the posterior sur-
face of the uterus. Dr. Hirst has had excellent results
from this operation and has seen ten uncomplicated
pregnancies following it. The operative treatment is
then completed by repairing the rectocele. Dr. Hirst's
paper was well illustrated by lantern slides and was
very instructive.
Dr. E. C. Kirk, ex-Dean of the Dental School, Uni-
versity of Pennsylvania, then presented motion pic-
tures of a resection of a ureter for stricture with new
implantation in the bladder, and also one illustrating
catheterization of the eustachian tube and the ana-
tomy of the region involved. These pictures were
wonderfully clear and instructive, and were thorough-
ly enjoyed by the society.
Following the program, refreshments were served
by Dr. Janvier and a very pleasant and profitable
meeting was adjourned. Geo. B. Sickel, Reporter.
FRANKLIN— MAY, JUNE
The regular monthly meeting of the Franklin Coun-
ty Medical Society was held at the Pennsylvania San-
atorium, Mont Alto, Pa., on May 17th, through the
courtesy of Dr. George O. Keck, Superintendent. Dr.
William E. Holland, the president, presided over the
meeting, which was well attended.
Application for membership was received from Dr.
Robert B. Brown, of Waynesboro. This was r^crred
to the censors. In consideration of the subjects and
time allowed for the speakers, the secretary moved
that the routine business be deferred to a later meet-
ing. This motion was accepted.
Dr. W. Estell Lee, of Philadelphia, in an interesting
way presented an illustrated clinic of "Treatment of
Traumatic Wounds." This moving picture plan con-
ducted by Dr. Lee is quite practical in the technique
of minor surgery and surgical treatment. A particu-
larly interesting picture was the exhibition of a deep
abscess in the leg, showing free incision, the antiseptic
treatment through to the healthy termination in a
normal recovery and the steps and technique of treat-
ment.
Dr. Allen Z. Ritzman, Harrisburg, gave a discussion
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THE PENNSYLVANIA MEDICAL JOURNAL
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of the roentgen ray, illustrating with diseases of the
upper intestinal tract, the gall bladder and gall stones.
Many x-ray pictures were shown, delineating the vari-
ous pathological conditions of the stomach, intestinal
tract and of the gall bladder. The speaker told of the
importance of careful and thorough examination of
the patient by the physician before referring the pa-
tient to the roentgenologist. He also pointed out the
importance of telling the operator what is desired to
be looked for.
Dr. Harvey F. Smith, Harrisburg, followed with a
discussion of the "Diagnostic Problems of the Upper
Intestinal Tract and Gall Bladder." His advice was,
not to depend upon the x-ray but to work out the
diagnosis yourself by thorough examination, getting
the history and symptoms from the patient. Do not,
however, depend upon that diagnosis and do not let it
carry you astray, but pick out symptoms for yourself.
Make the physical examination thorough. With this
the x-ray will Be of value. In treatment of all cases
of gastric disturbance, rest in bed is extremely im-
portant. When to advise surgical attention is a very
important matter and requires great care.
A vote of thanks was accorded Drs. Lee, Ritzman
and Smith for their interesting and practical discus-
sions.
The members after visiting and viewing the "City
of Hope" gathered at five o'clock around the table in
the Nurses' Home, where a dinner of chicken and
other good things was enjoyed. A vote of thanks was
accorded Dr. Keck for his cordiality in arranging for
this meeting.
The June meeting was held at Hotel Mercer, Mer-
cersburg, on June 28, 1921. The meeting was a "get
together meeting" under the auspices of the Medical
Society. The members of the Dental, Pharmaceutical
and Veternarian professions were invited and a good
representation of each was present. A dinner pre-
ceded the meeting. Dr. T. H. Weagley, Marion, made
an interesting address of welcome. Members of the
four professions expressed their appreciation of this
form of professional interests. The gathering of the
four professions of the county will likely be' repeated.
John J. Coffman, Reporter.
HUNTINGDON— MAY
The Huntingdon County Medical Society met in the
Huntingdon Club Rooms Thursday afternoon. May
1 2th, and was called to order at 2:30 o'clock by the
president, Dr. H. C. Wilson. The following members
were present: Drs. Beck, Hutchison, Reiners, Schum,
Harman, Koshland, Morgan, St. Clair, Brumbaugh,
Sears, Evans, Frontz, Locke, Keichline, Patterson and
Plymire.
Dr. Frontz gave us the rulings in regard to failure
to pay dues on or before March 31st, urged us to get
interested in politics, that each member should be
good for 100 votes, gave us the inside of the doings of
the Chiropractor Bill, etc. Greetings and felicitations
were sent Drs. Chisolm and Newlin. Dr. Harman
delivered a fine memorial to Florence Nightingale.
Interesting case reports were given by Drs. Brum-
baugh, Locke and Wilson.
Dr. A. H. Evans read a paper on Twenty-Nine
Years of Medical Reminiscences in which he gave
clever observations on general practice, necessity of
correct diagnosis, careful selection of drugs, more
mono-pharmacy and less poly-pharmacy. Priestly's
and Depew's observations shows we have not departed
far from the sheet anchors of material medica of
three hundred years ago. Hypocrates said, like cures
like, but in as many cases opposites cure. He ad-
vised progn"essiveness but not at tlie expense of get-
ting a poor substitute. He absolutely refused to
eulogize the general practitioner's ability to diagnose
skin diseases. If the science of eugenics had been
enforced several hundred years before the Christian
era, the nerve specialist might be minus his job. He
reported the case of a girl thirteen years of age, who
had an obstruction of the bowel from a round worm
working its way into the appendix, causing a collapse
of the colon. A successful operation was performed.
Organic and biologic chemistry have done wonders,
but the latter fails when it is put up against auto-
infections of the intestines. Our profession is the
greatest, but we should never commercialize it. Rev.
Sam Jones said the medical fraternity is the most
bigoted, ignorant and intolerant class of men in ex-
istence. He excepted the clergy, and acknowledged
that while he had no faith in M.D.'s he had employed
one that day. Jealousies and petty bickerings of the
medical men make them the laughing stock of the
community. If Sam is right, we should make an
earnest effort to retrieve ourselves. We are losing
out if we don't. Abandon a bad policy and play true
and intelligently. A big man can brook opposition.
He comes out more magnamiously when his ideas are
run counter to. The members of our society are all
on an equality, have equal privileges. The majority
rules. We should go with the majority. No physician
should isolate himself and tuck under him the eggs
of selfishness, bigotry and suspicion and cover himself
with the turtle shell of seclusion and thereby fail to
mingle with his medical society. Dr. Evans is an ex-
ponent of the above philosophy. We love him and he
in turn has a warm spot in his heart for the society
and every member thereof.
J. M. KfiiCHUNE, Jr., Reporter.
LEHIGH— JUNE
The meetings since our president. Dr. Peters, has
taken the chair have been humdingers. That spirit
shown us by Drs. Jump and Albertson certainly put
some pep into quite a few of our languid ones. Be-
hold the result, first in the state for increased mem-
bership and a hundred members on our roll. The
regular meetings are held the second Tuesday of each
month and a warm welcome is extended to all.
Dr. Deibert, of Allentown, was unanimously elected
a member of our society at the June meeting. The
society expects to have a probation membership elec-
tion, in other words will elect a man but not finally
until he has shown his worth. This would do away
with electing new members that came into our vi-
cinity until they have been tried and proved worthy
of membership.
•The average attendance percentage has risen above
35% and now a committee of live wires has been ap-
pointed to make our attendance 100%. The outing
committee was appointed to make arrangements for
our annual outing in August. A committee was also
appointed to help the editor of our monthly.
Quite a number of our members are leaning toward
the use of radium and are stretching every point to
put old Lehigh on the map. The cancer symposium
at St. Luke's Hospital was attended by over 70% of
our members and proved a great success. Drs.
Brewer, of New York City, and John G. Clark and
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August, 1921
COUNTY SOCIETY REPORTS
847
Pancoast, of Philadelphia, threw an impetus into this
section to further the propaganda on cancer. The
On To Philadelphia Club has been organized and we
expect to have 90% of our members attend the ses-
sions in part in Philadelphia in October.
At the June meeting Dr. W. J. Schatz presented a
very interesting, original, practical, and common
sense talk on Treatment of Obscure Chronic Cases.
He presented quite a few cases in which they were
treated by controlling the nerves and the source of
supply. "Summer Diarrhea" by Dr. T. H. Weaber
was very well presented, he also showed the advantage
of liberality of feeding in cases of severe diarrhea.
Both papers brought out much discussion and many
points of interest were presented.
The workings in part of the A.M.A. were pre-
sented by some of the members who attended its last
meeting at Boston. The work of the Chiropractor
and a few more unregistered practitioners took up a
great deal of time and it was decided that the Public
Policy Committee get busy and act at once with no
strings attached to them. The community is alive
with them, it being a good nidus for them here. We
hope by the next issue or two to show we have done
something toward their punishment.
pRBDeRiCK R. Bausch, Reporter.
MONTOUR— JUNE
The regular monthly meeting of the society was
held at the Episcopal Church Parish House, Danville,
June 17th, and was called to order by the president,
Dr. R. A. Keilty, at 7:30 p.m., with a good attend-
ance of members and visitors present. The meeting
was a specially enjoyable occasion. Preliminary to
taking up the business and scientific program of the
evening those present were treated to a fine dinner,
served by the ladies of the church, our efficient and
genial president being the host. -
After the dinner and a short social period the regu-
lar business of the society was entered into. Dr. H.
V. Pike was elected a delegate to the State Medical
Society with Drs. F. D. Glenn and Reid Nebinger as
alternates. A vote of thanks was tendered the presi-
dent for the enjoyable entertainment he had provided,
and a vote of appreciation was also given the secre-
tary for his faithful and efficient service to the so-
ciety.
The scientific paper of the evening was presented
by Dr. Keilty, subject, "Focal Infections; A Study
of the Bacteriology of 200 Cases of Pyorrhoea Al-
veolaris." He said that focal infections had, in too
many cases, come to be regarded as "fads and fancies"
in medicine, especially among the laity, but we as phy-
sicians should realize that they are very definite
things, not hard to demonstrate under proper study,
and that they are not fads. The 200 cases considered
were routine admissions to the Ceisinger Hospital,
cases which were admitted mostly without reference
to any disease of the gums or mouth. A patient suf-
fering from any infection usually presents the appear-
ance of a physical defective and should be treated as
such. In such cases it is necessary to study each case
in its entirety and not from the standpoint of a spe-
cialist or fadist. It should be born in mind that the
point of infection may be in a sinus, a tonsil, a mid-
dle ear, an appendix, at the apex of a tooth, at the
gums, etc. ; and when thus studied yre are apt to
come to proper conclusions. The disease under con-
sideration belongs not only to the physician but also
to the dentist and, if thoroughly grasped, is usually
curable. The gums are made up of dense fibrous
tissue, closely connected to the periostium of the
alveolar processes and surround the necks of the teeth.
They are covered with sqamous epithelium, and the
pathology, therefore, is much the same as that of
other mucous membranes.
In this series of cases, smears were made and ex-
amined for the spirilla of Vincent, or amoeba. Some
such cases may be due to food deficiencies. Of the
cases examined, 42 showed no alveolar disease; but
the remaining 158 did. In 95% of the affected cases,
the spirilla and amoeba were found in combination.
One hundred and thirty cases showed spirilla and 102
cases had amoeba. In 41 cases, the spirilla were found
alone and in 61 cases the amoeba alone. Seventeen
cases were found in which there were no teeth, the
affection being beneath the plates worn.
The treatment must naturally depend upon the cause.
It is good where the pathology is well, understood and
is apt to be disappointing where it is not. Emetine,
hypodermicatly, is suited to the amoebic cases, and
arsenic, in some diluted form, is adapted to the
spirillic cases. It is usually used in the form of a
paste, and little rubber cups, just large enough to re-
ceive a tooth, have been successfully used to apply
the paste. It should be remembered that pyorrhoea
or gingivitis makes a portal of entrance for all bac-
teria, and is a point of invasion.
Dr. A. B. Vastine, dentist, in opening the discussion,
stressed the fact that we may be dealing with a mixed
infection and it is often a question of who gets the
last foci. The nose and throat specialist may remove
one source of infection, the surgeon another, and the
dentist still another. He said he had seen some of the
worst cases of infection in cases where all the teeth
had been removed, due to small roots left behind,
which contribute to the formation of cysts. Where
we have the spirilla it means a local infection and
local treatment is especially in order.
Dr. Nebinger said that in acute cases, all foci
should be collected, and we should then proceed with
their removal in the order which seemed most prac-
tical; that old cases, that is, those of long standing,
and patients over 50 years of age, call for care in the
attack since the response to operative procedure is less
ready and the patients may be disappointed with the
result.
Dr. J. A. Jackson, of the State Hospital, stated that
he was much interested in the study of these condi-
tions in the insane. He found by cleaning up the
mouth and teeth, and removing teeth which were dis-
eased or had pus pockets at the roots, he would see
quite an improvement in the physical but not in the
mental condition. The facts brought out show that
these conditions have little bearing on mental cases.
When mental cases come to the hospital they not only
consider them from the standpoint of their mental
condition, but go over them from all angles. He con-
gratulated Dr. Vastine for his broadminded view, in
these conditions of focal infection, and his readiness
to cooperate with his medical conferees.
Dr. Pike stated that he has been in contact with
such investigations for some years; that in searching
for points of infection it is well to first x-ray the
teeth, then examine the stomach and duodinal con-
tents, next the tonsils, then the abdomen, etc. ; but we
may do all this and some cases will improve and some
will not.
Dr. Keilty, in closing the discussion, cited a severe
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THE PENNSYLVANIA MEDICAL JOURNAL
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case of herpes of the back, associated with a severe
angina; he treated the angina and the case improved,
for a time, but finally died. He said we can treat the
younger cases of infections so much better than. the
older ones, since in the latter we are apt to have de-
structive changes. J. H. Sandel, Reporter.
NORTHAMPTON— JUNE
The Medical Society of Northampton County held
its regular monthly meeting on June 17th at Seips
Cafe in Easton, Pa. In spite of the rainy day a large
number of physicians from all over the county gath-
ered to hear Dr. S. MacCuen Smith, of Philadelphia,
read a very interesting paper on "A Consideration of
Obscure Mastoiditis." The paper called forth a very
interesting discussion and the members felt much
benefited in having had the opportunity of hearing Dr.
Smith.
Drs. F. J. Dever, of Bethlehem, and V. S. Messinger,
of Easton, were chosen to represent our society at the
State Society meeting, having as their alternates Drs.
H. J. Schmoyer and P. H. Kleinhans, of Bethlehem,
for the first named and Drs. T. E. Swan and W. Gil-
bert Tillman for the last named. Dr. E. M. Green
was selected as our choice for district censor.
Resolutions on the death of the late Dr. W. H. Mc-
Ilhaney were presented and accepted by the society
with the further instructions that a copy be sent to
the bereaved family as well as to the State Journal.
There will be no meeting of the society in July but
an outing meeting will be held in August at Paxinosa
Inn, located on the mountain overlooking Easton, the
date of this meeting to be left to the following com-
mittee of arrangements : Drs. W. Gilbert Tillman and
V. S. Messinger.
The following committee was appointed to learn the
number of unlicensed and illegal practitioners in the
county : Drs. W. P. O. Thomason, of Easton ; W. D.
Chase, of Bethlehem; C. E. Beck, of Portland; H.
C. Pohl, of Nazareth, J. E. Longacre of Weavers-
ville, and D. H. Keller, of Bangor.
Luncheon was served at the expense of the society
and the meeting adjourned.
W. Gilbert Tillman, Reporter.
PHILADELPHIA— APRIL
Stated meeting, held April 13, 1921, the president,
Dr. George Morris Piersol, in the chair.
Studies Concerning the InAuence of Arsenical Ap-
plications upon Cutaneous Tests. Dr. Albert Strickler,
of Philadelphia, read this paper in which he said that
for a long time the medical profession had felt the
urgent need of a simple and certain diagnostic test for
syphilis. The wide distribution of lues, the fact that
syphilis could and did simulate many other diseases
and the fact that even the expert was at times baffled
in the diagnosis had emphasized the necessity for a
simple and certain diagnostic test for lues. For the
study of this problem the author had selected 14 pa-
tients from the Skin Dispensary of the Jefferson Hos-
pital. At least two Wassermann tests were made upon
each patient, both of which had to be negative before
they were selected for the experiment. The study
warranted his statement that arsenic probably induced
susceptibility of the skin in nonsyphilitic individuals
so that the administration of arsphenamin might cause
the production of a positive luetin test in nonsyphili-
tics. The repetition of the luetin test in nonsyphilitic
patients was capable of producing positive luetin re-
actions in about 21 per cent, of the subjects. - The in-
travenous administration of arsphenamin seemed to
stimulate the production of a luetin reaction in non-
syphilitic patients, this occurring in 52 per cent of
cases. The intravenous administration of sodium
cacodylate acted in the same fashion but more feebly.
Dr. Thomas McCrae, of Philadelphia, said that this
work made it necessary that we should revise a great
many of our ideas regarding specific reactions. The
positive Wassermann reaction following arsphenamin
injections, as noted by Dr. Strickler, as rather dis-
turbing. It was thought that some reactions had been
fairly definitely established. He had seen the vast
majority of these cases and there could be no ques-
tion but that there was a marked reaction. These
cases had come to the Dermatological Clinic and had
a skin condition to begin with. Did that render them
more likely to react to arsphenamin? That could not
be answered until similar conditions were considered
in individuals without any skin disease whatever. The
bearing of this with reference to the treatment by
arsphenamin was very evident. We have controlled
our treatment of syphilis largely by Wassermann re-
actions, but that had evidently gone by the board be-
cause patients to whom arsphenamin had been admin-
istered were apt to give positive Wassermann and
positive luetin reactions whether they had syphilis or
not. This he hoped would stimulate a great many
men in different parts of the country to take up simi-
lar work because it was only when we had a large
body of statistics such as no one man could produce
that we might perhaps get a little light on the subject
Dr. Randle C. Rosenberger, of Philadelphia, said
he had been privileged to see most of these reactions
with Dr. Strickler. It was very hard to explain the
positive reaction in these cases. He would ;iot attempt
to explain it A great deal more work wa-- required
on this problem of the specificity of the ixcatmen. oy
arsphenamin.
InAuensa and Epilepsy — Their keciproeal Influence.
Dr. Alfred Gordon, of Philadelphia, read this paper,
in which he said that in si 'dying epilepsy in all its
phases for a number of yea '5 one was struck by the
fact that an infectious proce:jS occurring in an epi-
leptic had a decidedly favorable influence upon the
frequency and severity of epileptic seizures which
were sometimes totally suppressed during the febrile
period of the infectious disease. It seemed that the
reactions of defense against toxins which had an
elective action upon the nervous system exerted a fav-
orable influence upon epilepsy. The relation of in-
fectious processes to the course of epilepsy had been
studied by the writer in a series of 25 cases of in-
fluenza. A complete suppression of convulsive at-
tacks was observed in each case. As soon as the
febrile state began to subside there was a tendency to
a return of the convulsions. For some time after the
temperature became normal the attacks were lessened
in severity. These observations indicated that a toxic
principle elaborated during an infectious state was
capable of neutralizing the toxic principles, existing in
the humors of epileptic individuals. Serotherapy was
therefore indicated and the problem was to produce
such a neutralizing biological product.
Dr. Joseph Sailer, of Philadelphia, said that we -had
all observed the effect of emotional shocks of various
kinds and operative procedures in stopping epileptic
attacks. At the time he had been a resident at the
Philadelphia Hospital there was great enthusiasm
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COUNTY SOCIETY REPORTS
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about the cure of epilepsy by removal of part of the
cerebral cortex. One of his fellow residents con-
ceived the ingenious idea that other measures would
1)e as successful as trephining the skull and he bled
some of the epileptics who had not been operated on
and some who had had an operation and the result
was that after venesection, which had never been con-
sidered seriously, most of these patients recovered for
■3L time from their epileptic attacks, but shortly there-
after they all recurred in the usual manner. It oc-
curred to him that possibly a severe infection might
have the same mental effect upon epileptics and there-
tore it would perhaps be wise to look into the subject
■A little more thoroughly from this point of view be-
fore we indulged too liberally in the various forms of
serotherapy for the purpose of arresting temporarily
the attacks of epilepsy. It was a very interesting ob-
servation that severe infections with high temperature
might have this inhibitory effect.
Dr. Theodore H. Weisenburg, of Philadelphia, said
that while he disliked very much to question Dr. Gor-
don's work, he thought his conclusions were far
fetched. He took for granted that the patients would
have had fits if they had not had fever. How could
one say that that was an indication for any particular
form of therapeutics? That was vicious propaganda.
Fits might come on or might be absent for some time.
He had never been more impressed with that than at
the Elwyn Colony for Epileptics where 30 patients
bad been selected for taking moving pictures. Those
having fits daily or even two or three times a day had
been selected. He went out with the moving picture
apparatus and it was taken for granted that they
would have fits arid not a single patient had a fit that
day. He went back the next day when the patients
had been accustomed to the camera and they had the
usual number of fits.
Neurologic Symptoms Occurring in Pernicious
Anemia Especially Antedating the Appearance of the
Blood Picture. Dr. Theodore H. Weisenburg, of
Philadelphia, read this paper in which he said that
during the past two years he had seen in consultation
about 10 patients in most of whom the diagnosis had
been supposedly either tabes or some other spinal cord
disease and in whom he had made the diagnosis of a
postero-lateral sclerosis occurring with pernicious
anemia before the blood changes had made their ap-
pearance. He had the impression that the medical
profession at large was not familiar with the fact that
in pernicious anemia nervous symptoms might appear
first, although in the majority of cases the nervous
sjonptoms came on either at the same time or follow-
ing the blood changes. It was probable that the nerv-
ous system was attacked in two ways, either directly
by the toxins or by metabolic changes produced by the
anemia itself. Practically without exception the pa-
tients complained of sensory phenomena such as
numbness, coldness or a burning sensation which first ,
•occurred in the feet and gradually extended upwards
to the thighs and abdomen and the upper limbs. These
symptoms should at once arouse the suspicion of the
presence of pernicious anemia. Later the patients
complained of weakness in the legs, cramps in the
calves, disturbance of the sense of smell, taste and
hearing, with the presence of dizziness and roaring in
the ears. One patient objected very much to the smell
of newspapers and dogs. At this stage there was
nearly always a spastic or ataxic gait, diminished re-
flexes and at times the Babinski sign. Mental symp-
rtoms were present in about 40 per cent, of the cases,
ranging from mild depression to violent maniacal
outbursts, irritability, delusions, hallucinations, apathy
and severe melancholia. Recent examinations showed
disease to be present in the brain, spinal cord and
other parts of the nervous system. These changes
were not specific and were similar to those found in
chronic intoxications. The blood vessels showed
swelling of the intima and some proliferative changes.
The brain, as well as the posterior and lateral columns
of the cord showed areas of degeneration. Prognosis
was very poor. Occasionally good results might be
obtained for a time. In one case the disease ran a
course of three years, but in all others the patients
died within lyi years after the onset of symptoms.
Dr. Joseph Sailer, of Philadelphia, said that per-
nicious anemia was a mysterious disease ; it is just as
mysterious at the present day as it was at the time of
Addison's discovery. Inasmuch as closely related
forms of anemia are due to intestinal parasites, it
causes one to question whether there might not be
undiscovered parasites operating as the cause of the
idiopathic forms of pernicious anemia. The interest-
ing thing about pernicious anemia which we are grad-
ually learning is that the blood picture is not by any
means the sole feature of the disease. There are
both mental and nervous symptoms due practically to
the same cause, that is, unexplained degenerative
lesions in the central nervous system which have the
pathology of a chronic sclerosis of the central nervous
system. John J. Repp, Reporter.
SUSQUEHANNA— MAY
The Susquehanna County Meii' al Society met at
the Park Hotel, New Milford, for its May meeting
and was called to order by the president. Dr. A. J.
Denman, of Susquehanna. A fair number of the
members of the society were present.
After the regular business meeting two important
cases were reported and discussed : one a case of
lethargic encephalitis, the other a case of fracture of
the ascending and descending rami of the pubis, to-
gether with x-ray plates.
The secretary was authorized to communicate with
the secretaries of Wayne and Lackawanna Medical
Societies with reference to holding combined clinics
as suggested by the State Medical Society.
H. D. Washburn, Reporter.
WARREN— MAY, JUNE
A small number of members attended the meeting
of our society on May 16th. Dr. Lambdon, of Pitts-
burgh, who was on the program, failed to arrive and
therefore the meeting was given over to the recital
of a few case histories.
The question of insurance against suits for mal-
practice was discussed. Many of the members present
are carrying policies in. companies which cost them
from $15 to $30 a year. A representative from one of
the companies explained a form of group insurance
which would cut down the premium 10% to 30%, de-
pending upon the number enrolled.
Your reporter would ask why the State Society
cannot make its insurance so effective that these pri-
vate company policies would not be necessary. Per-
sonally, your reporter is satisfied with the protection
afforded by the State Society, but if it could in addi-
tion to defense take out a group insurance in some
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THE PENNSYLVANIA MEDICAL JOURNAL
August, 1921
large company, which would in any particular case
indemnify against a judgment say up to $5,ooo, it
would meet the criticisms now made against the State
Society's protective policy. Your reporter was later
informed that nearly every dgctor in Warren Borough
purchased the policy of the insurance company.
Dr. O. S. Brown acted as host for the meeting
which occurred in the Elks' parlors.
Dr. J. C. Russell, who was seriously ill, has so far
recovered as to be able to attend to his practice.
The June meeting was held at the Elks' Parlors,
Warren, on Monday, June 20th, with 15 members
present. Dr. Robertson chose for his subject "Ten-
dencies in Medicine" and said that owing to the higher
qualifications, a different class of men, most of them
strangers to hardships, are graduated. They refuse to
go into country practice because unaccustomed to
hard work, and he thought this helped to make the
farms tenantless. Schemes to bring the sick from the
farm into the neighboring city hospitals are not prac-
tical. When the few men who now remain in country
practice die or move to the town, there will be no one
to take up the work. There is now a good living for
several physicians in our rural districts.
I>r. Robertson also spoke of the trend toward mak-
ing the hospital more and more a machine and less
and less an institution that ministers to the needs of
the individual patient.
Every member present then gave his views on these
questions. Many of the doctors had practiced in
country districts before coming to Warren and could
give both sides of the subject.
Dts. Bradshaw, Hyer, Cowden and Mervine gave
their views as to the reasons why the new men were
not going into the country.
Dr. Bradshaw thought that there should be in medi-
cine, like in the arts, different degrees, so that a man
who was less prepared might take up the country
work and later take out a higher degree for a special-
ist or doctorate.
Dr. Ball believed the same reasons that have de-
populated the country districts exist for the lack of
doctors. Warren County has the same population it
had twenty years ago, but Warren, Sheffield and
Youngsville have doubled in population and the rural
districts are being abandoned. It costs five times as
much to educate a doctor as it formerly did ; only
rich men's sons can stand the expense, which is about
$10,000 to $15,000. Surgery is the only practice that
attracts the young man. It seems to pay best. Sur-
gery can only be practiced in the larger towns and
cities ; therefore, the young men avoid the farming
centers. Again, with the aid of telephone and auto-
mobile, the town doctor can serve a larger population
than the old doctor did with his saddle horse, poor
roads and no telephone.
Dr. Brown thought that, given the larger capital re-
quired, the young man is wise not to suffer the hard ^
work, long hours, long drives and no greater income
of country practice. City practice is easier, and why,
if a living can be obtained at it, choose the more diffi-
cult work?
Dr. Mervine reported his visit to the Boston na-
tional convention of doctors, giving a very detailed
account of some of the newer methods.
Hugh Robertson, who is a student at the University
Medical School, stated that 90 per cent, of the grad-
uates are going into surgery and its specialties.
With the lengthening of the term of years required
to produce a doctor, the closing down of the smaller,
less-equipped colleges, the number of graduates in
medicine have greatly decreased, and as it was brought
out in the paper and discussion, the country districts
are the losers.
The state of New York has suggested state physi-
cians on salary, with community health centers, hos-
pitals and nurses, to meet the problem. This has met
with opposition from the doctors, who fear it to be
the beginning of state monopoly of the profession as
it is in England.
No other answer, however, has been proposed that
will meet the problem, which is by no means local
A very fine supper was furnished the members by
the Elks caterer. Dr. Beaty acting as hostess.
M. V. Ball, Reporter.
WAYNE— MAY
Attracted by the prominence of the speaker and
favored by ideal weather the Wayne County Medical
Society met at the Allen House, Honesdale, on May
19th, with practically every member present.
Dr. Reed Burns, of Scranton, addressed the society
on Diseases of the Stomach, dwelling especially upon
differential diagnosis and giving the symptomatolc^
of the rarer conditions as syphilis and angina.
After a short discussion, the meeting adjourned sub-
ject to the call of the presiding officer.
Edw. O. Bang, Reporter.
WYOMING— MAY
The regular meeting of the Wyoming County Med-
ical Society was held at Hotel Graham, Wednesday,
May 25, 1921. The meeting was called to order by
W. W. Lazarus, president, and the minutes of the
previous meeting were read and approved. Numerous
correspondence was read and discussed. The censors
reported favorably on the application of Dr. F. J.
Austin, Laceyville, Pa., and he was elected to mem-
bership. The bill for flowers for the funeral of Dr.
A. B. Fitch — amount six dollars — ^was approved and
ordered paid. A contribution of six dollars to the
Medical Conference of the State Medical Society was
ordered sent to Dr. G. A. Knowles, Philadelphia. Sev-
eral members were present.
H. L- McKowN, Secretary.
YORK— JUNE
The regular monthly meeting of the York County
Medical Society was called to order in the Colonial
Hotel by Eh-. Weaver at i p. m.
In the regular order of business the following reso-
lution was passed: Resolved. That the York County
Medical Society discourages the careless and indis-
criminate use of wines, beers and whiskies; and when
physicians prescribe such they should use great cau-
tion, for since the Palmer decision some in the pro-
fession are being accused of shady and unethical
transactions. Nothing in this resolution should pre-
vent any of us from fearlessly prescribing beer or
other alcoholic preparations when in his judgment it
is necessary.
Dr. Martha L. Bailey entertained the society with
a discourse on "The Country Doctor, His Problems. "
Dr. Bailey did not attempt to solve all of the problems
but pictured very clearly some of the trials that beset
the way of the real hard working country doctor.
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STATE NEWS ITEMS
851
Following the paper by Dr. Bailey the society elected
Drs. H. M. Alleman and L. M. Hartman as delegates
to the House of Delegates and Eh-s. N. C. Wallace, G.
E. Spotz, J. C. May and M. L. Bailey, alternates.
Gibson Smith, Reporter.
STATE NEWS ITEMS
DEATHS
Dr. Margaret Blanche Best, Meadville, died May
26th, of gangrene, aged 56. She was a graduate of
Allegheny College, 1897, and of the Medical Depart-
ment of the University of Toronto, 1899.
Dr. James E. Groff, Doylestown, died June loth, at
the age of 65 years, after being in active practice for
forty-one years, thirty-five of which were spent in
Doylestown. Death was due to a complication of
diseases.
Dr. Groff graduated from Jefferson Medical Col-
lege in 1880 after completing a course at Ursinus Col-
lege. He was a member of several large national
medical associations, was prominent in Masonic circles
and was an Odd Fellow. He is survived by a widow
and one son, H. R. Groff.
ENGAGEMENTS
The ENGAGEMENT OF Miss ADELAIDE PvLE, daughter
of Dr. and Mrs. Walter L. Pylc, Philadelphia, to Mr.
George W. Blabon, 2d, has recently been announced.
Dr. and Mrs. M. R. Ward, of Wayne, have an-
nounced the engagement of their daughter. Miss Mary
Eurana Ward, to Mr. Charles John Neeland, son of
Mr. and Mrs. M. A. Neeland, of Wayne.
MARRIAGES
The MARRIAGE IS announcbd of Dr. Harry Gallag-
her, Chester, to Miss Josephine Johnson, of Erie, Pa.,
on April 14, 192 1.
The MARRIAGE OF Miss Sarah H. Boies Penrose,
daughter of Dr. Charles Bingham Penrose, of Devon,
to Mr. Aadrew Van Pelt, was solemnized on July 12th.
Dr. Samuel D. Conner, of Waynesboro, was mar-
ried on June 30th to Miss Elva C. Negley, of Hagers-
town, a former teacher in the Waynesboro schools.
Dr. William J. Jacoby, of Mount Carmel, and Miss
Florence White, of Girardville, imtil recently clinic
nurse at the State Hospital at Fountain Springs, were
married June 22d, in St. Joseph's church at Girard-
ville.
items
Born, to Dr. and Mrs. Charles F. Mitchell, Phila-
delphia, a daughter, on July sth.
Dr. C. T. Altmiller, a member of the Columbia
County Medical Society, is seriously ill at Hazleton.
Dr. Llovd Thompson, of Hot Springs, Arkansas,
recently visited his mother at Mercer.
The contract has been awarded for the erection
of a hospital building at Waynesboro.
Dr. Harrv B. Ely, of Honesdale, after many weeks'
illness, is able to be about and see his patients.
Dr. Harry White, of Sharon, is taking a post
graduate course in gastro-enterology at Johns Hopkins
University.
Dr. Wilson J. Smathers, of Du Bois, has been
elected an honorary member of the Clearfield County
Medical Society.
Dr. Wm. E. Holland, Fayetteville, president of the
Medical Society of Franklin County, has been ill at
his home since July loth.
The Chambersburg Hospital building is being en-
larged by the erection of a commodious two-story
wing to the east side of the present structure.
Dr. J. Wm. Wood and A. J. Simpson, of Chester,
have been in Boston, attending the course in internal
medicine given by Dr. Richard C. Cabot
Dr. and Mrs. F. H. Hansell, of Philadelphia, sailed
on June 4 for the Mediterranean, and will spend the
summer in Europe. They will return in September.
Dr. Guy P. AspER, Chambersburg, who is a mem-
ber of the U. S. P. H. S., has been notified to report
for service at Fox Hills, Staten Island.
Dr. and Mrs. R. Tait McKenzie, of Philadelphia,
sailed June i8th from Canada for Europe, where they
will spend the summer traveling in England and Scot-
land.
Dr. a. M. O'Brien, of Sharon, attended the meeting
of the Rainbow Division held at Clevenland, Ohio.
Dr. O'Brien served with this division during the
World War.
Dr. Milton B. Hartzell, Professor of Diseases of
the Skin, University of Pennsylvania, is spending the
summer at the home of his brother. Dr. Chas. A.
Hartzell, of Fayetteville.
The medical and surgical staffs of the Chester
Hospital are conducting a competitive drive for stu-
dent nurses, the losers to entertain the winners at
dinner.
Dr. M. A. Neufeld, Chief of the State Dispensary
for Tuberculosis at Chester, recently returned from a
postgraduate course at the State Sanatorium at White
Haven.
Dr. Arthur J. Simons, of Newfoundland, who was
a sufferer from ear trouble and spent some time in the
hospital for special treatment, has resumed his prac-
tice.
Dr. James M. Anders, Philadelphia, has been elected
president of the American Therapeutic Society for the
ensuing year. Dr. Anders was also recently elected
president of the American College of Physicians.
Dr. J. Walter Bancroft, Secretary of the Cambria
County Medical Society, as a result of a recent auto-
mobile accident, is a patient in the Memorial Hospital,
Johnstown, suffering from a fractured left humerus,
which he had to have plated.
The Temple University School of Medicine has
elected Dr. Max H. Bochroch, of Philadelphia, Clin-
ical Professor of Neurology, and Dr. Albert H. Strick-
ler, of Philadelphia, Clinical Professor of Dermatology^
and Syphilology.
Armour & Company announce the addition of the
following preparations to their list : Suprarenal cor-
tex, suprarenal medulla, placental substance. Physi-
cians desiring to use these products may get them from
headquarters for the organo-therapeutic agents
The following full-time professors have been
added to the faculty of Temple University School of
Medicine, Philadelphia: Dr. D. Gregg Metheny, Pro-
fessor of Anatomy and Histology; Dr. J. Garrett
Hickey, Professor of Physiology ; Dr. William H.
Reese, Professor of Physiological Chemistry.
The Training School for Nurses of Buhl Hos-
pital, Sharon, held its graduating exercises on June
2ist, in the Masonic Temple, when six nurses were
graduated. The following program was rendered :
Prayer by Rev. Lewis; address by Mr. Jordan, of
New Castle ; presentation of diplomas by Mr. A. L.
Cromlich, vice-president of the Board of Directors;
presentation of pins. Dr. Edith MacBride ; violin solo,
Miss Cottron; vocal solo, Mr. Turner, and selections
by the orchestra, followed by dancing and refresh-
ments.
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THE PENNSYLVANIA MEDICAL JOURNAL
August, 1921
GENERAL NEWS ITEMS
Dr. Paul John Hanzlik has been appointed Pro-
fessor of Pharmacology in the Stanford University
Medical School to succeed Professor A. C. Crawford,
■who died recently.
The Medical School op Vanderbilt University,
Nashville, Tenn., has received a donation of $3,000,000,
half from the General Education Board, and half from
the Carnegie Corporation of New York, consequent upon
the removal of the School of Medicine from its pres-
ent site in South Nashville to a location on the West
Campus and upon the completion of a proper building
program. Funds for the erection of new buildings
-will be made available from the $4,000,000 appropria-
tion made by the General Education Board in 1919.
The $3,000,000 donation will be used for endowment
of the Medical Department of the University. It is
hoped that the new plant can be utilized by the fall
of 1924.
At the Seventy-seventh Annual Meeting of the
American Medico-Psychological Association, held in
Boston, May 31st to June 3d, inclusive, a new consti-
tution was adopted, which provided among other slight
<:hanges, a change in the name of the organization,
which will hereafter be known as the American
Psychiatric Association.
The publication, American Journal of Insanity,
Johns Hopkins Press, Baltimore, Md., will, hereafter,
be the official organ of the Association and will be
published under a new name — The American Journal
of Psychiatry, while the former transactions bound in
book form will be omitted.
The newly elected officers are: President, Albert
M. Barrett, M.D., Ann Arbor, Mich.; Vice-President,
H. W. Mitchell, M.D., Warren, Pa. ; Secretary-Treas-
urer, C. Floyd Haviland, M.D., Middletown, Conn.
Dr. Wallace Calvin Abbott, who died at his home
in Chicago, on July 4, was born in Bridgewater, Ver-
mont, October 12, 1857. His early education was ob-
tained at the State Normal School, Randolph, Vt, the
St. Johnsbury Academy, St. Johnsbury, Vt., and Dart-
mouth College, Hanover, N. H. Coming West, he
-worked his way through the University of Michigan,
winning his degree as Doctor of Medicine in Chicago,
building up a large practice on the North Side and
winning many friends. It was during this time that
Dr. Abbott established The Abbott Alkaloidal Com-
pany, now known as The Abbott Laboratories, of
-which firm he was president continuously from the
time of its establishment, more than thirty years ago,
until his death.
Dr. Abbott was a pioneer in the field of alkaloidal
medication. He labored incessantly, through his writ-
ings and personal contact with thousands of physi-
cians, to bring about a more careful study of the pa-
tient and the treatment of separate symptoms as they
developed, as contrasted with the older method of
treating by disease names only. His influence upon
the medical profession in this respect has been pro-
found. He was co-author, with Dr. Wm. F. Waugh,
of several medical books, including "The Practice of
Medicine" and "Positive Therapeutics." He was also
editor-in-chief of The American Journal of Clinical
Medicine.
He was a member of the Ravenswood Methodist
church, the American Medical Association, the Illi-
nois Medical Society, the Chicago Medical Society,
the Medical Editors' Association, American Drug
Manufacturers' Association, American Pharmaceutical
Manufactureres' Association, Ravenswood Lodge, 777,
A. F. & A. M., the Oriental Consistory and the Shrine.
CATHOLIC HOSPITALS PLAN STANDARDS
The adoption of a moral code for hospitals, and an-
nouncement of plans for the formulation of its own
standards, were features of the sixth annual conven-
tion of the Catholic Hospital Association of the United
States and Canada (according to Hospital Manage-
ment), held at St. Thomas College, St Paul, Miniu,
June 21-24, 1921.
A motion was o£Fered that the proposed code of
ethics be adopted by the association as a minimum. In
the ensuing discussion, the motion was amended to the
effect that the suggested code be understood merely
to be an initial effort along this line and that the code
be expanded and developed as the executive board of
the association saw fit. The motion with the amend-
ment was carried.
The code of ethics is as follows :
"Before beginning any operation in the hospital, the
surgeon is required to state definitely to the sister in
charge of the operating room what operation he in-
tends to perform.
"The following operations are tmethical and may
not, therefore, be performed :
"I. Operations involving the destruction of fetal
life. Such are:
"a. Dilatation of the os uteri during pregnancy and
before the fetus is viable.
"b. Introduction of sounds, bougies, or any other
substances within the os uteri, during pregnancy and
before the fetus is viable.
"c. Induction of labor by any means whatsoever be-
fore the fetus is viable. Neither eclampsia nor
hyperemesis gravidarum constitute any exception to
this rule.
"d. Curettment of the uterus during pregnancy.
"e. Craniotomy of the living child.
"f. Operations directly attacking a living fetus in
extra-uterine pregnancy, in the absence of material
shock from hemorrhage and before the fetus is viable.
Where operations for extra-uterine pregnancy in the
fallopian tube are performed, the rent or rupture in
the tube must be repaired whenever possible.
"II. All operations involving the sterilization or
mutilation of men or women, except where such fol-
lows as the indirect and undesired result of necessary
interference for the removal of diseased strtictures.
"Operations specifically forbidden are:
"a. Removal of an undiseased ovary. Whenever an
operation for the removal of a diseased ovary is per-
formed, enough of sucH organ must be left, if possible,
as will permit the same to fimction.
"b. Removal of a fallopian tube which is not so dis-
eased as to require removal.
"c. Section of an undiseased fallopian tube.
"d. Operations which result in obstructing the lumen
of an undiseased fallopian tube.
"e. Hysterectomy where the uterus is not so badly
diseased as to require the operation.
"f. Ventral suspensions and anterior fixations or
ventro-fixations so-called, in women of child-bearing
age, in the absence of proof positive of their necessity.
"g. The sterilization and castration of male patients.
"The fetus may be considered viable after six cal-
endar months.
"If the fetus is known positively to be dead, oper-
ations for emptying the uterus may be performed.
"The question of the presence of life, and of the
necessity for the removal of the reproductive organs,
or interfering therewith, by surgery or medicine, must
in all cases be determined by previous competent con-
sultation.
"All structures or parts of organs removed from pa-
tients must be sent in their entirety, at once, to the
pathologist for his examination and report 'These
specimens will, after examination, be returned by him
to the operator on request.
"The above rules are mandatory and the violation
of any one of them will result in excluding the oper-
ator from the privilege of the hospital."
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OFFICIAL TRANSACTIONS
The Medical Society oe the State of Pennsylvania
Organixed 1848 Incorporated, December 20, 1890
Seventy-first Annual Session of the Medical Society of the State'of
Pennsylvannia
Philadelphia, October 3-6, 1921
PRELIMINARY
SCIENTIFIC PROGRAM
GENERAL MEETING
BEU-EVUE-STRATFORO HOTEI. : CONVENTION HALL
Tuesday, October 4, 10 A. M.
Call to Order by the President.
Henry D. Jump, Philadelphia.
Invocation.
His Eminence, D. Cakdinal Doughekty, Arch-
bishop of Philadelphia.
Address of Welcome.
Hon. J. Hampton Moore, Mayor, Philadelphia.
Address of Welcome.
George Morris Piersol, President of the Philadel-
phia County Medical Society.
Presentation of Program.
Thomas G. Simonton, Pittsburgh, Chairman of
the Committee on Scientific Work.
Announcement of Entertainments.
John Bekton Carnett, Philadelphia, Chairman of
the Local Committee on Arrangements.
Introduction of Delegates from Other Societies.
Installation of the President^Elect.
(Note — Authors will please hand original copies of
their papers to the Secretary when through reading
them, as the printer will not accept carbon copies.)
No. I.
President's Address. Frank G. Hartman, Lancaster.
No. 2.
The Role of the Non-Medical Graduate in the Medical
Laboratory. (15 minutes.)
CoiTRTLAND Y. White, Philadelphia.
OuTLiNt. The Technician's part in the work of the I.abora-
t0f7. Who shall interpret laboratory examinations? The
financial return of the laboratory workers. Recommendations
for the betterment of the service.
Discussion opened by Samuel R. Haythorn,
Pittsburgh; Paul Lewis, John A. Kolmer,
Philadelphia; Grover C. Weil and John A.
Lichty, Pittsburgh:
No.3-
The Peril of Wood Alcohol Toxaemia and the Rem-
edy. (15 minutes.)
S. Lewis Ziecler, Philadelphia.
OuTLiNI. Wood alcohol must be recognized as the most
deadly poison of commerce. Its manufacture should be pro-
hibited or its sale strictly regulated by law. It is a proto*
plasmic poison, small doses destroying vision and larger ones
menacing life itself. The post of entry is usually through the
mouth but may be through the nose or skin. It has a selrr'ive
affinity for the delicate nerve-tissues of the eye and probably
for the pituitary body. Our intensive study should be directed
to its toxic symptoms and their prompt alleviation before de-
structive corrosion of the neurons can occur.
The public must be thoroughly educated as to the dangers of
wood alcohol poisoning and the physician trained to detect its
slightest manifestation and to institute early and efficient treat-
ment.
A quick and reliable test for the presence of wood alcohol is
outlined in the paper.
Discussion opened by James M. Andres, Phila-
delphia.
Stenographer — Miss L. C. ALEXAHOtR, 313 S. Seventeenth
St., Philadelphia.
Wednesday, October 5, 9 A. M.
(Note — Essayists will please deposit original copies
of their papers with the Secretary of the Section, when
they have finished reading them. The printer will not
accept carbon copies.)
No. 4.
Sterility: The Causes and Their Correction. (10
minutes. F. Hurst Maier, Philadelphia.
Outline. Sterility may be relative. In a strict sense it im-
flies the absence of fertilization and implantation of the ovum,
n a paper of this kind it is more instructive to consider it in
a broader and more comprehensive manner, namely: the ina-
bility of the woman to give birth to a viable child. Frequency
of sterility difficult to determine. Blame falls on the woman.
Large percentage due to male, direct and indirectly by trans-
mission of disease to the female. In a study of the etiology of
sterility, influence of the internal secretions on the development
of the genital organs and their functions must be considered.
Causes may generally speaking, be condensed under two heads,
local and general. Local: A: Congenital, a: Anatomical
Deformities, b: Endocritic Anomalies. B. Traumatic Condi-
tions. C: Infections. D: New Growths. E: X-Ray. Gen-
eral: A: Physiological Causes, B: Selective Sterility. C:
Disturbances of the Endocring Organs. D: Psychoses. E:
Nutritional Disturbancrs. F: Debilitating Disease. Treat-
ment- Medical and S.:rgical. Medical Treatment: Considera-
tion of appropriate measures with special reference to organo-
therapy, selective sterility and artificial impregnation. Sur-
gical: Correction of primary and acquired pathology of the
genital organs. Consideration of the value of ovarian implana-
tation and transplantation.
Discussion opened by Henry D. Jump, Philadel-
phia.
No. 5.
The Practitioner's Part in Acquiring the Knowledge
Necessary for Intelligent Interpretation of Atypi-
cal Wassermann Reactions. (10 minutes.)
Samuel R. Haythorn, Pittsburgh.
OuTLiNt. Properly interpreted atjrpical Wassermann reac-
tions have a place in clinical diagnosis. Where the laboratory
technique is reliable and thoroughly established on a quantita-
tive basis, so that tests done on the same patient from time to
time can be compared as nearly as possible, the differences
which occur are due to changes in the serum rather than in the
test itself. The analysis of 8,500 Wassermann tests, from the
standpoint of a typical reactions, indicates that changes in the
serum which alter the reaction may result from the manner of
collection, the condition of the patient at the time of the collec-
tion, and from the treatment which the patient has received.
More information regarding the patient is due the serologist
from the clinician so that the knowledge of the diagnostic value
of the atypical reaction may be improved.
Discussion opened by John A. Kolmer, Philadel-
phia.
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THE PENNSYLVANIA MEDICAL JOURNAL
August, 1921
SYMPOSIUM : THE TREATMENT OF
SYPHILIS
No. 6.
Primary, Secondary and Early Tertiary. (1$ min-
utes.) Jay Schamberg, Philadelphia.
OuTUNB. I. Modern comprehension of syphilitic infection.
a. The intravenous treatment of exposed individuals. 3. The
treatment of sero-negative primary syphilis. 4. The treatment
of sero-positive primary syphilis and of secondary syphilis. $.
The treatment of tertiary syphilis. 6. The clinical interpreta-
tion of the Wassermann reaction. 7. The choice of the
arsphenamines. 8. The use of mercury. 9. The relationship
of arsenical to mercurial treatment. 10. The effect of the
arsphenamines and of mercury on the structure of organs. 11.
Divergent views on treatment. 12. Statement as to prognosis
and curability of disease.
No. 7,
Tertiary Stage of Syphilis. (15 minutes.)
Thomas McCrea, Philadelphia.
OuTUNK. Discussion of the relative importance of treating
the specific infection itself and the results of the infection, and
how much of the results obtained arc due to each of these.
The questions as to how much dependence should be placed on
the complement fixation test as a guide to treatment. The
relative value of mercury and arsphenamine in the tertiary
stage.
No. 8.
Neurosyphilis. (20 minutes.)
Harry C. Solomon, Boston, Mass. (by invitation.)
OtrTLiNS. There is no uniformity of opinion concerning the
pathogenesis of neurosyphilis. The question of neurotropic
strains, the time of the entrance of the virus into the nervous
system, the localization and activity during the symptom-free
period, the reason for development of the benign meningo-
vascular or the malignant parenchymatous types are all prob-
lems of investigation. Nor is there any agreement as to the
possibility of preventing the development of some of the late
neurosyphilitic manifestations despite early and intensive treat-
ment. The question of the treatment of late syphilis is there-
fore quite involved from the theoretical standpoint. However,
practice has shown that valuable results may be obtained in
many cases, especially of the meningo-vascular type. How far
equally good results are to be obtained in the treatment of so-
called parenchymatous types, namely tabes and general paresis,
is a point about which there is the very greatest difference of
opinion. Whether general treatment is sufficient in cases of
neurosyphilis or whether one must add some special method
such as drainage, intraspinal, intracistemal or intraventricular
injections is another matter still in the investigative stage.
Certain results obtained in the treatment of various types of
neurosyphilis by different methods are reported with the gen-
eral conclusion that no method is to be considered of universal
applicability, and in the majority of cases that can be improved
by therap:ir the results may be obtained by general treatment;
but there is an important group of cases which give satisfactory
results only when special methods are used.
Discussion of papers six, seven and eight opened
by George J. Weight, Pittsburgh, and David
Reisman, Philadelphia.
No. 9.
Family Syphilis. Its Relation to Public Health. (10
minutes.) Elmer Hess, Erie.
OnTLiKB. I. Conservative figures place eight per cent, of the
population in the luetic class which means at least eight million
leutics in the United States. A distinct Public Health Problem.
2. Many more people must have unrecognized lues as a direct
result of family contact. 3. Family lues when recognized is
very often in the Tertiary Stage during which time a negative
Wassermann but a positive Colloidal Gold Test is the rule. 4.
Clinical signs are vastly more important than any known labora-
tory test. 5. Family history, if not as important as clinical
signs is at least secondary to them and of more real value
than laboratory findings. 6. Absolute necessity for cooperation
between the family physician and the syphilographer in han-
dling these families.
Discussion opened by Edward Martin, Harris-
burg.
No. 10.
Post-Graduate Instruction in Pennsylvania. (10 min-
utes.) Daniel A. Webb, Scranton.
OuTLiNit. Heretofore the main efforts of educators and edu-
cational agencies have, in matters medical, been centered upon
the undcr-graduate. For the greater number graduation is not
the "Commencement" but the finish of serious concentrated
study. After that comes perhaps a busy life, seldom a studious
one. The sudden and complete withdrawal of professional
stimulation leaves open the well intentioned one to his own
unsunported enthusiasm. That is soon impaired or destroyed
by the distractions of practice and continuity of study, once
broken, is seldom restored. Its restoration, or rather the pre-
vention of its loss, ought be part of the function of a State
University. That it is desired by the Post-Graduate student
body, viz, the general practitioners, is evidenced by the avidity
with which he seizes instruction when brought to his County
Society, or, with which he goes in search of it at P. G. Centres,
The first ought to be the method of instruction, as also the
remed^jT for a defect in our educational system. University
extension, or extramural courses, by sending every year ac-
credited teachers to several large centres where there are no
schools in cooperation with County Medical Societies would
make study the voluntary life work of the mature physician
and not solely the emergency enthusiasms of his undergraduate
years. The expense to be borne by the County Medical So-
ciety.
Discussion opened by George H. Meeker, Dean of
the University of Pennsylvania, Graduate
School of Medicine; John B. Roberts, Phila-
delphia, and William T. Sharpless, Chester.
Thursday Afternoon, October 6, a P. M.
(Note — Essayists will please deposit original copies
of their papers with the Secretary of the Section, when
they have finished reading them. The printer will not
accept carbon copies.)
SYMPOSIUM: DIABETES MELLITUS
No. II.
The Treatment of Diabetes from the Point of View
, of a General Practitioner. (25 minutes.)
Eluott p. Joslin, Boston, Mass., (by invitation).
Outline. The responsibility for improvement in treatment
of diabetes with methods now available rests upon the general
practitioner rather than upon the specialist. The newer
methods of treatment discussed and their applicability to office
practice explained.
No. 12.
Ophthalmologist's Standpoint. (15 minutes.)
Edward A. Weisser, Pittsburgh.
OuTUNl. Eye complications seen in diabetes. Statistics as
to their frequency. Changes seen in the range of accommo-
dation, refraction and the extrinsic muscles. A study of the
cornea, iris, lens, and retina with its blood vessels and optic
nerve when pathologically complicated through diabetes. Prog-
nosis of these various conditions. Treatment.
No. 13.
The Chemical Procedures of Use in the Control of
Diabetes. (15 minutes.)
R. R. Snowden, Pittsburgh.
Discussion of papers eleven, twelve and thirteen
opened by Frederick M. Allen, Morristown, N.
J.; William Campbell Posey, Philadelphia,
and O. H. Perry Pepper, Philadelphia.
No. 14.
Primary Carcinoma of the Lung. (10 minutes.)
Francis J. Dever and Clayton E. Royce, Beth-
lehem.
OuTUNE. Narration of the signs and symptoms of a case
with a discussion of the pathology and a brief review of the
literature.
Discussion opened by William Egbert Robert-
son, Philadelphia.
No. 15.
Local Responsibility in Relation to Community Wel-
fare. (10 minutes.)
A. P. Francine, Chief of Tuberculosis Division,
Harrisburg.
Outline. Community welfare is essentially largely the re-
sponsibility of the local community, either through voluntary
organizations or by municipal aid, both in relation to construc-
tive effort and to maintenance. This does not mean that the
State should not aid, but that it should not do it all. This is
a widely recognized principle outside of Pennsylvaina and is
becoming so here. The fundamental function of a centralized
official body, such for instance, as a State Department of
Health, lies largely in so-called consultant work in public
health. It should assist financially so far as this does not
handicap its constructive effort along broader lines. As a
specific example, the State should not be called upon nor ex-
pected to maintain the full cost of the local State Oinics.
I.ocal communities should bear their share, for they are run
for the benefit of these communities, under local administra-
tion. The State should help support them with the object of
miking them permanent, of maintaining a certain standard,
givin? them official backing and linking the separate units to
the State Sanatoria. Paternalism as exemplified in local insti-
tutions entirely suoported by the State is un-American and on
account of its multiplied cost for many communities, prohibitive.
Discussion opened by J. G. CrEssinger, Sunbury,
and Charles H. Miner, Wilkes-Barre.
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August, 1921
SCIENTIFIC PROGRAM
855
No. j6.
Treatment after Operation Upon the Stomach and In-
testines. (15 minutes.)
Levi J. Hammond, Philadelphia.
OuTUHI. I( the alimentarjr csnal is the seat of operation,
miccess, in a very large measure, depends on special after at-
tention.
Discussion opened by
SECTION ON MEDICINE
CONVENTION HALL
OfncERS OP Section
Chairman— Howard G. Schi.Eiter, S004 Jenkins Ar-
cade, Pittsburgh.
Secretary— Edward J. G. Beardsley, 258 S. Sixteenth
St., Philadelphia.
Executive Committee— Irwin J. Mover, Pittsburgh;
George E. Holtzapple, York; M. Howard Fus-
SEU., Philadelphia.
Stenographer —
(Note. — Essayists will please deposit original copies
of their papers with the Secretary of the Section when
they have finished reading them. The printer will not
accept carbon copies.)
Tuesday, October 4, a P. M.
No. I.
Address by the Chairman.
Howard G. Schleiter, Pittsburgh.
No. 2.
The Diagnosis of Portal Cirrhosis.
Adam J. Simpson, Chester.
Odtlihs. The difficulties of diagnosis; signi6cance of earl^
and slight symptoms; frequency and importance of hematemesis
and ascites as symptoms; lues and tuberculosis as complica-
tions; the importance of an early and correct diagnosis to in-
sure proper treatment Report of case with necropsy.
Discussion opened by Frederick J. Kaltever,
Philadelphia, and Frank AllEman, Lancaster.
No. 3.
Acute Articular Rheumatism.
Harry H. Penrod, Johnstown.
OuTMMt. Importance of the subject; frequency; etiological
factors; symptoms; complications; dinerential diagnosis; pre-
vention ; treatment.
Discussion opened by George E. Holtzapple,
York.
No. 4-
The Mental Side of Hyperthyroidism.
Max H. Weinberg, Pittsburgh.
OuTlINE. An analysis of the mental symptoms of a series
of cases of this disease; emphasis regarding the importance of
a consideration of the mental symptoms as an aid to early
diagnosis and treatment; presenting the view that it is a mis-
take to neglect proper treatment until the physical ^mptoms
appear when the mental state reveals the diagnosis.
Discussion opened by Charles W. Burr, Phila-
delphia.
No. 5.
Disturbances of the Circulatory Mechanism in Cardiac
Disease. Charles C. Wolferth, Philadelphia.
OnTliNE. Recent advances in hemato-respiratory physiology;
present-day conceptions of the inter-relations of the various
mechanisms that carry on the circtilatory function. The work
of the heart; its adaptation to stress. Cardiac inadequacy;
some of its principal causes and effects. Attempts at adapta-
tion within the heart and in the extracardiac circulatory me-
chanisms. The evidences of these disturbances. Methods of
eliciting them. The importance of clinical study. The value
and limitations of laboratory investigations and functional tests.
Discussion opened by Lawrence Litchfield, Pitts-
burgh.
No. 6.
Achylia Gastrica. Joseph Sailer, Philadelphia.
Outline. Frequencjr of the condition; the various forms of
deficiency in the acid secretion; general symptomatology;
nervous and mental symptoms; attacks simulating gall stones;
the importance of the manifestations to be observed by an in-
spection of the tongue.
Discussion opened by J. Quincy Thomas, Con-
shohocken.
No. 7.
Cytology of the Cerebrospinal Fluid.
Jambs H. Whitcraft, Wilkinsburg.
OtJTLiNt. The kind of cells and their number normally
found in cerebro spinal fluid. Observations in acute diseases,
i. e., typhoid fever, pneumonia, measles, sinusitis and influenza.
The importance of proper technique in the examination and
especially in counting the cells. The importance of cell counts
in all forms of irritation or disease of central nervous system.
Cell counts in various forms of meningitis, encephalitis, hemor-
rhage, neoplasm and poliomyelitis. Relation of cell findings to
other laboratory examinations in cerebro spinal diseases.
Discussion opened by Orlando H. Petty, Phila-
delphia.
No. 8.
Tuberculosis of the Peritoneum.
Henry K. MoblER, Philadelphia.
Outline. Frequency; symptoms, diagnosis, discussion of
other conditions resembling tuberculosis of the peritoneum;
treatment and prognosis.
Discussion by Alexander Armstrong, White
Haven.
Wednesday, October 5, a P. M.
Report of Executive Committee.
Election of Section Officers.
No. 9-
Evidence of General Infection in Tuberculosis.
Albert J. Brubcken, Pittsburgh.
Outline. Frequencjr of generalized infection greater than
is indicated by clinical incidence and probably greater than post
mortem findings indicate. Many cases of generalized infection
recover without being detected. Post mortem examination long
after fails to reveal infection because of the healing of tu-
bercles. Small miliary tubercles can heal without leaving any
vestiges as is seen in human infection in the rabbit. Certain
organs fail to develop tubercles except in very severe infec-
tions. Renal tuberculosis in the guinea pig of this nature.
Rabbits inoculated with bovine bacilli intraveaously, show
bacilli in blood and urine immediately after injjection, indicat-
ing a continuous bacteremia and inefficiency of lung filter. Fail-
ure to produce experimental local tuberculosis without general-
ized infection in animals.
Discussion opened by Samuel R. Havthorn,
Pittsburgh.
No. 10.
A Study of One Hundred Autopsied Cases of Miliary
Tuberculosis at the Pennsylvania Hospital.
George W. Norris and David L. Farley, Phila-
delphia.
Outline. Paper based upon a correlation of clinical versus
autopsy findings. An effort to throw more light upon this, too
frequently, unrecognized condition.
Discussion opened by Paul Lewis, Philadelphia.
No. II.
Mechanical Aspects of Chronic Valvular Heart Dis-
ease. Andrew P. D'Zmijra, Pittsburgh.
Outline. Possible ovcr-emphaais of the role of heart mus-
cle; factor of relative mobility of ventricular portion while
auricles are fixed; possible pressure effects secondary to in-
volvement of various chambers; variations in symptoms and
signs in mitral and aortic lesions; dtagtiostic aid to be gained
by x-ray and electrocardiographic studies; prognostic signifi-
cance of various mechanical signs and symptoms; possible com-
pensatory phenomena; suggestions for treatment based upon
mechanical considerations.
Discussion opened by Hobart A. Hare, Philadel-
phia.
No. IS.
Goitre — From the Standpoint of the Clinician.
Carl E. Erwin, Danville.
Outline. Geographic distribution; function of thyroid
gland; properties of its active ingredient, thyroxin. Clinical
and anatomical classification of thyroid disorders. Et<olo<rv ind
symptomatology. Diagnosis; classical syndrome, ban! metabol-
ism and other laboratory measures. Treatment; prophylactic,
medical, radit^ and x-ray. Surgical treatment of the toxic
cases. Statistical review of five hundred and thirty cases of
goitre. Responsibility of the clinician.
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THE PENNSYLVANIA MEDICAL JOURNAL
August, 1921
Discussion opened by S. Solis Cohen, Philadel-
phia.
No. 13.
The Bacteriology of the Gall Bladder.
De Wayne G. Richey, Pittsburgh.
Outline. Results of routine cultures from drained or re-
noved gall bladder; an analysis of over three hundred exami-
nations; conclusions.
Discussion opened by Stanley Reiman, Philadel-
phia.
A'o. 14.
The Chemical Control of Respiration.
J. J. R. MacLeod, Toronto
A'o. 15.
The Importance of Examining the Diaphragm.
Elmer H. Funk, Philadelphia.
OuTLiNt. The frequent neglect of the diaphragm in the or-
dinary physical examination. The methods of examination.
The information obtained from the study of the diaphragm.
Some common lesions involving this organ. Illustrative cases.
Lantern demonstration.
Discussion opened by James L Johnston, Pitts-
burgh.
No. 16.
Spinal Cord Changes in the Anaemias.
George Wilson and Joseph Mclvrai, Philadelphia.
Outline. The type of anaemias in which the cord disturb-
ance develops; the frequency with which cord_ changes occur
in patients presenting a nearly normal blood picture; general
symptomatology including the characteristic sensory loss. The
pathology illustrated by lantern demonstration; differential
diagnosis.
Discussion opened by George J. Wright, Pitts-
burgh.
Thursday, October 6, a P. M.
A'o. 17.
A Consideration of Certain Basic Factors in Disease.
Ralph Pembbrton, Philadelphia.
OuTLtNE. Modern developments in physiology show wide
influence of disturbances in fundamental processes; many facts
then to suggest a common origin and possibly the common na-
ture of various disease conditions formerly considered as dis-
crete entities. Changes conceptions of the nature and treat-
ment of certain chronic processes as a result of the above con-
siderations.
Discussion by Irwin J. Moyer, Pittsburgh.
A'o. 18.
The Urea Concentration Test for Kidney Function.
Edward Weiss, Philadelphia.
Outline. Review of general methods for testing the state
of kidney function; advantages and disadvantages of these
well known methods. Advantages of urea as a test substance.
Technic of the urea concentration test. Comparison with other
methods in diagnosis and prognosis. Conclusions.
Discussion opened by Roy Ross Snowden, Pitts-
burgh.
A'o. 19.
The Subjective Symptoms of the Cardiac Arrhyth-
mias.
John H. Mi;sser, Jr., and Thomas MacMillan,
Philadelphia.
Outline. Relative frequency of subjective symptoms in pa-
tients with cardiac irregularities; types of irregularities gen-
erally associated with subjective symptoms; tyfxes in which
there is an absence of cardiac symptoms; subjective symptoms
as an aid to objective symptoms in diagnosis of type of ir-
regularity; a study of these symptoms.
Discussion opened by James D. Heard, Pitts-
burgh.
A'o. ^o.
Unresolved Pneumonia.
George Morris Piersol, Philadelphia.
Outline. Definition, incidence and etiology of the condition.
A discussion of its pathology with special reference to the
question as to whether so-called unresolved pneumonias fol-
lowing acute lung infections are not really inter-lobar empyemas
or lung abscesses. Diagnosis of the condition and the import-
ance of its early recognition.
Discussion opened by Charles H. Miner, Wilkes-
Barre.
No. 21.
Further Reports on a Form of Chronic Unilateral
Bronchopneumonia of Non-Tuberculous Origin.
David Riesman, Philadelphia.
Outline. Several years ago attention was called by the
writer to a form of sub-acute or chronic lung infection assuxa-
ing a lobar form and always located in the lower lobe, a little
more often on the left than on the right side. The condition
is a cause of long<ontinued fever of low grade and often of
persistent cough. The cases are most often considered to be
tuberculous. Sometimes the diagnosis of typhoid fever is made.
They are not tuberculous, even when hemoptysis is present
The chief physical signs are described and reference made to
differential diagnosis and treatment.
Discussion opened by Henry R. M. Landis, Phila-
delphia.
A'o. 2i.
The Importance of Maintaining a Standard Weight
Lawrence Litchfield, Pittsburgh.
Outline. The importance of weight control in the main-
tenance of health and in the management of disease. Ab-
normalities of weight most obvious. Do not receive from the
physician the attention which they should. Scales and measor-
mg rod most important office equipment. Rules for estimat-
ing normal weight variations from normal causes and effects
of excessive and deficient weight in health and in disease. At-
petite as related to the body need. Faulty traditions. Water
and food, most imperative needs of the body in health and
disease, should be considered before drugs. Effects often tt-
tributed to disease due to malnutrition. Effects of proper do-
trition on disease. Relation of nutrition to vital resistance be-
fore operation. Glands of internal secretion. Neurasthenia.
Importance of follow-up treatment after rest cures with forced
feeding. Report of cases. Cardiac. Gastro-intestinal. Neu-
rasthenic. Diabetic. Hypertensive.
Discussion opened by Alfred Stengel, Philadel-
phia.
A'o. 23.
Primary Thrombosis of the Pulmonary Artery.
Frederick T. Billings, Pittsburgh.
Outline. Accepted theories regarding the etiological factors
involved in the formation of thrombi during life. The diffi-
culty if not the impossibility of assigning a specific cause to
certain cases of thrombosis. Recital of toe usual location of
thrombi. Frequency of primary thrombosis of pulmonary ar-
tery. Autopsy reports quoted. Report of cases and review of
literature.
George W. Norris, Philadelphia.
No. 24.
The Clinical Interpretation of the Phthalein Test and
Ambard Coefficient and Certain Disturbances of
Kidney Function.
John A. Lichty and William A. Bradshaw,
Pittsburgh.
Discussion opened by O. H. Perry Pepper, Phila-
delphia.
A'o. 25.
The Classical Endocrine Syndromes.
Lewellys P. Barker, Baltimore.
SECTION ON SURGERY
clover room
Officers of Section
Chairman — Elwood N. Kirby, 1202 Spruce St, Phila-
delphia.
Secretary — William L. Estes, Jr., Bethlehem.
Executive Committee — John L. Atlee, Lancaster;
Donald Guthrie, Sayre; T. Turner Thomas,
Philadelphia.
(Note. — Essayists will please deposit original copies
of their papers with the Secretary of the Section when
they have finished reading them. The printer will not
accept carbon copies.)
Stenographer— Mas. M. C. Repp, 926 S. Sixtieth St, Phila-
delphia.
(Unless otherwise noted, all papers will be limited
to fifteen minutes.)
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August, 1921
SCIENTIFIC PROGRAM
857
Tuesday, October 4, a P. M.
No. I.
Address of the Chairman.
Elwood N. Kirby, Philadelphia.
No. 2.
Some Thoughts on Fracture Replacement and Treat-
ment. (10 minutes.) (Lantern Demonstration.)
Harvey C. Masland, Philadelphia.
OuTLtMt. The mechanics of traumatic fractures of the
major long bones, with a consideration of the muscles and
fibrous tissue as factors in displacement. Essentials in the sat*
isfactory replacements of deformed fractures. The Thomas —
ice tonais — Whitman and Masland treatments for such fractures.
Illustrative cases.
Discussion opened by Dauon B. Pfeipfee and
George P. Muuer, Philadelphia.
No. 3.
Abduction Treatment in Fracture of the Neck of the
Femur.
George M. Dorrance and Eugene C. Murphy,
Philadelphia.
OtrTUNE. The abduction treatment is advised for cases of
fracture of all parts of the neck, including the intertrochanteric
fracture; the anatomical reasons for the displacement; the
description of the usual displacement; if impacted, whether it
should be broken up or let alone; results to be expected; the
length of time for bony or Abrous union; contrast between
this and the operative treatment, as bone pegging, plating, etc.
No. 4.
Non-Union in Fractures of the Neck of the Femur.
M. S. Henderson, Rochester, Minn, (by invita-
tion).
OuTLiNi. Non-union in fractures of the neck of the femur
is usually the result of no treatment. Impaction is too fre-
quently relied upon and the patient let go without fixation.
Non-union once established is very difficult to deal with. The
question of operative procedure depends entirely upon how
much of the neck of the femur is left, the age, and the general
condition of the patient Non-union of the neck of the femur
is not necessarily hopeless.
Discussion on preceding two papers opened by A.
P. C. AsHURST, Philadelphia; Levi J. Ham-
mond, Philadelphia; Paul Mecray (by invita-
tion), Camden, and Charles E. Thomson,
Scranton.
No. 5.
Fracture of the Shaft of the Femur.
T. Turner Thomas, Philadelphia.
Outline. Defense of the open method of reduction and
fixation for fractures of the shaft of the femur.
Discussion opened by William L. Estes, Beth-
lehem; George P. Muller, Philadelphia, and
William O. Sherman, Pittsburgh.
No. 6.
Diseased Conditions of Bone and Joints as Influenced
by Menstruation. (10 minutes.)
J. Torrance Ruch, Philadelphia.
Outline. Physiology of menstruation. Immediate and re-
mote effects upon diseased tissues. Illustrative cases.
Discussion opened by David Silver, Pittsburgh,
and Edward A. Schumann, Philadelphia.
No. 7.
Transfusion. (10 minutes.)
Walter T. Lundblad, Sayre.
Outline. History; rapid development with simplification of
technique; present methods; practicability; extraordinary skill
unnecessary; indications, including hemorrhage in the new
bom; cases; special considerations in the operation; conclu-
sion.
Discussion opened by Jonathan M. Wainwricht,
Scranton, and George M. Dorrance, Philadel-
phia.
Wednesday, October 5, a P. M.
Report of Executive Committee.
Election of Section Officers.
No. 8.
Recurrence in Hernia. Hubley Owen, Philadelphia.
Outline. Classification of recurrence — statistics relative to
recurrence; causes of recurrence; indication for operation;
selection of operation; post-operative care to prevent recur-
rence.
Discussion opened by John C. Da Costa, George
C. Ross and William J. Taylor, Philadelphia.
No. 9.
Gastro-Jejunal Ulcer. John J. Gilbride, Philadelphia.
Outline. Persistence of symptoms following gastro-enter-
ostomy for ulcer is suggestive of gastro-jejunal ulcer; tech-
nique of operation; uneven mucosal edges; non-absorbable
suture; trauma by instrument: position of anastomotic open-
ing in the stomach; all as factors in the causation; some
gastro-jejunal ulcers heal with closure of the stoma; advantages
of gastro-duodenostomy ; importance of intelligent and prolonged
medical after-treatment.
No. JO.
Instruction for Prevention of Recurrence Following
Gastro-Enterostomy.
Harry M. ARMnACE, Chester.
Outline. The inspired criticism which has given rise to
the extreme views of mtemists and surgeons regarding the end
results of their respective methods of treatment of gastric and
duodenal ulcers, is often prejudiced and nearly always il-
logical; there should be a middle ground when they both may
meet; types of ulcers amenable to medical treatment and those
requiring surgery; some late recurrences are due to marginal
ulcers and mechanical defects of the operation; emphasis laid
on the avoidance of recurrences where a technically perfect
operation has been performed. Cause of pain following opera-
tion. Intense post-operative medical management reduces the
percentage of recurrences more successfully than mechanically
intricate operations; the card of directions used by the author;
conclusions.
Discussion on the preceding two papers opened by
Charles Frazier, John Gibbon, Philadelphia;
Donald Guthrie, Sayre. and Alfred C. Wood,
Philadelphia.
-Vo. //.
Treatment of Cancer of the Large Intestine.
George W. Crile, Cleveland (by invitation.)
Discussion opened by John Deaver and Damon
Pfiepfer, Philadelphia.
No. /?.
A Consideration of Non-Surgical Biliary Tract Drain-
age as an Aid to the Surgeon.
B. B. Vincent Lyon, Philadelphia.
Outline. Brief resume of the method; the importance of
diagnostic information pre-operatively secured for the surgeon;
the importance of its use as an aid to the surgeon in the post-
operative follow-up treatment; citation of illustrative cases.
Discussion opened by Francis J. Dever, Bethle-
hem, and John J. Gilbride, Philadelphia.
No. 13.
Tuberculin Therapy in Surgical Tuberculosis. (Lan-
tern.)
H. A. McKnight and Herman Tracer, Philadel-
phia.
Outline. Why tuberculin has failed of recognition as a
therapeutic a^ent in the past. The immune response produced
and the relation of hypersensitivity and tolerance. The cause
of the different reactions; methods of administrative dilutions,
dosage and increase of same bpr non-reaction methods. Tuber-
culous glands, bones, and joints, intestines and peritoneum,
tests, etc.; contrast in surgery with tuberculin and without;
statistics of cases treated; results; lantern slides of photo-
graphs before and after one year's intensive treatment.
Discussion opened by Morris M. Miller, Phila-
delphia.
Thursday, October 6, 9 A. M.
No. 14.
Late Toxemia in Pregnancy.
J. Stuart Lawrence, Philadelphia.
Outline. Status of the question; material used^ evidence
of post-mortems; evidence of physiological chemistry; evi-
dence of clinical observation in mild toxemia, severe or pre-
eclamptic toxemia, and in eclamptic "stroke." Summary of
probable sequences.
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THE PENNSYLVANIA MEDICAL JOURNAL
August, 1921
Discussion opened by Paul Titos, Pittsburgh;
WiiiiAM E. Parke, Philadelphia, and Thomas
P. Cole, Greensburg.
Ko. 15.
What Cases of Eclampsia Shall We Section?
Wiu,iAM £. Pakke, Philadelphia.
OuTLiNC. Introduction; specific cause of the condition not
known; methods of treatment in vogue; symptomatic, opera*
tive and methods of operation; cautions to be observed in
selection of cases; interest of baby; report of thirty cases;
conclusion.
Discussion opened by Paul Titus, Pittsburgh;
' and Thomas P. Cole, Greensburg.
No. 16.
Pyelitis in Pregnancy; Paul Titus, Pittsburgh.
Outline. Pyelitis is more frequent during pregnancy than
is generally appreciated. Right positions of the foetus, pendu-
lous abdomen, constipation, leucorrhea, causative factors.
Quiescent pyelitis during pregnancy often flares up during
puerperium and much may be done m the way of prophylactic
treatment when recognized early. Rectal examinations during
labor have a possible bearing on the occurrence of pyelitis. In
the early stages, treatment of pyelitis is simple but effective,
whereas in the more advanced cases, catheterization of the
ureters and injection of the pelves of the kidneys may be nee*
essary, even in the presence of pregnancy.
Discussion opened by Edward A. Schumann,
Philadelphia; Thomas A. Evans, Jr., Pitts-
burgh, and Colin Foulkrod, Philadelphia.
No. 17.
Conservative Obstetrics.
George M. Boyd, Philadelphia.
OuTLiNK. Some lessons learned in a thirty years' service; a
brief report of ten thousand cases; the importance of an in*
telligent test of labor; spontaneous labor versus artificial labor.
Discussion opened, by Barton C. Hirst, Philadel-
phia.
No. 18.
Conservation in Pelvic Surgery.
Frank B. Block and H. M. Mikelberg, Philadel-
phia.
Outline. Classification of inflammation; types treated in
dispensary practice; pathology found in usual cases; methods
of treatment available; advantages and disadvantages of each;
results obtained with non-operative treatment.
Discussion opened by Floyd E. Keene, Philadel-
phia.
No. 19.
Treatment of Fibromyomata Uteri.
Stephen E. Tracey, Philadelphia.
OuTLiNS. Degenerations in the tumor; the associated ma-
lignancies arid tne age at which these occur; the abdomino-
pelvic lesions which co-exist; the age at which patients seek
relief; results secured by surgery; the percentage of cases
cured by x-ray and radium; a comparison of the results se-
cured by the different forms of treatment.
SECTION ON EYE, EAR, NOSE AND
THROAT DISEASES
junior room
Officers of Section
Chairtnan— Luther C. Peter, 1529 Spruce St., Phila-
delphia.
Secretary — William Hardin Sears, Huntingdon.
Executive Committee — Edward StierEN, Pittsburgh;
Fielding O. Lewis, Philadelphia; George B. Job-
son, Franklin.
Stenographer — Miss P. E. Dillon. Indianapolis, Ind.
(Note — Essayists will please deposit original copies
of their papers with the Secretary of the Section, when
they have finished reading them. The printer will not
accept carbon copies.)
Tuesday, October 4, a P. M.
Address of the Chairman.
Luther C. Peter, Philadelphia.
No. I.
Nasal Accessory Sinus Disease; Report of HI Cases
in Adults and Children Covering a Period of
Two Years. John J. Suluvan, Jr., Scranton.
Outline. Report of III cases, showing routine method of
procedure in examination and method of treatment. Contrast-
ing the conservative with the more radical procedures. The
bearing severity of the epidemic has on choice of treatment or
operation. The great frequency with which we have encoun-
tered "Optic Neuritis" of the focal type, prevalent the last two
years. Simple method in treatment ot sinus conditions in chil-
dren.
No. 2.
Optic Neuritis in Disease of the Nasal Accessory
Sinuses. Leonard G. Redding, Scranton.
Outline. Symptoms. Diagnosis. Increased frequency, what
is the reason? Treatment instituted earlier, rhinologists more
thorough, cause formerly undiagnosed and untreated. Many
hopeless cases seen. Local pain or inflammatory symptoms not
necessary. Prognosis. Report of cases.
No. 3.
A New Procedure in the Opening of the Maxillary
Antrum. George B. Wood, Philadelphia.
No. 4.
Vaccine Therapy in Accessory Sinus Infection.
J. Leslie Davis, Philadelphia.
Outline. _ A review of the author's own experience in the
use of vaccines during the past six years for infections in the
nasal accessory sinuses, middle ear and mastoid. Comparison
of results from autogenous and stock vaccines in acute and
chronic infections. Results by present method compared with
those used prior to my adoption of vaccine therapy. Conclu.
sicns.
Discussion on above papers opened by Herbert
M. Goddard, Philadelphia; Edward B. Heckel,
Pittsburgh; William A. Hitschler, Philadel-
phia.
No. 5.
The Treatment of Concomitant Squint with Especial
Reference to Training of the Fusion Sense.
H. Maxwell Lancdon, Philadelphia.
Outline. Concomitant squint is most frequently of the
convergent type and is a condition of childhood; the age of
onset being usually before the fifth year. It is most always
found in hyperopes, but not of necessity in those where the
error is hi^h. Quite often there is a great difference between
the refraction of the two ey^s, and in such cases the eye with
the higher error is usually the deviating eye. The vision of an
eye which has deviated for some time is always sub-normal,
and the sense of fusion in such cases is always poor. Treat-
ment consists of glasses, training the amblyopic eye, training
the fusion sense, and if deviation still persists, operation.
Discussion opened by William W. Blair, Pitts-
burgh.
No. 6.
Gold Ball Implantation in the Scleral Cavity by the
Dimitry Method.
Frank C. Parker, Norristown.
Outline. Indications for the operation. Types of cases
suitable for the operation. The operation: form of incision,
suction for removal of blood from scleral cavity, removal of
button of sclera embracing nerve head, suturing, dressing.
The reaction, degree and length of time. Results.
Discussion opened by Burton Chance, Philadel-
phia.
Wednesday, October 5, a P. M.
Report of Executive Committee.
Election of Section Officers.
No. 7.
The Endocrine System; Some Relations to Oph-
thalmology and Oto-Rhinology.
P. H. Fridenberg, New York, N. Y. (by invita-
tion).
No. 8.
Experimental and Clinical Evidence of the Relations
of the Eye and the Endocrine Organs.
William Zentmayeb, Philadelphia.
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SCIENTIFIC PROGRAM
859
OuTLiNS. Experimental evidence. Removal of the thyroids
may produce keratitis, cataract, partial blindness without oph-
thalmoscopic changes, etc. Removal of para-thyroids may pro-
duce cataract. Suprarenal injections of epinephrtn cause dila-
tion of pupil and slight ptosis. Ocular phenomena in the
pituitary b<Mly are probably the result of direct pressure, in-
creased intracranial tension and disturbed secretion.
Clinical Evidence. Thyroid gland; exophthalmos, lid symp-
toms, dissociation of the extrinsic muscles, retrobular neuritis,
are evidences of hypersecretion. Myxedema cretinism and
Mongolian idiocy, evidence athyroidism. Thymus gland: ex-
ophthalmos evidence of persistent thymus.
Suggestive Etiology. Hereditary optic nerve atrophy, optic
atrophy, pigmentary de^neration of the retina, amaurotic fam-
ily idiocy, recurrent retinal hemorrhages of adolescence.
No. 9-
The Role of the Thyroid in Oto-Laryngology ; Ex-
perimental and Clinical Studies.
Henry A. Schatz, Philadelphia.
OuTUHC. lUsuroi of ear, nose and throat manifestations
hitherto reported in the various hypothyroid states; cretinism,
myxedema, hypothyroidia, myxedematous infantilism. Effects of
experimental thyroidectomy on the nose, throat and ear in the
mammal. Clinical studies.
Discussion opened by Robert Scot^ Lamb, Wash-
ington, D. C. (by invitation) ; George M.
CoATES, Philadelphia.
No. 10.
Sympathetic Ophthalmia ; Report of an Unusual Case.
Nelson S. Weinberger, Say re.
Outline. Sympathetic ophthalmia developing three weeks
after enucleation. Review of literature. Results obtained with
Gifford treatment with this and other cases.
Discussion opened by George H. Cross, Chester.
No. II.
Otitic Phlebitis, Without Thrombosis.
B. Alexander Randall, Philadelphia.
OtJTLiNE. Otitis with the steepled chart of septicemia and
perhaps chills, suggests involvement of the jugular and lateral
sinus, as the most vulnerable adjacent serous membrane. If in
a chronic case, septic thrombosis of the knee is most probable,
with need to clean out the sinus and tie if not exsect the jugu-
lar. Acute otitis may oftener pass the inflammation to the
jugular bulb, some of these forming a clot, which however ex-
tensive, ma^ not fully occlude nor break down into septic
emboli. Otitic phlebitis ma:ir tend therefore to resolution and
call for expectant, conservative treatment.
Discussion opened by Ben C. GilE, Philadelphia.
Thursday, October 6, 9 A. M.
No. 12.
Vitreous Loss; Its Effect on the End Result of Cat-
aract Extraction ; Its Prevention.
L. Webster Fox, Philadelphia.
OliTLiNl. Brief resume of embryology and histology of
vitreous, function of the structure, pathology of the vitreous,
factors inducing expulsion of the vitreous, complications possi-
ble after expulsion, method of restoration, and results of loss
of the vitreous humor.
Discussion opened by Prop. J. Van der HoevE,
Leyden (by invitation), and William Campbell
Posey, Philadelphia.
No. 13.
Bronchoscopic Observations on Cough.
Chevalier Jackson, Philadelphia.
Outline. Review of the accepted bechic physiological mech-
anism. Bronchoscopic observations on the cough reflex in
normal individuals. Bronchoscopic observations on the cough
reflex in diseased conditions. Bronchoscopic observations in
cases of foreign body in the lung. Cough in cases of disease
and also of foreign body in the esophagus.
Discussion opened by J. Homer McCready, Pitts-
burgh.
No. 14.
Pulmonary Abscess from Lodgment of a Tooth;
Peroral Bronchoscopic Cure. (Illustrated by
Lantern Slides.)
Ellen J. Patterson, Pittsburgh.
Outline. Tendency to aspirate tooth during extraction
under anesthesia. Importance of having immediate radiograph
in all cases of doubt. Necessity of early bronchoscopic re-
moval, to prevent lung abscess.
Discussion opened by Chevalier Jackson, Phila-
delphia.
No. 15.
External ' Ophthalmoplegia Associated with Extensive
Neuro-Retinitis ; A Case Study.
G. Oram Ring, Philadelphia.
Outline. The report concerns itself with a consideration of
the association of two important ophthalmic findings; the one,
unilateral external ophthalmoplegia having proved to be fuga-
cious, the other, a high optic nerve and retinal swelling upon
the side of the ophthalmoplegia, with a similar but less marked
intro-ocular condition upon the opposite side.
Discussion opened by Peter N. K. Schwenk,
Philadelphia.
No. 16.
The Present Status of the Radical Mastoid Operation.
S. Mac CtJEN Smith, Philadelphia.
Outline. A well recognized procedure in selected cases.
Unless complications become manifest suddenly, all non-sur-
gical measures must be tried first. Our only means of pre-
venting certain intracranial complications. A necessary pre-
liminary operation for the relief of an existent otitic brain ab-
scess or chronic otorrhea. Our sole means of correcting certain
dangerous types of chronic otorrhea. Value of skin grafting in
rapid healing. Importance of x-ray examination to locate sinus.
Discussion opened by George W. Mackenzie,
Philadelphia.
SECTION ON PEDIATRICS
RED room
Officers of Section
Chairman — Henry J. Cartin, 100 Main St., Johns-
town.
Secretary — Henry T. PJhcE, Westinghouse Bldg.,
Pittsburgh.
Executive Committee — Percival J. Eaton, Pittsburgh ;
Charles H. Miner, Wilkes-Barre ; William N.
Bradley, Philadelphia.
Stenographer — Miss Ma»y G. Lvnch, io8 West End Trust
Bldg., Philadelphia.
(Note. — Essayists will please deposit original copies
of their papers with the Secretary of the Section when
they have finished reading them. The printer will not
accept carbon copies.)
Tuesday, October 4, a P. M.
No. I.
Address by the Chairman.
Henry J. Cartin, Johnstown.
No. 2.
Post-Diphtheritic Paralysis.
Theodore J. Elterich, Pittsburgh.
Outline. Frequency of occurrence; clinical symptoms;
diagnosis, prognosis and treatment. Report of an apparently
fatal case. Recovery following large doses of strychnine.
Discussion opened by J. P. Crozer Griffith,
Philadelphia.
No. 3.
Malnutrition as a Pre-Tuberculous State in Children.
John D. Donnelly, Philadelphia.
Outline. Dangers of contact with tuberculosis patienta
I^owered resistance due to fatigue and overactivity as a de<
termining factor in the development of tuberculosis in children.
Resistance is increased by building up the general health of the
child after all physical defects have been corrected.
Discussion opened by Thomas Klein, Philadel-
phia.
No. 4.
Nutrition Classes for Children.
Sarah D. Wyckoff, Wilkes-Barre.
Outline. Experience with nutrition classes in the State
Clinic at Wilkes-Barre. Discussion of plans of bringtns[ under-
nourished children of school age up to the normal weight for
the height.
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THE PENNSYLVANIA MEDICAL JOURNAL
August, 1921
Discussion opened by Charms H. Miner, Wilkes-
Barre.
No. 5.
The Right of the Child to Healtli.
Edwin A. Glenn, Berwick.
O'.'ruNE.
Discussion opened by Samuei< McC. Kamill,
Philadelphia.
No. 6.
Splenic Anaemia in Children.
Ralph Engle, Philadelphia.
Outline. Dehnition and stages of the disease. Jncidence,
«tiology, pathological findings. Clinical history ana course.
Blood findings. Differential diagnosis. Treatment. Keport cf
case.
Discussion opened by Edwin E. Graham, Phila-
delphia.
No. 7.
Basal Metabolism Studies in Constitutionally Inferior
Children. Harry O. Pollock, Pittsburgh.
OcTLiKi. The general consideration of basal metabolism
stunies in certain typfs of disorders. Prevalence of endocrine
disturbances in the ccnstitutionally inferior. Difficulties in
diagnosis, especially as to hypo and hjrper function. Value of
basal metabolism studies in classifications and as a guide to
therapy. Illustrative ca^es.
Discussion opened by E. Boswoith McCrcady,
Pittsburgh.
Wednesday. October 5, a P. M.
Report of Executive Committee.
Election of Section OflScejS.
No. 8.
Some early Problems in Infant Feeding
Thomas E. Mendenhall, Johnstown.
OliTLIHK. It is important to early secure the cooperation of
the mother, in many cases a good nurse is indispensable.
There is a great difference in baoies, some are good nursers
and some bad ones. Baby should be kept out of the mother's
hearing when not nursing. Regular short nursing periods dur-
ing first few days is important. Practically all mother's milk
is good during first few days. Occasionally an exception in a
primipara. It is important to weigh the baby before and after
nursing and supplement its feeding accordingly. The food of
the mother is an important factor.
Discussion opened by William N. Bradley, Phila-
delphia.
No. p.
Importance of Nursing Slowly.
Maurice Ostheimer, Philadelphia.
Outline. A large number of infants have been weaned
when all that was needed was to have them nurse slowly.
Bottle-fed infants are not taught to nurse slowly.
Discussion opened by Percival J. Eaton, Pitts-
burgh.
No. 10.
The Difficulties and Practicability of Infant Feeding
in a Country Practice.
Fred P. Simpson, Mapleton Depot.
OuTLiNK. Chief difficulties encountered. Advantages and
disadvantages of Infant Feeding in Country Practice. Phy-
sician as a teacher. Importance of detailed instruction. The
method of artificial feeding which has given the best results.
Discussion opened by Herbert A. Bostock, Nor-
ristown.
No. II.
Frequency of Indigestion of Fats During First Two
Years of Life. . .Causes and Treatment.
John D. Stevenson, Beaver.
Outline. A discussion of th* etiologic factors concerned in
the production fat indigestion. Predominating symptoms and
types of fat stools. Differential diagnosis and importance of
chemical examination of stools. Treatment.
Discussion opened by Theodore LeBoottilliER,
Philadelphia.
No. 12.
Vomiting as a Symptom in Childhood.
Charles Gilmore Kerlev, New York City.
. OuTLiMB. The life of the child divided into three periods:
infancy, runabouts, and the older children.
Discussion opened by Perciyal J. Eaton, Pitts-
burgh.
-Vo. 13.
An Analysis of the Causes of Fever in Early Life
With a View to Diagnosis.
John C. Gittincs, Philadelphia.
OuTLiN*. An analysis of $00 febrile cases showing the pto-
r'>rtion of co: jnon and rare causes of fever and the compan-
tively hi?h percentage of cases of fever of undetermined origin,
Discussion af diagnostic aides.
Discussioi: opened by Howard Childs Carpenter,
Philadelphia.
Ao. 14,
Xeroderma Pigmeniosum.
WiULAM H. Guy, Pittsburgh.
Outline. A malignant disease usually developing in early
hildhood characterized by the appearance of irregular pigroen
tation, atrophic spots, telangiecUses, hjrperkeratoses and &>ally
childhood characterized by the appearance of irregular pigroen
tation, atrophic spots, telangiecUses, hyperkeratoses and &>ally
er>itheliomata on the txposed parts of the body, and usually
ending fatally. 'Symptoms — early and late, etiology, pathology.
Keport of a patient developing Xeroderma Pigmentosun: in
early life who attained adult years probably the result of hit
own ingenuity.
Frank C. Knowles. Philadelphia.
Thursday, October 6, 9 A. M.
No. IS.
Report of a Case of Suppurating Paciaitis with Exten-
sive Inter and Intra Muscular Calcification.
(Lantern Slide Demonstration.)
^ Harry Lowenburc, Philadelphia
Outline. Report of case. Relation to myositis ossificao>.
etiology, prognosis, treatment.
Discussion opened by W. Wayne Babcock, Phila-
delphia.
No. 16.
Spasmophilia. John Mark Higgins, Sajne.
Outline. Discussion of history of disease. Frequently un-
recognized. Etiology—Possible relation to rachitis. Symptams
— Tetany — reflexes — electrical reactions. Diagnosis — Differ
ential. Treatment — Including prevention.
Discussion opened by A. Gr.\eme MitchEU.
Philadelphia.
No. 17.
Enuresis — Its Causes and Treatment.
Francis B. Jacobs, West Chester.
Outline. Importance of intelligent diagnosis of abnormal
physical conditions. Large number of cases showing no ab-
normal physical defects and in which there is no apparent
cause. Results obtained by treatment with pituitrin in a aerie.'
of 100 cases in private and hospital practice. Compariaon 01
this with former methods of treatment
Discussion opened by Henry Pleasant, West
Chester.
No. 18.
Discussion of Some of the Recent Tendencies in In-
fant Feeding. John Lovett Morse, Boston.
Outline.
Discussion opened by Alfred Hand, Philadelphia.
No. 19.
Cerebral Abscess Following Old Meningeal Hemor-
rhage. Henry C. Flood, Pittsburgh.
Outline. Acute supniirative encelphalitis. (Brain absceta.)
Etiology. Symptoms. Differential diagnosis. Case report.
Discussion opened by Henry T. Price, Pittsburgh.
No. 20.
A Study of Heart Cases in the Pediatric Dispensary
at Jefferson Hospital.
Ralph M. Tyson, Philadelphia.
Outline. Importance of careful search of family and per.
sonal history; differential diagnosis of congenital and acquired
conditions; importance of careful direction of treatment.
Discussion opened by Edwin E. Graham, Phila-
delphia.
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August, 1921
SCIENTIFIC PROGRAM
861
PHILADELPHIA HOTELS AND GARAGES
AVAILABLE FOR THE ANNUAL
SESSION
THE ALDINE, Chestnut and Nineteenth Streets.
Single room, $2.50 and $3.00; with bath, $4.50
and $S.oa Double room, $3.50 and $4.00; with
bath, $6.00 and $7.00. Hotel contains 350 rooms;
25 to 30 rooms available.-
THE ADHLPHIA, Chestnut and Thirteenth Streets.
Sir.g.L room with bath, $5.00, |6.oo and $7.00.
Double room with bath, 2 beds, $9.00 and $10.00.
Hotel contains 365 rooms; 25 single and 100
double rooms available.
THE BELLEVUE-STRATFORD, Broad and WW-
nuf Streets. Outside rooms with bath— single,
$7.00 and $8.00; double, $9.00 and $10.00. Inside
rooms with bath — single, $4.00 and $5.00; double,
$7.oa Parlor, bedroom and bath, $20.00, $23.00
and $25.00. Hotel contains 734 rooms.
THE COLONNADE, Chestnut at Fifteenth Street.
Single room, $2.00 and up; with bath, $3.50.
Double room, $4.00 ; with bath, $6.00. Hotel con-
tains 150 rooms.
THE CONTINENTAL. Ninth and Chestnut Streets.
Single room, $2.00, $2.50 and $3.00; with baiii,
$3.00, $3.^0 and $4.00. Double room, $4.00 and
$4.50; with bath, $5.50, $6.00 and $7.oa Hotel
contains 400 rooms.
GREEN'S HOTEL, Eighth and Chestnut Streets.
Front rooms with bath — single, $3.50 and $5.00;
double, $S.oa Front rooms without bath — single,
$2.50; double, $3.50 and $4.00. Inside rooms with
bath—single, $3.50; double, $3.50 and $4.00. In-
side rooms without bath — single, $2.00 and $2.50;
double, $5.00 Hotel contains 320 rooms.
lilE LORRAINE, Broad and Fairmount Ave. Sin-
gle rnom, $2.50; with bath, $3.00 and $4.00.
Douh:* room, $4.00; with bath, $5.00 and $6.00.
Hotel contains 270 rooms.
THE LONGACRE, Walnut Street, west of Broad.
Single room with bath, $4.50 and up. Double
ri>om with bath, $6.00 and up. Parlor, bedroom
and bath (two persons), $7.00 and up. Hotel con-
tains 185 rooms; room for 100 persons with two
in a room.
THE MAJESTIC, Broad Street at Girard Avenue.
Single room, $2.50 and up; with bath, $4.00 and
up. Double room with bath, $5.00 and up; with
twin beds, $6.00 and up. Hotel contains 600 rooms.
THE NEW HANOVER. Twelfth and Arch Streets.
Single room, $2.50 and up; with bath, $4.00 and
up. Double room with bath, $5.00 and up; with
twin beds, $6.00 and up. Hotel contains 200 rooms ;
room available for 50 or 60 persons.
THE RITTENHOUSE, Chestnut and 22d Streets.
Single room, $2.50 and $3.00; with bath, $4.00.
Double room, $3.50 and $4.00; with bath, $6.00.
Hotel contains 200 rooms.
RITZ -CARLTON, Broad and Walnut Streets. Double
room, outside, with bath and twin beds, $10.00.
Hotel contains 200 rooms; 20 double rooms avail-
able.
THE ST. JAMES; Walnut Street and Thirteenth.
Single room with bath, $4.00 to $7.00. Double
room with bath, $7.00 and $8.00. Hotel contains
200 rooms; 100 rooms available.
THE VENDIG, Thirteenth and Filbert Streets.
Rooms with bath — single, $5.00; double, $7.00.
Hotel contains 216 rooms ; 50 rooms available.
THE WALTON, Broad and Locust Streets. Rooms
with bath — single, $5.00; double, $7.00. Hotel
contains 350 rooms ; 50 rooms available.
THE BELGRAVIA, Eighteenth and Chestnut Streets.
Rooms with bath— European plan — single, $s'.oo;
double, $7.00. American plan — single, $8.00; dou-
ble, $14.00. Hotel contains 200 rooms.
GREEN HILL FARMS, City Lane and Lancaster
Road. (Suburban garage attached.) Outside
rooms, private bath, twin beds, $5.00, $6.00, $7.00
and $8.00. 150 rooms available.
GARAGES LOCATED IN CENTRAL PART
OF CITY
ADELPHIA GARAGE, 134 N. Juniper St. Capacity
150 cars. Can accommodate 15 cars.
AMERICAN GARAGE, 1411 I.acust Street. Capacity
150 cars. Can accommodate 10 tc 15 cars.
BELLEVUE-STRATFORD GARAGE, 1407 Locust
Street. Capacity 200 cars. Can accommodate 50
cars.
CAMAC STREET GARAGE, 2SS S. Thirteenth St.
Capacity 250 cars. Can accommodate 75 cars.
CENTRAL AUTO GARAGE, 314 S. Camac Street.
Capacity 75 cars. Can accommodate 7 to 10 cars.
PENNSYLVANIA GARAGE, 329 S. Broad Street
Capacity 500 carsf. Can accommodate 100 cars.
NEW HANOVER GARAGE, 1125 Cherry Street.
Caf^acity 70 cars. Can accommodate 25 cars.
NEW AND NONOFFICIAL REMEDIES
GuAiACOL Benzoate. — Benzosol. — The benzoic acid
ester of guaiacol Guaiacol benzoate is slowly decom-
posed in the intestinal tract into benzoic acid and
guaiacol, which exert their usual action. It is said to
be useful in the incipient pulmonary tuberculosis, as
an intestinal antiseptic and a urinary antiseptic.
Guaiacol Benzoate-Seydei-. — A brand of guaiacol
benzoate N. N. R. Seydel Manufacturing Co., Jersey
City, N. J. (Jour. A. M. A., June 4, 1921, p. 1575)-
Salicenin-Abbott. — A brand of saligenin N. N. R.
For a discussion of the actions, uses and dosage of
saligenin, see New and Nonofficial Remedies, 1921. p.
35. Abbott Laboratories, Chicago.
Santyi Capsules 7 Drops. — Each capsule contains
7 drops of Santyl. See New and Nonofficial Reme-
dies, 1921, p. 270. E. Bilhuber, Inc., New York.
Silver Salvarsan. — A brand of silver arsphenamine
N. N. R. For a description of the actions, uses and
dosage of silver arsphenamine, see Jour. A. M. A.,
May 7, 1921, p. 1312. Silver Salvarsan is marketed in
ampules containing respectively 0.05 Gm., o.I Gm., 0.15
Gm., 0.2 Gm., 0.25 Gm., 0.3 Gm. silver salvarsan. H.
A. Metz Laboratories, New York {Jour. A. M. A.,
June 11, 1921, p. 1654).
PiTUCLANDOL-RocHE. — An aqueous solution contain-
ing the active constituents of the posterior lobe of the
pituitary gland of cattle, free from preservatives. It is
physiologically standardized on the isolated uterus of
the virgin guinea pig so that i Cc. responds in activity
to 0.003 Gm. betaiminazolylethylamine hydrochloride.
For a discussion of the actions and uses see General
Article, Pituitary Gland, New and Nonofficial Reme-
dies, 1921, p. 219. Pituglandol-Roche is marketed in
ampules, each containing i.i Cc. Hoffmann LaRoche
Chemical Works, New York.
Pollen Antigens-LederlE. — Liquids obtained by ex-
tracting the dried pollen of plants with a liquid con-
sisting of 67 per cent, gly serin and 33 per cent: sat-
urated solution of sodium chloride. For the actions
and uses of pollen extract preparations, see New and
Nonofficial Remedies, 1921, p. 239. Pollen antigens-
Lederle are supplied in 15 pollen unit strengths. They
are marketed as follows: Series A, containing five
vials containing, respectively, 1.5, 3, 6, 12 and 15 pollen
units. Series B, five vials containing 18, 30, 45, 60 and
90 pollen units. Series C, five vials containing, re-
spectively, 150, 225, 300, 450 and 600 pollen units.
Complete Series, containing the fifteen doses of Se-
ries A, B and C. Diagnostic Test, containing 0.01 Cc.
of a dilution representing 60 pollen units.
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862
THE PENNSYLVANIA MEDICAL JOURNAL
August, 1921
PROPAGANDA FOR REFORM
"National Iodine Souhtion" Not Admitted to N.
N. R. — The Council on Pharmacy and Chemistry con-
sidered National Iodine Solution, a proprietary of the
National Drug Co., because inquiries indicated that it
was brought extensively to the attention of physicians.
The name implies that it is a solution of iodin, and
the inference is given that it has the advantages of
iodin without the disadvantages. According to the
label, "each fluid ounce represents three grains Proteo-
albuminoid compotmd of iodin (National)"; also an
alcohol declaration of 7 per cent is made. Otherwise
no information is given as to the composition either of
the "solution" or of "Proteo-albuminoid compound of
Iodine." Analysis in the A. M. A. Chemical Labora-
tory indicated that each 100 Cc. contains about 7 Cc.
of alcohol, 0.5 Gm. of zinc sulphate U. S. P., 0.03 Gm.
iodin (the solution gave tests which indicated a very
small amount of free iodin; most of the iodin was in
the form of ordinary iodid), o.o'i Gm. protein and
some hamamelis water. While the preparation is
claimed to contain 3 grains of "proteo-albuminoid corn-
pound of iodine," yet the sum of the protein and iodin
is equivalent to less than one-fifth grain. The Council
reports that it is evident that "National Iodine Solu-
tion" is not a solution of free (elementary) iodin as
the name suggests; instead, it appears to be a solu-
tion of zinc sulphate in witch hazel water containing
less than 0.03 per cent of combined iodin and not more
than a trace of free iodin; that it is sold under un-
warranted therapeutic claims, and that a similar or
identical preparation sold to the public for the self-
treatment of gonorrhea by the National Drug Co. as
Gonocol has been declared misbranded by the Federal
authorities (Jour. A. M. A., June 4, 1921, p. 1592).
Proteogens in Syphilis.— C. F. Engels, Tacoma,
Wash., reports that two persons came to him who had
been treated with Proteogen No. 10 for almost a year.
Both patients were four plus to the Wassermann test.
He writes: "The tragedy of the whole thing is that
here are two people, at least, who have been deprived
of adequate treatment for a year, spending their
money for ignorance and fakery, getting worse instead-
of better, and all because of the cupidity of these peo-
ple (the promoters of the Proteogens) and their suc-
cess of putting over on some of the weak sisters of
the profession this pseudi-scientific bunk." The Pro-
teogens have been the subject of an extensive report
by the Council on Pharmacy and Chemistry, which de-
clared the twelve Proteogens inadmissible to New and
Nonoflficial Remedies because their composition is se-
cret; because the therapeutic claims made for them
are unwarranted, and because the secrecy and com-
plexity of their composition makes their use irra-
tional {Jour. A. M. A., June 4, 1921, p. 1593).
Reolo. — This is a "patent medicine" which is based
on the theory, which has no scientific foundation, that
ail disease is due to a deficiency or variation in the
inorganic constituents— the "cell salts" — of the cells
and blood. Reolo is claimed to furnish the needed
cell salts and thus to cure diseases due to the de-
ficiency. The asserted discovery of Reolo is described
thus: "Dr. A. L. Reusing has finally succeeded in
combining by electrical treatment the phosphates of
calcium, sodium and iron with the phosphates of potas-
sium and magnesium and has obtained a perfect com-
bination of these revitalizing Cell Salts that he has
named 'Reolo' " The A. M. A. Chemical Labora-
tory reports that Reolo consists of grayish brown tab-
lets having a sweet, chocolate-like and faintly bitter
taste. Very small quantities of a phosphate and traces
•of Magnesium and of an iron compound were present.
Large amounts of calcium carbonate (chalk) and
sucrose (cane sugar) were present. The tablets did
■not appear to be medicated in the usually accepted
sense. From this examination it would appear that
Reolo is essentially a mixture of sugar and chalk
Uour. A. M. A., June 11, 1921, p. 1697).
Disappointments in Endocrinology. — In the cur-
rent enthusiasm for so-called endocrinology, medidne
may become humiliated by the drift toward a sort of
pseudo-science bolstered up with meaningless words
and unfounded assumptions. _ Stewart deserves the
thanks of the medical profession for the fearless and
critical manner in which he has questioned (Endo-
crinology, vol. S, p. 283 (May), 1921) much of the
verbal rubbish that goes under the designation of the
endocrinology of the suprarenals. There is something
stinging, yet deserved, in its implied rebukes, in the
words of Dr. Stewart: "On the whole," he says, "It
must be granted that hitherto the attempts made to
evoke in animals a well marked syndrome character-
istic of adrenal deficiency have been singularly disap-
pointing. The contrast is great when we leave this
desert, where the physiologists and experimental
pathologists have wandered, striking many rocks but
finding few springs, and pass into the exuberant land
of clinical endocrinology, flowing with blandest milk
and honey, almost suspiciously sweet." How much
longer will the medical profession continue to merit
such criticism? Just so long as the profession con-
tinues to give serious consideration to pseudo-scientific
rubbish promulgated by the exploiters of organic ex-
tracts {Jour. A. M. A., June 11, 1921, p. 1685).
Mon-Arsone Not Admitted to N. N. R. — The Coun- ■
cil on Pharmacy and Chemistry reports that Mon-
Arsone was put out by the Harmer Laboratories Co.,
as "A new and nontoxic arsenical for the treatment of
syphilis" and that it was claimed that the drug had a
therapeutic value equal to arsphenamine but was de-
void of toxic action. Chemically, Mon-Arsone is re-
lated to sodium cacodylate, which latter^ has been
proved inefficient in the treatment of syphilis. After
examining the available evidence, the (Council voted
not to admit Mon-Arsone to New and NonofiBcial
Remedies and held that the claim that Mon-Arsone
has a therapeutic value equal to that of arsphenamine
was unwarranted; that Mon-Arsone should not be
used except under conditions that justify the experi-
mental trial of an unproved drug, and that the adver-
tising propaganda for the drug by the Harmer Labora-
tories Co. was to be deprecated. When the Council
sent its report to the Harmer Laboratories Co., prior
to publication, the firm announced that the claim that
Mon-Arsone is therapeutically equal to arsphenamine
had been abandoned. In publishing its _ report, the
Council endorsed the recent warning against the use
of imtried medicaments issued by the U. S. Public
Health Service. It also calls attention to a report on
the effect of Mon-Arsone on experimental syphilis re-
cently published by H. J. Nichols, which showed that
the drug, when tested on rabbits infected with experi-
mental syphilis, showed no spirocheticidal power
{Jour. A. M. A., June 18, 1921, p. 1781).
BOOK REVIEW
EMBRYOLOGY; A LABORATORY MANUAL
and TEXTBOOK OF EMBRYOLOGY, by Charles
W. Prentiss. Late Professor of Microscopic Anato-
my, Northwestern University Medical School, Chi-
cago. Revised and Rewritten by Leslie B. Arey,
Professor of Microscopic Anatomy, Northwestern
University Medical School. Third edition, enlarged.
Octavo volume of 412 pages with 388 illustrations,
many in color. Philadelphia and London: W. B.
Saunders Company, 1920.
The rapid exhaustion of the second edition of this
work has hastened the third edition. The contents
hav-e been subjected to a systematic revision. There
has been an addition of much new material, and the
recasting and modifying of former descriptions. This
work is worthy of consideration by all medical schools.
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The Pennsylvania Medical Journal
Owned, Controlled and Published by the Medical Society of the State of Pennsylvania
Issued monthly under the supervision of the Publication Comoaittee
VOLVMB XXIV
Number 12
212 North Third St., Harrisburg, Pa., September, 1921
SuiscitiPTiuii :
^3.00 Per Year
ORIGINAL ARTICLES
OBSERVATIONS ON THE TREATMENT
OF TABES*
(based on 140 cases)
GEORGE J. WRIGHT, M.D.
PITTSBURGH
Three years ago, while going through the
wards of the Philadelphia Hospital, I came
across Dr. Mills examining a large group of pa-
tients assembled in a room. Dr. Mills, Emeritus
Professor, Dean of Neurologists, \itas making
an especial study of tabes dorsalis. Tabes is
perhaps the most frequent disease of the spinal
cord and in its usual form probably the most gen-
erally recognized by the general practitioner, but
yet to the neurologist it has continued to be in-
teresting for almost three-quarters of a century.
Masterly studies have been made by Romberg,
Duchenne, Erb, Moebius, Strumpel, Nageotte,
Frenkel. The years have solved the problem of
etiology, completed our knowledge of symptom-
atology and diagnosis, and added much to our
understanding of the pathology and pathologic
physiok^y. A perfect flood of clinical reports
has emphasized the peculiar variations in the
clinical course of this disease and, even before
the advent of salvarsan, the records had partially
disproved the dictum of Romberg: "For none
of these patients is there hope of recovery. All
are condemned to death." A dis^ise so common
as tabes, which usually strikes an individual in
the prime of life and tends to a gradually in-
creasing disability, has naturally called forth the
utmost therapeutic endeavors of neurologists.
With the appearance of salvarsan and its special
methods of administration renewed interest in
the treatment of tabes has occurred. Fulsome
reports have appeared ; the general impression
is probably very favorable, due largely to the
extravagant claims for intraspinous therapy, but
in my opinion the new cliapters on the prognosis
and treatment of tabes dorsalis are still being'
written.
•Read before the Seclion on Medicine of the Medical Society
of the State of Pennsylvania, PitisburKh Session, October 7,
1920.
My experience with tabes was obtained chiefly
at the New York Neurological Institute, where
I served as chief of clinic during the years 19 17-
1920, in which time more than 140 cases of tabes
were seen and kept under observation and treat-
ment ^or variable periods. All of these cases
were inbulant, most of them were diagnosed for
the first time at the clinic, the majority belonged
to the so-called first stage, and only two or three
to the paralytic stage. It may be safely said no
two cases of tabes are exactly alike and yet the
picture of the usual or average case seen in the
clinic was singularly constant and easily diag-
nosed. But I wish also to emphasize how few
symptoms some cases of tabes showed, how un-
like the usual type tabes may be, and therefore
how easily overlooked. Chronic progressive dis-
eases of the nervous system are insidious in de-
velopment, and yet somehow our conception of
various diseases (as, for example, multiple scle-
rosis, tabes and combined degenerations) are
based on the developed picture. Rational diag-
nosis in neurology cannot rest on matching pic-
tures or comparing experiences. We must be
jirepared to interpret single symptoms, correlate
them with others, and base them on the probable
pathologic process. A. R. pupils, a band of
hyperesthesia, unequal ankle jerks is tabes;
sluggish pupils, ulnar hyperesthesia, loss of sex-
ual power is tabes ; beginning visual disturbance,
optic atrophy, nicking pains or areas of hyper-
esthesia is tabes, just as much as the typical case
with A. R. pupils, lancinating pains, absent knee
jerks and ankle jerks, Romberg and bladder
weakness. Every syphilitic is a possible later
case of tabes (some figures have indicated five
in every one hundred) but of those syphilitics
who show an early loss of sexual power or slight
sensory disturbances or transient diplopias, more
than this percentage will become tabetics.
, I feel, therefore, in any consideration of the
therapy of tabes the old, old story of an early
diagnosis must be repeated. To make advances
in the tuberculosis problem this lesson was
driven home hard, and we must do the same in
the neurosyphilis problem. It is not as neces-
sary perhaps to recognize the various types as it
is to know what the hall-marks of neurosyphilis
are.
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864
THE PENNSYLVANIA MEDICAL JOURNAL Septembi-r, 1921
Now the tabetic conies to the clinic because of
sonie subjective conii)laints, such as pain, numb-
ness, unsteadiness in walking, bladder or sexual
weakness, diplopia, visual disturbances. The
complaint may date back for a few months or
even for as long as ten years. The objective ex-
amination may reveal few or many symptoms;
the case may be a recent one with many symp-
toms or an old one with few symptoms. There
may be evidence the disease has existed for
twenty years and been practically stationary,
and on the other hand the clinical history may
show an acute course with a wealth of symptoms
in the course of a few months. This has been
known for years and as illustrating it numerous
types of tabes have been recc^nized : ordinary,
benign, malignant types, slow tabes, rapid tabes,
arre-sted tabes, incomplete tabes, formes frustes,
etc. These names were given in presalvarsan
days, and I think it important to remember this
now. Personally it was the one big lesson I
lejirned from my experience with this group of
cases. The clinical course is then extremely
variable, and the prognosis is an individual one,
quite apart from any consideration of treatment.
Now what relationship has salvarsan to the
tabes problem ? I think perhaps I can best intro-
duce an answer by a brief review of some illus-
trative cases.
A traveling salesman, age 55, never had a ve-
nereal sore but years ago had repeated attacks
of gonorrhea. For two years he had "rheu-
matic" pains in the legs. There were A. R. pu-
pils, absent knee and ankle jerks, bladder and
sexual power O. K. No ataxia. Serology posi-
tive with 60 cells. He had in all thirteen intra-
venous arsenobenzols. Negative serology. No
jKiins. Gained weight. Still well one year later.
A clerk, age 36, had pains in the legs for live
years. No history of lues. Absent knee jerks
and ankle jerks, slight Romberg. vSerology posi-
tive, 56 cells. Under intravenous treatment of
arsenobenzol over a period of two years, ser-
ology finally negative. Gained weight, happy,
still well two years later, although he w;is taking
aspirin occasionally for ])ain.
A banker, age 60, had tabes at least twenty
years. At long intervals he would have shocks
of lightning pains in the legs lasting for three or
four hours, usually relieved by aspirin, occa-
sionally codeine or a hypodermic. A. R. pupils,
absent knee jerks, slight Romberg, but no ataxia.
Had all kinds of treatment, including salvarsan
when it first came out ; various courses since.
All kinds of rest cures, baths, massage. Prac-
tically no improvement, but also no worse.
Serology in July, 1919. entirely positive, over
60 cells.
An arfi.st, age 49, first came to tiie clinic in
1915. For eighteen months he had sluKiting
p.iins in the legs, slight Romberg, and bladder
weakness. Serology positive, 42 cells. Under
repeated intravenous and intraspinous treatment
until 1917, when his serology became negative.
Good condition physically. Rarely a pain. Re-
tired, bought a farm, not .seen again until May,
1919, when he vfas in bad .shape: pain, poor
bladder control, .sexual power gone, ataxia, car-
diac distress due to aortitis. Blood i-f, spinal
fluid negative. Died of cardiac disease one week
later.
These four cases represent reasonably mild
pre-ataxic types. Two responded well to treat-
ment, a third did equally well, had a negative
serology, but in two years the trouble returned
in aggravated form. The fourth showed abso-
lutely no clinical or serological improvement in
spite of every possible care, and after twenty
years is reasonably comfortable, able to play golf
and having a good time as a retired business
man.
A firemnn, age 41, first noticed unsteadiness
in walking nine months before coming to the
clinic. In addition to the usual signs there was
marked ataxia in station and gait. He had to
use a cane. Practically no pains, but sexual
I)oweT gone and bladder weak. Serology posi-
tive. He was put to bed for a month, later given
Frenkel exercises. After fifteen intravenous
salvarsans his bladder was O. K., sexual power
stronger, all pains gone, and he was able to walk
alone. The serology remained positive.
A similar case of a railroad brakeman, age 35.
with even more marked ataxia, so that he could
walk only with assistance, improved under rest,
Frenkel exercises and intravenous salvarsan to
such an extent that his serology was negative
and his ataxia relieved so that he could walk
without a cane. I could not get this man back to
work however because he became perfectly ob-
sessed over the question of his health, and espe-
cially his walking exerci.ses.
A married woman, age 36, infected by her
husband in 191 1 showed her first symptoms in
1 91 7 — numbness in the rectum, then shooting
pains, and finally a distinct degree of ataxia in
gait and station. Her general physical condition
was poor, her weight 84 pounds. Her case ex-
cited a great deal of sympathy, and supreme ef-
forts were made to do her some goo<l. She wa.<
under constant treatment and supervision during
1917-18-19. Intravenous and intraspinous ther-
apy was persisted in imtil May, 1919, when the
serology bec.ime entirely negative. Patient at
that time showed .ibsolutely no clinical improve-
ment. She was still in torment with her pains
Digitized by VjOOQIC
Septembbr, 1921
TREATMRN'T OF TABRS— WRIGHT
865
and liandicai)i)ocI by ataxia and fatiguahilily.
The husband, who had been treated in the begin-
ning by the family doctor, had a negative blood
and was free from all symptoms. The little
daughter, aged 8, had an extremely stubborn
iritis which was not well when last I saw her.
A haberdasher, age 43, came to the clinic as a
well marked ataxia case, with loss of sexual
power, incontinuence of urine, pains all over the
l)ody. It was an advanced case and the outlook
was discouraging. After over four years of intra-
venous and intraspinous salvarsan, Frenkel ex-
ercises and tonic treatment an almost unbeliev-
able improvement occurred. In eighteen months
he threw away his canes, was able to get up from
the floor without help and could feed himself
w'thout accidents. In May, 1917, the serology
was negative, bladder and rectum O. K., pains
practically gone. This represented the high-
water mark of his improvement. Shortly after
he began to go doVn in weight — the ataxia was
returning. In December the blood Wassermann
was again positive. Salvarsan seemed to have
\xo effect whatever. In January, 1919, while still
under treatment he developed an osteomyelitis
of the mandible and two weeks later died in con-
vulsions. This is the best example I have of
optimism and course on the part of the patient,
persistence in treatment on the part of the physi-
cian, with remarkable improvement up to a cer-
tain point, then decline, then fulminating end.
When first seen, the patient was as much of a
wreck as an ataxia, hypotonic, painful, inconti-
nent tabetic could be.
This group of four cases in the so-called ataxic
stage shows that two made very satisfactory im-
provement, one did not, and the fourth, after
almost unbelievable improvement, finally re-
lapsed and died a vascular death. Further three
of these cases illustrate the great value of the
Frenkel exercises.
A cabinetmaker, age 49, had tabes for fifteen
years. He was ataxic, had a complete third nerve
jialsy. He begged for relief from his crises of
pain in chest, abdomen and legs. The serology
was entirely negative. In spite of this we
thought we would try intraspinous treatments,
and after the seventh he was absolutely free
from pain, gained 25 pounds, and returned to
work. Six months later when his son returned
from the army he took a long walk, got caught
in the rain, and his pains returned as before.
. Everything was tried : intravenous, intraspinous
treatments, drainage, rest in bed, electricity,
actual cautery, etc., but with no benefit in a
year's effort. When last heard from he was en-
deavoring to get some relief from various seda-
tive drugs. His serology was still negative.
.\n actress, aged about 45, suffered from gas-
tric crises. She was a pre-ataxic tabetic. After
intraspinous and intravenous treatment she had
relief for two years, when the crises returned.
She again went through two courses of treat-
ment, intravenous and intraspinous, but this time
without benefit.
These two cases represent types of so-called
tabetic crises. Both were apparently relieved,
but the trouble returned. It is perhaps well to
remember that, even before salvasan, it was
known that the intervals between attacks were
very variable, sometimes weeks, months, or
years would elapse.
An army officer, age 32, first noticed some
trouble in his vision in the spring of 1919 while
in France. He was discharged and went to New
York. He was a pre-ataxic tabetic. Serology
positive. Vision in R. eye 20/40, L. eye 20/200.
His loss of vision had been quite rapid. Under
intravenous salvarsan the serology became al-
most negative, the loss of vision became ar-
rested and, when last heard from a year later,
h.id remained so.
An Italian went to the Vanderbilt Clinic in
December, 19 17, and was treated as an early
tabetic. In October, 1918, he began to show
visual changes with optic atrophy while still
under treatment. He had numerous intra.spinous
and intravenous treatments, together with mer-
cury, but in spite of all, his atrophy progressed
and when I saw him in May, 1919, serology was
negative. With the right eye he could count
fingers at four feet, and with the left at fifteen
feet. Patient did not return for treatment.
A taxicab driver consulted an occulist in 1904
for visual trouble and diplopia. He was found
to have beginning optic atrophy and early tabes.
He was put on the old treatment, which he con-
tinued for six months and was not heard from
again until July, 191 7, thirteen years later. His
vision, examined by the same occulist, was prac-
tically the same, but he was ataxic and had a
marked diplopia. The serology of blood and
spinal fluid was strongly positive.
The above three cases of tabes with optic
atrophy show that one case improved or became
arrested under intravenous therapy, that another
developed and steadily progressed while the pa-
tient was actually under intensive treatment for
an ordinary early case of tabes, and that the third
case which showed a beginning optic atrophy
thirteen years before had become arrested under
old-fashioned treatment, and with the later de-
velopment of his tabes had not progressed at all.
In a paper of this length there is not time to
detail further cases but in the same way I could
illustrate a similar experience with cases present-
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THE PENNSYLVANIA MEDICAL JOURNAL September. 1921
ing particular problems. For example, in some
cases of loss of sexual power the results were
good and in others not ; in some cases with blad-
der disturbance the improvement was striking,
in others not.
Now the purpose of this paper is not by any
means to leave a discouraging impression. I
could, if I had wished, emphasize the good re-
sults, but by so doing I would not be expressing
my real attitude toward the problem of the prog-
nosis and therapy of tabetic neurosyphilis. En-
thusiasm and optimism I felt in my first six
months or year of contact with this group of pa-
tients, but as time went on and old patients re-
turned, and a failure here and there and else-
where occurred, the problem seemed entirely dif-
ferent. And, most important of all, I was im-
pressed with the Vciriations in the clinical course
of the different cases, as revealed by the history
of onset and development prior to all treatment.
The problem of tabes for me became then an in-
dividual one and the prognosis could not at once
be determined. In the best cases there might be
disappointments, and in the worst cases sur-
prises. It did not seem advisable to be too sure.
And as far as actual therapy was concerned the
only weapon was not salvarsan ; securing a nega-
tive serology, much as this is desired, did not
necessarily bring clinical improvement. The pa-
tient's entire mode of life had to be regulated, not
in a general casual way, but with meticulous at-
tention to detail. This included his occupation,
the danger of over-exertion and fatigue, exposure
to cold and wet. The factors controlling weight
and general nutrition, such as diet and the condi-
tion of the gastrointestinal tract, requireid regu-
lation. Hydrotherapy was of value, but had to
be at a mild temperature and not prolonged. For
the ataxic cases the Frenkel exercises were of
immense value if the patient would only persist
in their use. At certain times nothing was more
helpful than rest in bed for from four to six
weeks, especially in cases where the ataxia was
relatively acute in onset. I am sure in recent
years, our results in tabes dorsalis are better than
formerly, but even so I feel that after an expe-
rience with a reasonably large group of cases
there are grounds neither for optimism nor pes-
simism, but for hopefulness in the individual
case.
5004 Jenkins Arcade.
DISCUSSION
Dr. Cornelius C. Wholev (PiUsburgh) : I am sure
we feel thankful to Dr. Wright for reviving our inter-
est in tabes and for the excellent manner in which he
has done it. I feel as he does with regard to the
tabetic, you can never tell what a tabetic will do re-
gardless of how bad he looks. I recall one individual
who was placed in a state institution. He got away
from that institution and entered a hospital. He was
the most tabetic individual I have ever seen. He had
incontinence of the bladder and a great many incom-
moding features. Under intravenous and intra-
spinous treatment this man improved to such an ex-
tent that he was able to work in the iron mills and he
has now been self-supporting for five years, whereas,
formerly he was a complete wreck.
I could cite some other striking examples of that
sort, but it is hardly necessary to do so. The lesson 1
have drawn from seeing such cases is not to disregard
the general symptoms or to become disturbed by the
gloomy clinical picture these cases present until they
have been tried out by treatment.
There is one point in connection with the use of
salvarsan that gives rise to a great deal of discussion
when it is mentioned. I refer particularly to the
intraspinous treatment. I do not recall that it was
emphasized particularly in the paper, but it is of diag-
nostic value. In other words, if we get a sharp re-
action and a reproduction of the symptomatology
which has been experienced by the patient, especially
the pains, the gastric crises, or other crises which we
get temporarily as a result of the intraspinous end of
this treatment, that, to my mind, has proved a favor-
able sign. Where there is no reaction, I have found
that these individuals belong to the class of purely
degenerative type of cases, who show no response to
any sort of treatment. These are the cases that have
not responded to treatment and have not gotten better.
So I think, regardless of the value of the intra-
spinous treatment as against the intravenous, this is of
especial diagnostic importance in a great many cases.
In regard to the other treatment, my belief is that
there are certain individuals who respond purely to
the intravenous treatment, while others require the
intraspinous in addition to the intravenous in order to
get results.
Dr. M. Howard Fusseu. (Philadelphia) : I should
like to ask Dr. Wright to make clear to myself and
others one point. There seems to be a feeling among
physicians at large that the intravenous use of sal-
varsan and the Swift-Ellis treatment are two distinct
things. Is it not a fact that in the Swift-Ellis treat-
ment the patient gets intravenous treatment, or that
the Swift-ElHs is completed by the intraspinous treat-
ment. I believe the average general practitioner be-
lieves these are two entirely distinct things. As I
understand it, the Swife-Ellts method is the addition
of intraspinous treatment to the intravenous treatment.
I should like Dr. Wright to make that point clear in
his closing remarks.
Dr. Wright (in closing) : The Swift-Ellis metho.1
always presupposes intravenous treatment. It is pos-
' sible to take blood from another patient, make a
serum, and inject that into the individual without hif
getting the intravenous treatment ; but when you are
seeing a tabetic you give the intravenous treatment,
and note the reaction time, withdraw the blood, pre-
pare a serum, and inject it into the subarachnoid
space. I have used intraspinous treatment, but as time
goes on, I have used it less and less. I prefer the
Ogleby method, which is a definite method of giving
salvarsan to the patient's serum. The average dose
is about three-tenths of a milligram. The Ogleby
method is much more beneficial in my experience and
is much more effective. If there is any indication at
all for intraspinous treatment, I believe the Ogleby
method is the one to use.
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APOPLEXY— POTTS
8(j7
Dr. Wholey touched on a point which has been the
cause of much discussion and argument among neu-
rologists, and that is the intravenous and intraspinous
question. Formerly, I used to give a great deal of
intraspinous treatment, but as time has gone on, I
have been giving less and less of it. In cases ol so-
called "meningeal tabes," in which the character of the
pains, sensory disturbances, and usually a high cell
count seem to indicate that the pathology is chiefly
meningeal rather than parenchymatous, intraspinous
therapy would seem to be indicated, especially if intra-
venous treatment alone has failed. I have been amazed
at the readiness of many physicians of surely only
limited experience in the treatment of neurospyhilis to
give or advise intraspinous therapy in any kind of
case. I am sure much more is expected of it than can
usually be realized, and besides there is a certain risk
of doing harm that only those of considerable expe-
rience and unbiased judgment will admit. The facts
arc that intraspinous therapy started in New York and
has swept over the country like a wave, but in the
meantime, the original .sound which caused the wave
has largely been dying out at its source.
SOME MISTAKEN IDEAS CONCERNING
APOPLEXY*
CHARLES S. POTTS, M.D.
PHILADELPHIA
It is not my intention to write a sy.stematic
paper on apoplexy, but merely briefly to call at-
tention to some mistaken ideas concerning it.
For instance, in my consultation and teaching
work it has been my experience to find that
many physicians believe that the lesion in cere-
bral apoplexy is always hemorrhage. This is
not so and, as the treatment recommended for
hemorrhage may do harm in cases due to other
causes, it is important that a clear idea be had
of the different lesions which may cause such an
attack and their diagnosis.
By ajjoplexy we mean the occurrence of a sud-
den paralysis, sometimes accompanied with un-
consciousness, and due to lesion of the vascular
system. These lesions may be either hemorrhage
due to the sudden rupture of a vessel, or the
blocking up of a vessel by an embolus or throm-
bus, or its temporary closure due to spasm or to
lacunar degeneration. Hemorrhage and soften-'
ing, due to either thrombosis or embolus, are the
nio.st frequent and the latter probably somewhat
more frequent than the former. Statistics on
this point vary somewhat as will be seen by the
following, quoted by Thomas:'
Henwrrhat/c Sofleninq
John Hopkins Hospital 26 30
Philadelphia Hospitals (Lud- •
lum) 24 69
•Read before the Section on Medicine of the Medical Society
of the State of Pennsylvania, Pittsburgh Session, October 7,
ipao.
I. Osier's Modern Medicine, ist Ed., Vol. vii, 396.
Hemorrhage Softening
Royal Victoria Hospital, Mon-
treal 29 35
Montreal General Hospital ... 53 44
Boston City Hospital 132 78
Presbyterian Hospital, N. Y. . . 112 48
University College Hospital,
London 123 37
499
341
While in several of these hospitals softening
was much more frequent than hemorrhage, the
total figures are in favor of the latter, but as
Gowers has pointed out, hemorrhage is more
fatal and therefore there are more deaths from
this cause in hospitals. In a hospital like the
Philadelphia General, where chronic cases are
the rule, those having the clinical history of soft-
ening are much more frequent. Of the two
causes of softening thrombosis occurs more
often.
While usually the symptoms indicating either
hemorrhage or softening are characteristic,
cases occur in which it is impossible to determine
which has happened. The characteristic symp-
toms of hemorrhage are sudden onset, with loss
of consciousness occurring soon ; slow, full
pulse and high blood pressure; slow and deep
respiration, often stertorous and at times Cheyne-
Stokes in type; at the time of the attack a fall
of temperature of 1° or 2° followed in an hour
or two by a rise which is often greater on the
paralyzed side; some choking of the optic disc
may or may not be present. The limbs of the
paralyzed side are frequently rigid (the early
rigidity of irritation) and the eyes may be
turned toward the paralyzed side (spastic or
irritative conjugate deviation). The pupils may
be either dilated, contracted, equal or unequal,
but do not respond to light.
Thrombosis has a gradual onset, it .sometimes
being several hours before paralysis is complete.
Consciousness may not be lost at all or some
clouding may occur. Frequentiy the patient will
go to bed feeling comparatively well- and on
awakening in the morning find he is paralyzed.
The pulse is rapid and feeble and the blood pres-
sure may be low, for this lesion is most apt to
occur either in syphilitics, in whom the calibre
of the vessel is markedly narrowed, or in tho.se
past fifty who have atheromatous arteries with
consequent roughening and weakened heart ac-
tion due to myocardial changes, conditions which
promote thrombosis. Respiration is frequently
not disturbed and the temperature changes that
occur in hemorrhage are usually absent, except-
ing .shortly before death, when a considerable
rise may take place. There is no papillo-edema
and the pupils and ocular movements are not dis-
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868
THE PENNSYLVANIA MEDICAL JOURNAL Sei-tember, 1921
turbed. As a cortical artery is frequently the
seat of thrombosis the paralysis may never be
complete, that is, it may be confined to only one
limb or the face may escape. Convulsive sei-
zures, sometimes jacksonian in type, may also
rarely occur. As hemorrhage almost always in-
volves the capsule, the paralysis is complete and
convulsive movements do not occur.
The disagnosis of embolus depends largely on
finding a cause, which in most cases is a lesion
of the cardiac valves especially the mitral. It
may be derived from thrombi on the arterial
walls or calcareous matter detached from an
atheromatous plaque. The symptoms usually
develop suddenly and consciousness is not al-
ways lost. It lodges usually in either the middle
cerebral or one of its branches. If the latter,
the paralysis may be confined to one limb or
motor aphasia only may develop. If thrombosis
takes place back of the embolus, hemiplegia may
gradually develop and the development of pa-
ralysis resembles that frequently due to throm-
bosis alone. The left side of the brain is usually
affected and it is most likely to occur between
late childhood and middle life.
As has previously been said, ca.ses occur in
which it may be impossible to be sure which of
these cau.ses is present. Thus, in thrombosis
there may be sudden development of paralysis,
loss of consciousness, and high blood pressure,
but it is not the rule.
It is well known that degenerated arteries
are liable to spasm, which may be a cause
of angina pectoris and the temporary paralysis
after exertion known as intermittent claudica-
tion. Similar conditions occur in both cere-
bral and spinal arteries. When the former,
attacks occur which are apoplectiform in their
symptoms, but in which the symptoms disappear
in a few hours or possibly days. Con.sciousness
is usually not lost. Patients, usually elderly peo-
ple, may have a considerable number of such at-
tacks. Similar attacks may also be due to the
development of small areas of .softening, second-
ary to arteriosclerosis, termed lacunae. In this
connection it is important to remember that
transient apoplectiform attacks may occur in the
course of paresis, multiple sclerosis, and brain
tumor. In the former, especially, such an attack
ni.iy be a very early symptom. It should also
be remembered that paralysis, often of the
hemiplegic type, may be due to uremia. Such
ca,ses may be very difficult to distinguish from
apoplexy, as kidney disease is so frequently pres-
ent in tho.se suffering from it. The paralysis is
apt to be transient and, if other symptoms of
uremia are present, the diagnosis would be in
favor of this as a cause. Coma occurring in
pregnant women is not always due to toxemia
l)ut may be apoplectic in origin ; therefore,
motor paralysis should be looked for.
The treatment of an apoplectic attack due ti>
hemorrhage differs from that due to thrombosis
or embolism. When it cannot be determined
with reasonable certainty which of these is the
cause, the treatment should be expectant, care
being taken to do nothing that would be harmful
in either case.
When hemorrhage is believed to have occurred
the question of venesection is to be considered.
This as a routine proceeding is to be avoided.
High blood pressure is not always, by any means,
an indication. In many cases it is secondary and
compensatory, being due to increased intracranial
pressure with consequent effort to send blood to
the vital centers in the medulla. The intracranial
pressure (the force which the brain exerts
against the skull) depends upon blood pressure
and is equal to the pressure of blood in the ve-
nous sinuses, which is normally the same as gen-
eral venous pressure. If intracranial pressure
be raised above the general arterial pressure, no
blood can enter the skull and death occurs.
Cushing showed that, when the pressure became
so great as to embarrass the medullary centers,
there was a corresponding rise of general arterial
pressure. If intracranial pressure was again in-
creased a further rise of arterial pressure would
occur. This would be repeated until the vaso-
motor centers were exhausted. If, however,
there is known to have been increased pressure
for some time before the stroke, and the patient
i- seen early, venesection may sometimes be of
service, as in such cases it may help to stop the
bleeding. I have seen some good results in a
few ca.ses from bleeding several days after the
attack. In these cases there had been no im-
provement in the .symptoms and there was a his-
tory of high blood pressure for some time pre-
vious. It should be advised with great caution.
When thrombosis or embolism are believed to be
present bleeding is absolutely contraindicated.
In cases in which, no matter what the cause of
the attack, there is very high blood pressure and
especially if it is increasing, Cushing' has opene<l
the skull and endeavored to remove the clot.
Even if this cannot be done the decompression
is claimed to be of .service. In some, the results
were good which, as they were desperate cases,
is some encouragement for its employment.
Marie has advised opening the skull on the side
opposite the lesion for similar reasons. Abso-
lute quiet is essential in all cases and when coma
I. Amcr. Jour. Med. Sci., 1903, cxxv, 1017.
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September, 1921
APOPLEXY— DISCUSSION
869
is present the patient should not be disturbed
with efforts to give food or medicine. The pref-
erable position for the patient is on the side, so
that the tongue falls forward and does not im-
pede respiration.
If the pulse is weak, as is thrombosis, cardiac
stimulants should be given. In such cases a com-
bination of the nitrites or benzyl benzoate and
caffein is serviceable, as we dilate the vessels and
increase the heart's action, and thus get more
blood to the affected area which, when a vessel
is blocked, is indicated. Remember that these
lesions are often in cortical arteries, and in the
cortex there is collateral circulation. Attempts
to exercise paralyzed muscles should not be made
for at least two weeks.
The fact that apoplexy is not infrequent in
early life does not seem to be generally recog-
nized. In the statistics collected by Thomas
from the records of Johns Hopkins Hospital, of
740 cases 135 occurred during the first decade
of life — a number greater than during any pe-
riod until the fifth. Excluding meningeal hem-
orrhage occurring at birth, it mUst be remem-
bered that the infectious fevers may cause arte-
rial disease, a weakening of the heart muscle and
a tendency to the formation of thrombi and con-
sequent apoplexy, usually embolic or thrombotic.
In this connection it should be stated that some
of these cases may be inflammatory (encepha-
litis) and not apoplectic, but the distinction
clinically may be hard to make and the end re-
sults are the same. Embolism has already been
mentioned as occurring in early life. Syphilis
is a frequent cause in young adults and is the
probable cause in such cases when- infectious dis-
ease or embolism can be excluded. Hereditary
syphilis may also so act.
While the lesions usually involve vessels sup-
plying the motor region of the brain (middle
cerebral or its branches), such is not always the
case. Any artery may be involved ; a not infre-
quent one is the posterior inferior cerebellar, a
branch of the vertebral. When this is involved
the symptoms develop suddenly without com-
plete loss of consciousness. The resulting con-
dition is usually paralysis of the vocal cords,
muscles of deglutition and soft palate, loss of
sensation for pain and temperature in the dis-
tribution of the fifth nerve, signs of paralysis
of the cervical sympathetic and ataxia of the
limbs on the side of the lesion. On the other
side there may be slight motor weakness, some
loss of sensation and ataxia. Not all of these
symptoms are always present and .sometimes
other cranial nerves may be affected. A lesion
in the pons causing crossed paralysis, shown by
involvement of either the fifth, sixth or seventh
cranial nerves on the side of the lesion and the
arm and leg on the opposite side may be due to
thrombosis in the basilar artery or its branches.
If a branch of the posterior cerebral is in-
volved, Benedict's syndrome may occur, in which
there is oculomotor palsy on the side of the
lesion while paralysis of the limbs and tremor
or choreiform movements may occur on the
other; or the optic thalamus may be involved,
when there will be hemianesthesia, choreiform
and ataxic movements but no, or slight, motor
paralysis of the limbs, and often homonymous
hemiano|>sia. Loss of emotional expression on
one side of the face may also be present. The
Babinski reflex will be absent. Occlusion of the
superior cerebellar is believed to cause the sud-
den development of ataxia of the limbs on the
same side and loss of pain and temperature
sense, power of emotional expression and deaf-
ness on the opposite side. A branch of the mid-
dle cerebral supplying' the corpus striatum may
be involved, in which event there will be hyper-
tonicity of the muscles on the affected side with-
out paralysis and absence of the Babinski reflex.
In view of the medicolegal questions that may
arise, the occurrence of apoplexy several days or
weeks after the patient has received a concussion
of the brain is of interest. Such cases occur and
are believed to be due to an injury to some of
the vessels by the concussion, which injury may
lead to the formation of a thrombus or a rup-
ture. Such cases are known as late apoplexy.
DISCUSSION
Dr. M. Howard Fussell (Philadelphia) : I should
like to ask Dr. Potts as to the diagnostic value of
spinal puncture in these cases simulating hemorrhage
into the brain. In a certain way, if there is much
hemorrhage, spinal puncture will show a bloody fluid,
but it does not show a bloody fluid if there is a throm-
bus or embolism, and I should like to know what his
experience is as to its value.
In certain cases, where patients come in unconscious,
it is utterly impossible to develop signs of paralysis,
nothwithstanding the hemorrhage may have occurred,
and we are at a loss to know what the unconsciousness
is due to. In such cases I have often found comfort
in using spinal puncture and finding bloody fluid. If
there is bloody fluid- there is hemorrhage, but the pres-
ence of the blood to me has been of some value.
Dr. Potts (in closing) : We probably only get
bloody spinal fluid when the hemorrhage has extended
into the ventricle. Probably such cases always die.
Of course, if the hemorrhage is in the meninges, from
traumatism to the head, bloody spinal fluid is valuable
as a diagnostic sign. The hemorrhage may be in the
brain substance, and if outside the ventricle you would
not get bloody fluid and would not receive any help in
a diagnostic way, but in a ventricular hemorrhage you
would. Sometimes, by the time you make the diagno-
sis, the patient is dead.
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THE PENNSYLVANIA MEDICAL JOURNAL Septembkr. 1921
REPORT OF A CASE OF INFANTILISM
WITH RICKETS*
D. HARTIN BOYD, M.D.
PITTSBURGH
HISTORY
Madeline R., the second child of healthy par-
ents, was 5 years old. Her sister is a normal
child, aged 6. She was delivered spontaneously
with no asphyxia, was breast fed for lo months,
then fed on a modified milk mixture. She de-
veloped well the first year, was fat when I2
months old. The first teeth erupted at 6 months,
she sat up at 7 months, never crawled and never
walked. She would slide across the floor on her
buttocks during her second and third years.
The first trouble noticed was that her wrists
were unusually flexible, would bend back easily
when she was putting her weight on them. This
was at about 15 months of age. Then she began
to lose weight although fed proper mixtures. A
physician at this time pronounced her rachitic
and gave her cod liver oil, orange juice and raw
cow's milk. During this time she had a good
appetite, ate a varied diet under direction of a
physician but still did not develop.
During her third year she had a severe attack
of diarrhea, lasting 6 or 7 weeks. Her abdomen
became very large, protruding and seemed
"hard" to her mother. Following this the stools
were always profuse and abundant, 3 or 4 daily,
a gray or green color, with foul odor. Her appe-
tite at this time was always good, would eat
large quantities. Her weight had remained about
the same for the succeeding 2 years, the heaviest
known weight being 24 pounds when 4 yea!rs old.
Her mental condition was good. She was able
to learn .stories, talked well, counted up to 10.
Began to form sentences when 2j^ years old.
Her bones began to show curvatures during her
second year and the process involved all the long
bones. Her appetite then became very poor, and
for the past 6 months her cheek bones had been
protruding gradually with increasing protrusion
of the eyeballs, particularly the rigiit, and some
constant discharge from the right nostril. She
never complained of any pain. She had frequent
attacks of bronchitis, but none of the infectious
diseases.
P. E. — At time child was first seen she was 4
years old and weighed 24 poimds. Her height
was 31 inches. She sat with legs drawn up in
Turkish fashion and supported her trunk with
her hands, though she could sit erect without put-
ting her hands to the floor. She was irritable
*Rcad before the Section on Pediatrics of the Medical So-
ciety of tbe State of Pennsylvania, Pittsburgh Session, October
7. 1920.
and cried easily. She was very pale and the en-
largement of her abdomen was particularly no-
ticeable. The head was large, circumference
205^ inches, was of the square type, fontanelle
closed. Hair profuse and soft in texture. Head
sweated a great deal. There was a moderate
exophthalmos, more marked on right side, pupils
reacted normally and vision was apparently
good ; no hemianopsia. The cheek bones were
prominent with more marked protrusion of the
right side. The nose was poorly developc<l.
bridge low. Transillumination of the sinuses
showed all obscured. There had been 20 teeth
but gums receded from some of the incisors and
several teeth had dropped out, with no evidence
of local disease of gums. Teeth were good size
and not carious; the front teeth projected
slightly backward. Tongue clean and moist.
Tonsils were not enlarged but there was some
difficulty in breathing through nose. There was
a sinall polyp in right nares. The palate was
low. The cervical glands were moderately en-
larged. Thyroid gland not palpable. The lower
jaw was not enlarged nor prominent.
The chest was very much deformed, ribs flar-
ing, Harrison's groove, marked curvature of
clavicles, retraction of axillary region with each
inspiration, transverse diameter very narrow.
Circumference i6j^ inches. Heart sounds were
normal. P-2 slightly accentuated. Lungs were
clear. Respirations rapid and labored. Lung
expansion much restricted. There was no de-
monstrable thymic dullness. The abdomen was
very much enlarged, circumference 24 inches,
considerable gaseous distension, tympanitic an-
' teriorly with slight dullness in flanks. The dull-
ness in flanks changed with change of position,
but a definite fluid wave could not be deter-
mined. This dullness in flanks later entirely dis-
appeared. The liver was palpable 2 fingers'
breadth below the flaring edge of the ribs and
the spleen was also palpable, about i finger's
breadth below costal margin. Consistency of
liver and spleen about normal. Kidneys not pal-
pable, no tumor mass felt, slight umbilical her-
nia. All of the extremities showed curvature of
varying degrees in the long bones, even metacar-
pal bones being bent. A small irregularity could
be felt in lower third of left ulna, apparently a
callus formation following previous fracture.
The hands were small with no enlargement of
distal phalanges. The left femur was much
curved anteriorly, the knee joints were large;
all movements of arms and legs were pos.sible
but left leg was moved with more apparent diffi-
culty than the right. There were no enlarge-
ments along the course of the bones except slight
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INFANTILISM— BOYD
871
thickening of e|)ipliyses, most noticeable in
wrists. The nniscles were soft and flabby, sub-
cutaneous tissue moderate, skin wrinkled in
folds of axillae and groins. The reflexes were
normal. There was marked lateral curvature of
the spine when sitting.
CLINICAL FINDINGS
Urine. Usually showed a faint trace of albu-
min, specific gravity 1015-1020. Acid reaction,
no sugar, no acetone, indican positive at times,
sediment showed a few white blood cells emd
ei)ithelial cells, urates, bacteria and no casts. The
24-!iour quantity averaged 600- ycx) c.c.
Stool. Always large amounts, usually pale
yellow, almost clay colored, greasy appearance,
semi-fluid consistency, foul odor. No fresh
blood was found in the stool, microscopic ex-
amination showed usually many fat globules, a
few white blood cells, no pus, epithelial cells. A
s]>ecimen treated with antiformin and examined
for tubercle bacilli was negative. Bacteriological
examination by Dr. Lacy at Singer Memorial
Laboratory on direct smear showed many large
gram positive and variable sized gram negative
bacilli, and gram positive and gram negative
cocci.
Cultures. Aerobic culture contained princi-
pally bacilli acid lactici with few colonies of
bacillus f ecalis alkaligines. Anaerobic culture
contained bacilli acidi lactici and bacilli Welchii.
No colon bacilli were found and none of the
ovoid bodies nor branching forms described by
Herter were found.
Blood Examination. R. B. C, 4,310,000; W.
B. C, 11,200; Hemoglobin, 72%. Differential
count showed: Polymorphonuclears 72%, lym-
phocytes 18%, large mononuclears 6, eosino-
philes 1%, basophiles 3% ; no myelocytes, no
Ix)ikik)cytosis, no blasts. The blood VVasser-
niann was negative. A von Pirquet skin test,
done twice at intervals of 6 months, was nega-
tive both times. In testing the liver function, 60
grams of glucose was given with no reduction
of Fehlings until 24 hours after ingestion when
there was a very slow and indefinite reduction
with both Fehlings and Benedict's reagent. Ehr-
Hch's urobilinc^en test was negative. Sahli's
glutoid capsule test of pancreatic function was
tried once with no reaction in the urine for
.salicyluric acid 8 hours after ingestion. Loewis
pupillary test showed no dilatation of the pupil
following instillation of adrenalin, which is
against the existence of pancreatic internal in-
sufficiency and hyperfundion of the thyroid
, gland.
X-RAY REPORT BY DR. RAY
"Exceedingly thick skull, in places one-half inch
thick. The sinuses have all been filled with solid bone.
This solid bony growth is encroaching on the sockets
of the eye. The sella-turcica is not seen, most likely
entirely destroyed. Two unerupted teeth are seen in
the upper jaw, one on each side. There is a very thin
place in the skull in the region of the auditory meatus.
Distal ends of femurs very much enlarged. Fracture
shaft of left femur."
DIAGNOSIS
Infantilism has been defined as a conspicuous
delay or arrest of development. This case cer-
tainly showed conspicuous delay in development.
The type of infantilism is questionable.
Herter gives as the signs and symptoms of in-
testinal infantilism: i. an arrest in development
of body, 2. maintenance of mental powers and
fair development of brain, 3. marked abdominal
distension, 4. a moderate grade of anemia, 5.
rapid onset of physical and mental fatigue, 6.
various obstructive irregularities referable to the
intestinal tract, 7. the bacterial flora of the intes-
tinal tract shows a predominance of gram posi-
tive organisms, the bacillus bifidus of Tissier,
the bacillus acidophilus of Moro, the bacillus in-
fantilis and gram positive coccal forms. Colon
bacilli are infrequent. The stools are large, gray,
sour odor, mucus and epithelial elements with
defective absorption and retention of calcium
and magnesium and excessive loss of fat in the
stools. This case corresponded to the above de-
scription with the exception that the bacterial
flora was not typical. The condition of the bones
was sufficient evidence of defective absorption
and retention of calcium.
The pancreatic type of infantilism would give
similar , symptoms. The efficiency tests of the
pancreas were, however, normal and feeding
pancreatic extracts over a period of time pro-
duced no improvement.
An infantilism produced by disturbance of
some internal secretion must be considered. The
ductless glands assume a considerable influence
in the regulation of metabolism. The pancreatic
insular apparatus, the chromaffin tissue of the
suprarenal glands, and the thyroid gland seem to
govern the carbohydrate metabolism while the
thyroid gland is especially important for albu-
min metabolism. Falta says that "the fact that
a normal grown man retains the same bodily
weight for years depends on a correct relation
between assimilation and dis.similation, assured
by such different factors as appetite, impulse for
movements, etc. On these processes the ductless
glands have a considerable influence. We can
with great probability divide the hormones into
anabolic and cataboHc (retarding and acceler-
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872
THE PENNSYLVANIA MEDICAL JOURNAL September. 1921
atory, or as.siniilatory and dissiniilatory)." Ap-
parently in this case the catabolic hormones
were stronger. As so little is definitely known
about the thymus gland, a thymic type of
infantilism cannot be ruled out. In consider-
ing the pituitary gland, the bony overgrowth in
tlie skull and malar bones and the broadening of
the epiphyses of the long bones, would suggest
a hyperfunction of the anterior lobe as in acro-
megaly. This is very rare in childhood. There
is no enlargement of the hands and feet; the
sella turcica is obliterated ; there is no symptom
of brain pressure ; there is no tendency to glyco-
suria or polyuria. Hyperfunction of the hy-
pophysis in early youth may, but does not neces-
sarily lead to gigantism. In hypofunction of the
pituitary glands, the usual symptoms are accumu-
lations of fat in definite places, obesity, inhibi-
tion of development of the interstitial glands ;
when the disease occurs in youth, by the inhibi-
tion of growth and inhibition of ossification, a
polyuria, and symptoms of pressure on the op-
tic nerves. There was no polyuria and no
bitemporal hemianopsia, no headache, no inr
creased tolerance for carbohydrates and no obes-
ity in this case.
The best known type of thyroid infantilism is
the cretin, and the patient was not a cretin,
though the thyroid may be influenced by the
other gland secretions. The therapeutic test in
this case produced no results, and the fairly nor-
mal intelligence ruled out much involvement of
the thyroid. Multiple ductless glandular scle-
rosis presents a type of infantilism characterized
by cachexia, emaciation and marked thinning of
the hair of the head, eyelashes, etc., very thin
bones with premature ossification. None of
these symptoms were present. Achondroplasia
was suggested by the condition of the head and
bridge of the nose but there was no dispropor-
tion in length of arms and forearm nor thighs
and legs.
The presence of fracture in the forearm and
thigh would suggest osteogenesis imperfecta, but
the condition of the skull was not typical.
Fragilitas ossium (ideopathic osteopsathyrosis)
would give the fractures but not the other symp-
toms. Osteomalacia is very rare in children and
would be characterized by more marked soften-
ing and bending of the bones,* enlargement of
the medullary cavity and usually some pain in the
bones. Leontiasis ossea (hyperostosis of the
skull) would .show a diffuse hypertrophy of the
bones of the skull, the air sinuses disappearing,
with encroachment on the orbits, all of which
were present in this patient. Up to this time
there were no pressure symptoms, no compres-
sion of the nerves, no neuralgia, deafness, blind-
ness, paralysis, difficulty in swallowing, etc. By
.some this is considered a similar condition to
osteitis deformans, occurring earlier in life. The
cases reported all began late in childhood or at
puberty. The development of a sarcoma in the
malar bone must be considered a possibility. All
the typical signs of rickets were present, the
bony deformities, enlarged epiphyses, head
sweating, etc., but the institution of an efficient
treatment for rickets at an early age apparently
did not benefit this child.
The most logical conclusion would seem to be
to consider the case one of intestinal infantilism
wilh rickets with a secondary hypophyseal in-
volvement to account for the hyperostosis in the
skull.
TREATMENT
A fat free diet was instituted with oral ad-
ministration of iron and cod liver oil and phos-
phorus. Later a colonic flushing was given
daily over a period of 5 weeks on the supposi-
tion that an idiopathic dilatation of the colon
might be present. Raw sweet breads were given
daily for 2 months. During this time the cir-
cumference of the abdomen was reduced to 21^
inches and the spleen reduced in size. The char-
acter of the stools remained the same. For 3
months fels bovis was given with slight improve-
ment in stools, a fat free diet being continued.
Mixed gland tablets were given for a period of 5
months. The diet recommended by Herter was
given but the child lost considerable weight and
the stools did not show much improvement after
3 months. Iron in various forms was given at
intervals. Massage, manual and vibratory, was
])racticed daily ; oil rubs were given.
The autopsy report is possible through the
kindness of Dr. S. R. Haythorn. Death was
l)receded by a gradually increasing edema of the
legs, finally becoming general, with marked
asthenia.
M. R., age 5 y., 6 m. ; outside case ; Dr. D. H. Boyd ;
autopsy 12-20-20, 10:00 a.m.; A-20-28; died 12-20-20.
Drs. Haythorn, Mabon and Brown.
Rickets. General hypoplasia or atrophy of the
glands of internal secretion including hypophysis, pineal
body, thymus, thyroid gland and adrenals. Amyloid
disease of the liver, spleen and kidney. Hemorrhages
from intestine, liver and gall bladder, fatty infiltration
of liver, generalized edema. General hyperplasia of
the bony structures of head, face, ribs and extremities.
Fractures of the left radius and left femur (spon-
taneous).
The body was that of an abnormally developed,
moderately nourished, white female child 81 c/m in
length. The head, which was covered with brown
curly hair, soft in texture, was generally enlarged.
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September, 1921
INFANTILISM— BOYD
873
more markedly on the right. The frontal bosses were
prominent, giving a square appearance to the forehead.
The eyes showed marked exophthalmos. The pupils
were equal, dilated to s m/m. The sclerae were clear.
The eyelids were somewhat bulging and presented nu-
merous small dilated venules. The malar eminence
were very prominent, particularly on the right. The
bony portion of the nose was flattened. The teeth were
irregular, there being marked recession of the lower
jaw. The skin was of fair texture throughout. The
thorax was small, showing a marked Harrison's
groove; no external rosary was present. The abdo-
men was markedly distended, the umbilicus level. The
liver palpable, 8 c/m in mamillary line. The spleen
was just palpable. The lower thighs, legs and feet
showed rather marked edema and pitting on pressure.
There was slight pitting over the sacral region. The
left radius showed two callus formations, one near
the elbow and a second near the wrist. There was a
callus formation on the left mid-femur.
Head. The scalp was negative. The external sur-
face of the calvarium was a purplish-red in color.
The bone was soft, spongy, and very vascular, measur-
ing 1.4 to 1.5 c/m. in thickness.
Brain. Wt. 1040 G. The dura was very adherent
to the calvarium. The pia and arachnoid were mod-
erately congested and the subpial and arachnoid spaces
were filled with clear straw colored fluid. On opening
up the lateral ventricles the ependyma appeared nega-
tive and the ventricles were not increased in size. The
consistency of the brain was rather soggy and wet.
The third and fourth ventricles were open and also
appeared negative.
Pineal Body. The pineal body appeared rather
small, cystic and negative.
Hypophysis. The hypophysis was small and ap-
peared to be pressed upon all sides by bony hyper-
plasia. On section it appeared to contain a cyst filled
with cheesy material.
Thyroid Gland. The thyroid tissue was small in
amount and presented a pale pink glistening appear-
ance.
Thora.r. The thymus gland was very small in
amount. The thymic fat and gland stibstance extended
down over the pericardium 10x7 c/m. Very little
thymic substance was present. The pleural cavities
were free from adhesions and fluid, the cavities ante-
riorly being encroached upon by the liver. The lungs
were small and compressed. At the juncture of the
costal cartilages with the ribs on both sides a marked
internal rosary was found, the individual enlargements
varying from 0.75 to 1.25 c/m.
I^eft Lung. Wt. 70 G. The pleural surfaces were
smooth and glistening. The lung tissue was air con-
taining throughout. On section the surface appeared
mottled, some areas being pale pink while others were
blood red in color. On opening the bronchi, it was
found that the bronchial mucosa was stained bright
red as if by fresh blood. As no consolidated areas
were present, it is probable that the blood was in-
spired. The peribronchial nodes were small and nor-
mal in appearance.
Right Lung. Wt. 75 G. The right lung resembled
the left in all macroscopic appearances.
Heart. Wt. 91 G. The epicardium appeared nega-
tive. The cavities contained some bright red blood
and some currant jelly clot. The foramen ovale was
closed. The valve cusps and the endocardium were
negative on both sides of the heart. The pulmonary
veins united just before entering the left auricle so
that only two external openings were presented. The
myocardium was pale but of good consistency. The
aorta appeared negative.
Abdominal Cavity. The primary incision showed
the muscles to be thin and the subcutaneous fat sparse.
The intestines were distended. The appendix meas-
ured about 6.5 c/m in length and appeared normal.
About 200 c.c. of straw colored free fluid was present
in the abdominal cavity.
Spleen. Wt. 45 G. The capsule was drawn tightly
over the spleen which was firm and wood-like in con-
sistency. On section, the color was deep purplish-red
and there was much highly refractive purplish mate-
rial distributed throughout the pulp.
Gastrointestinal Tract. The esophagus appeared
edematous and was stained bright red with blood. The
stomach was distended and contained about 100 c.c. of
brownish-black, partially digested, blood. The pylorus
was negative. Just below the pylorus there appeared
to be a small ulcerated area about $ m/m in diameter.
This portion of the duodenum was stained bright red.
The papillae of Vater appeared edematous and more
prominent than normal. The remainder of the duode-
num contained a bloody, bile-like fluid. The jejimum
and ileum contained some whitish curd-like tnaterial,
and in the last foot of the iletun the material was
stained red and the mucosa appeared bright red. The
appendix was negative. The Peyer's patches stood out
very prominently and were red in color. The colon
contained a small amount of yellowish, clay colored,
undigested, fecal matter. The solitary follicles were
prominent. There was no blood stained material in
the colon. The walls of the small and large intestines
were so markedly edematous that the serosa could be
readily stripped from the muscularis.
Liver. Wt. 493 G. The liver extended down 10 c/m
in the mamillary line. The capsules appeared to be
stretched tightly and presented a mottled yellow and
reddish appearance. The margins of the liver were
broadened and rolling. On section the liver cut with
a somewhat woody resistance. The lobules were dis-
tinctly outlined and were made up of yellowish fatty
portions intermixed with an orange-brown irregular
granular substance. On applying iodin« and sulphuric
acid to the surface, the granular sulfstance turned
mahogany-brown and later blue. On opening up the
hepatic duct it was. found that it contained what ap-
peared to be fresh red blood. The material in the gall
bladder was thin and bloody, being of a reddish-brown
color. The common bile duct contained material simi-
lar to that found in the gall bladder.
Pancreas. The pancreas measured 11x3x2 c/m, and
appeared to be of firm consistency and negative in ap-
pearance.
.4drenals. The adrenals were small. The left ad-
renal weighed 2 gms. They presented a bright pale
yellow cortex and very little medullary substance.
Kidneys. Wt. 57 and 58 grams, respectively. The
capsules stripped with slight difficulty leaving a smooth
surface. The kidneys were large and pale, being al-
most of a buflF color. There was little differentiation
between the cortex and medullary portions, and the
glomeruli were not prominent.
Bladder. The bladder walls were thick and edema-
tous. The mucosa was pale, almost white. The viscus
contained about 100 c.c of clear straw-colored fluid.
The uterus, tubes and ovaries were of the infantile
type, and apparently normal.
Bacteriological Report (B-^o-jisgd). Culture from
heart's blood — negative ; culture from peripardial
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874
THE PENNSYLVANIA MEDICAL JOURNAL September, 1921
fluid — ^staph. aureus, probably contamination ; culture
from small bowel — staph, aureus and a sarcina lutea.
No bacilli were present.
Microscopic. Heart. The interstitial connective tis-
sue of the heart was slightly edematous atid infiltrated
with lymphocytes. There was an atrophy of the sub-
epicardial fat which was also accompanied by lympho-
cytic infiltration. Very slight interstitial myocarditis.
Aorta. There was a moderate separation of the elas-
tic tissue of the media of the aorta with a prolifera-
tion of the connective tissue between the elastic fibers.
Slight replacement of media of aorta. Lung. The
liuig was edematous and the alveoli filled with many
endothelial leucocytes which were phagocytic for
brown and black pigment. Chronic passive congestion
hi the lung. Another section shows many of the
alveoli to contain free red blood cells.
Spleen. The follicles were Rightly hyperplastic.
The pulp was congested but was practically free from
polynuclear leucocytes, and the interlobular connective
tissue was large in amount and appeared edematous.
Liver. The tissues around the central veins showed
very advanced fatty infiltration. The central portions
of the lobule were hemorrhagic and infiltrated with
polynuclear leucocytes. The peripheral portions of
the lobules showed fatty infiltration. Midzonal ne-
crosis and fatty infiltration. Pancreas. There was a
general edema of the interlobular tissues. The islands
of Langerhans appeared both numerous and increased
in size. Hyperplasia of islands of Langerhans. Sec-
tion of the duodenum showed hyperplasia of glands of
Lieberkiihn and a small ulcerated area, the base of
which was infiltrated chiefly with endothelial leuco-
cytes. The infiltrating cells extended for some dis-
tance into the deeper structures. Section of the small
intestine showed the surface covered with purulent
exudate. The mucosa appeared thickened and rather
fibrous. The serous glands were separated and the
spaces between them extensively infiltrated with poly-
nuclear leucocytes, lymphocytes and endothelial cells.
The muscle layers also contained similar cellular in-
filtration. Chronic enteritis. Section . from the colon
showed the absence of the surface epithelium and a
slight hyperplasia of the solitary follicles. Gall blad-
der. The epithelium was absent from the greater part
of the mucosa. A considerable number of free red
cells were found in the debris covering the mucosa.
The wall of the gall bladder was infiltrated with
plasma cells and endothelial leucocytes. Chronic
cholecystitis.
Adrenal. The medullary substance appeared unusu-
ally large in amount. In some places it was extremely
congested. About two-thirds of the thickness of the
adrenal was made up of medullary tissues. The mid-
zonal area was infiltrated with fat and the cortical
area appeared congested. » Medullary hyperplasia of
adrenal. Thyroid. ' There were apparently two proc-
esses in the thyroid. One was characterized by a hyper-
plasia of the epithelium of the acini. In such areas
there was very little colloid substance, the trabeculae
appearing rather thick and the epithelium resembling
that seen in exophthalmic goitre. The other process
apparently consisted in the secretion of a considerable
amount of colloid which was accompanied by a dila-
tation of the acini and a flattening or atrophy of the
epithelium. Areas both of hyperplasia and colloid
goitre. Hypophysis. The glandular portion appeared
quite cellular and there was a great predominance of
acidophilic cells. As the central portion was ap-
proached the cells appeared much smaller and con-
tained very fine granules. In the central area thtrc
were several large thin-walled cysts filled with colloid
material. The nervous portion contained cystic artaj
and in one of the cysts there was a mass of fibria
and polyntKlear leucocytes. The nervous tissue was
very small in amount. Cystic degeneration of tht
hypophysis. Ovary. The ovary showed a large nom-
ber of normal graafian follicles, also several cystic
graafian follicles, many of which contained well
formed disci. Follicular cysts of ovary. The lymph
node contained no well formed foHicles. The sinuses
were widely dilated and filled with fluid and contained
large numbers of phagocytic endothelial cells. Chronic
lymphadenitis.
Kidney. The kidney appeared edematous. The glo-
meruli were swollen and the glomerular capsules filled
with fluid. All of the tubules were dilated and the
epithelium was very much flattened. Most of the
tubules contained granular debris and a few of then
jvere widely dilated and contained casts. Chronic
parenchymatous nephritis and edema.
Nodule from rachitic rosary. The cartilaginous por-
tion was made up of a bland hyalin cartilage contain-
ing an occasional marrow space. These spaces passed
abruptly into an area of osteoid tissue in which there
were numerous canaliculi filled with fibrous connective
tissue. Extending outward from each side of the car-
tilage and also from the central portion of it there were
islands of cartilage in which the chondroblasts were
arranging themselves in columns. Between these por-
tions there were areas of atypical bone with well de-
veloped trabeculse and with fibrous connective tissue
filling the marrow spaces. In some of the marrow
spaces there was true marrow formation but such a
space was likely to be completely surrounded by other
spaces containing connective tissue only. Section from
the sella turcica showed a very loosely arranged
bone in which there were some well-developed
bony trabecnalae with a prominence of fibrous tra-
becualse containing no calcium salts. Some of the
spaces contained islands of calcification. The por-
tions of bone which were near the external surfaces
had a fine recticulated fibroblastic tissue in the mar-
row spaces with no evidence of marrow. Those por-
tions separated by the fibrous osteoid trabecube con-
tained typical bone marrow. A portion from the skull
showed practically an identical condition. By far the
greater number of marrow spaces were filled with the
fibrous reticulum. Rickets of costochondral articula-
tion. Osteoid hyperplasia of bones of skull.
DISCUSSION
Dr. M. Howard Fusseli, (Philadelphia) : This re-
markable case that Dr. Boyd has presented reminds
me of a case which I saw some years ago and I pre-
sume that Dr. Boyd must have heard of my experience
in the particular condition. From my own experience
this case is certainly a case of rickets and what other
changes are present perhaps are open to doubt. Cer-
tainly the head condition is not the head condition of a
typical case of rickets. I confess that I do not ex-
actly understand why Dr. Boyd classes it as one of
infantilism due to gastrointestinal disturbance. I
would rather think that the gastrointestinal disturbance
which is present is the result of a faulty metabolism
due to rickets and whatever other intestinal condition
there is. It certainly does not agree with the tj-pical
cases of infantilism reported by Herter and certainly
it is not similar to the case which I saw.
(Slides shown and report of cases pven.)
Digitized by
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September, 1921
PARAFFIN AND WAX— STAHLMAN
875
Dr. Boyd has told you exactly the ordinary symp-
toms of an ordinary case of infantilism due to intes-
tinal disturbance. I would doubt, as I stated in the
beginning, whether we have the right to class this case
of Dr. Boyd's as a true case of infantilism due to
intestinal disturbance. I think the intestinal disturb-
ance is rather a secondary one.
THE USE OF PARAFFIN AND WAX IN
EAR AND NOSE SURGERY*
T. M. STAHLMAN, M.D.
PirrSBUBGH
Although I cannot recall the name of the phy-
sician who a number of years ago wrote a brief
article on this preparation, I desire to acknowl-
edge my indebtedness to him for the valuable
suggestions which he made. This paper there-
fore has been prepared for the purpose of pass-
ing along his ideas and, if possible, adding to
them something of value to those who may not
be familiar with the preparation and its uses.
Surgeons doing operative work on the ear and
nose as well as on other parts of the body, are
occjisionally in need of a material that can be
sterilized readily, moulded into any size or shape
desired, is non-irritating and will not become a
medium for bacterial growth. ParaflRn and bees-
wax united in the proper proportions meet these
requirements very well. There may be other
material of equal or greater merit but I have not
foimd them. The preparation I have been using
for about twelve years is known commercially
under the name of "Extra Tough Pink Paraffin
and Wax," made by S. S. White Dental Manu-
facturing Co., for dental use. This wax is put
up in sheets 3 inches wide, 6 inches long and
1/16 inch thick. It has a pleasant odor, moulds
readily, can be brought to the boiling point with-
out destroying its usefulness, thus insuring an
aseptic material, and softens enough under
bodily temperature to conform to the shape of
the cavity, thus preventing undue pressure and
pain. The wax is non-irritating and can be used
for weeks.
(Preparation shown, and specimens of splints
explained.)
The uses of the wax are (i) to facilitate the
removal of dressings, (2) to keep separated two
raw surfaces until an epithelial covering is
formed, (3) to maintain an opening until the
edges are covered by skin or mucosa, (4) to
produce absorption by pressure and (5) to carry
medicinal agents.
The first dressing after an intrana.sal operation
is greatly facilitated and the patient spared much
•Read before the Section on Eye, Ear, Nose and Throat
Diseases of the Medical Society of the State of Pennsylvania,
Pittsbtirgb Session, October 7, 1920.
discomfort and pain when a splint made of this
material is placed against the uncut surface, or
against the cut surface also, if the control of
bleeding has not been a factor. For example,
take a case of partial turbinectomy. Place a
splint made of this material against the septum
and then fill in the balance of the dressing with
whatever material desired. More than one splint
may be used. These splints may be lubricated if
thought best. The wax splints are removed
first, and the space thus gained enables the sur-
geon to remove the other dressing readily. The
wax splints should extend to the posterior naris.
The entire dressing may be made of wax as in
some cases of submucous resection.
A problem is solved by this preparation in
those cases where two opposite raw surfaces ex-
ist. For example, in intranasal adhesions the
surgeon always has had difficulty in preventing
the reforming of them. By placing a splint or
plug made of the wax between the surfaces of
the desired thickness the epitheliimi will grow
over the raw surfaces and no further trouble
will occur. This is the greatest use for the ma-
terial. The splints are removed every few days
and the parts cleaned. Often the patient can be
taught how to remove the splint, irrigate the cav-
ity and replace it. This use is applicable in a
great many conditions in surgery.
A condition very similar to the last one is
found in occlusion of the nasal passage or the
external auditory canal. This may be due to a
membranous, fleshy or bony obstruction. The
surgeon may have a long stretch of raw surfaces,
as in a case of union between the lower turbinate
and the nasal septum throughout its length; a
ring-like condition where the nasal passage is
closed by a membrane or bony wall ; or the ex-
ternal auditory canal may be congenitally closed,
or closed as the result of injury or inflammation.
A plug or splint is made to fit the opening after
the obstruction has been removed, and is kept in
place until the skin or mucosa has reformed. It
is a great comfort to know you can maintain the
opening you have made and do so without fur-
ther operation or pain to the patient.
The wax works well where it is desired to in-
crease an aperture or passage way by absorption
due to pressure. The parts are shrunken by
means of adrenalin solution and cocain. The
splints or plugs are pressed in and held in posi-
tion if necessary.
Medicinal agents in the form of ointments
may be spread on the splints. This enables the
surgeon to keep the agent in contact for a long
time with the diseased area. There are other
uses for the preparation. These will suggest j
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876
THE PENNSYLVANIA MEDICAL JOURNAL September. 1921
themselves to the surgeon who becomes familiar
with it.
Permit me to detail two cases briefly in which
the wax material worked well. These cases give
a clear idea of its uses.
The one case was that of a young woman, age
24, giving a history of inability to blow the right
nostril or breath through it, with loss of sense of
smell. She suffered frequently from attacks of
severe pain accompanied by a purulent discharge.
Diagnosis: bony occlusion of the posterior part
of the right nasal passage complicated by intra-
nasal infection. After controlling the infection,
the bony partition was removed until the iX)Ste-
rior opening conformed to the left one. A plug
of wax was moulded to correspond in shape and
size to the newly made opening and placed so
that part of it extended into the vault of the
pharynx. This was held in place by a little pack-
ing in the nose. Every few days it was re-
moved, the nasal pa.ssage cleaned, and the plug
replaced. In a few weeks the surface was cov-
ered by the mucosa and the passage way re-
mained patent. I examined the opening a num-
ber of years afterward and it remained the same
as when the patient was discharged.
The other case Wcis also a young woman, aged
20, who several years before she came to me
had been operated on for suppurative mastoid-
itis, complicated by a brain abscess. The sur-
geon who had her in charge was unable to keep
the external auditory canal open. He told me
the patient was critically ill for a long time and
that this interfered very much with the treat-
ment. At the time she consulted me she gave a
history of frequent attacks of severe pain for
days, followed by pus forcing itself to the surface
through a small opening where the auditory
canal had been. Examination showed no trace
of an external auditory canal until the pus ap-
peared. There existed then a sinus to the mid-
dle ear. This was curetted out and the passage
way was found to be small. A thin pencil-like
plug of wax was forced into the newly made
canal and held in place by a pad of cotton and a
bandage. This was removed daily and the ear
treated. As weeks and months passed the plug
was increased in size, and the suppuration in the
ear ceased. The skin followed down the newly
made canal and finally united with the lining of
the middle ear. The canal to-day is about.,nor-
mal in size, and the ear has given no trouble for
about 3 years. She now hears ordinary conver-
vation at 3 or 4 feet.
This case illustrates absorption by pressure
and the restoration of a canal by securing an
epithelial lining for it, etc. The plugs were made
larger about every 2 weeks. They were cleaned
with alcohol, and frequently lubricated. The
case was under treatment for about one year.
The result in my opinion justified the effort.
DISCUSSION
Dr. George W. Mackenzie (Philadelphia): I have
never used dental wax as an obturator or for any other
purpose. We have conditions following operations where
something seems to be needed to keep the opening patu-
lous. For instaiKe, I recall when the Krause operation
on the maxillary sinus was in vogue, we endeavored to
make the opening large enough to admit the finger, hop-
ing thereby that it would not close over. When a wound
of the kind is made we have on the inner surface the
mucous membrane lining of the sinus, and on the nasal
side of the mucous membrane layers we have the con-
nective tissue which tends to grow faster than the mu-
cous membrane and thereby bridge across and occlude
^e opening and nullify our results. There is nothini;
better for burning out these granulations than nitrate
of silver. Nitrate of silver has the advantage of re-
diKing the granulations without disturbing the normal
epithelium to any great extent. The result to be de-
sired in operations on the maxillary sinus is to obtain
a permanent one that will not close, and this can be
accomplished only by keeping the granulative tissue
reduced sufficiently to permit a growth and tmion of
the epithelial lined mucous membrane of the maxillary
sinus and that of the nasal cavity proper, so that in
the end we have an epithelial covered rim. This same
principle applies to the cases of radical operation oti
all the sinuses. We have all seen cases where after
an otherwise thorough operation upon the frontal
sinus all went for naught because of lack of attention
to the after treatment. It is possible dental wax may
have prevented subsequent occlusion, but of this I am
uncertain. I have been accustomed to bring down
granulations with nitrate of silver judiciously applied.
It may be that dental wax might have accomplished
the results better.
It occurs to me that the presence of this wax might
act as an irritant and tend to keep up the granula-
tions so that after its removal the connective tissue
might keep up its lead in the race with the epithelium
Dr. Claren'ce M. Harris (Johnstown) : My use of
the wax splint has not been extensive, but I can testify
to its efficiency in all cases of nasal synechia, as the
doctor has set forth in his paper.
Dr. WauAM H. Sears (Huntingdon) : That is the
only thing I have used this wax for, but it is very
efficient. I imagine it would be equally good in the
other conditions he has mentioned.
Dr. Watson Marshali. (Pittsburgh): Have you
had occasion to use it in intranasal operations for
dacryocystitis?
Dr. Luther C. Peter (Philadelphia): Have you
used it in the eye, and in those instances have yon
found that the wax changes its form after being in
the eye?
A Member: What influence does it have in case of
cicatricial contraction of the orbit?
A Member: What were your prehminary steps in
the case where there was practical occlusion of the
external auditory canal, where you used it to enlarge
the canal? Did you cut away any portion of the ad-
ventitious tissue, or did you insert a small piece?
Dr. Stahlman (in closing) :^1 .am g|ad_^o_know
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September, 1921
LENTICON US— MACKENZIE
877
that you are interested in this material and its uses.
The results depend on the man who uses it.
In regard to what Doctor Mackenzie said about
nitrate of silver, of course we have all used it many
times and yet the granulations show a tendency to
spring up. I have used it to shrink granulations with
fair results.
In regard to ear work, you cannot restore the canal
of the ear, or any canal, so that it will remain in good
condition after you are through unless you can get the
skin to follow down your canal until it meets the
epithelial lining from within. I recall a man who
was operated for mastoid trouble a number of years
ago and all he has inside the mastoid wound to-day is
a mass of scar tissue. It gets infected and has to
be treated and cleaned out three or four times a year.
In many of these cases of mastoid trouble where there
is failure to bring about complete epidermization, if
you can encourage the skin to follow the external
opening until it meets the mucosa within, you have
solved the problem.
The reason we have been unable to close the eusta-
chian tube after a radical mastoid operation is because
we failed to remove all epithelium lining the tube. In
rare cases the epithelium from the pharynx has ex-
tended up the tube until it united with the epithelium
from the tympanic cavity, especially in the cases where
a discharge has been finding its way down the old tube.
In chronic dacryocystitis, I have used this material
but with no marked success. I have passed a small
plug or pencil-like structure into the duct after it had
been enlarged by probing. Owing to the small caliber
of the plug it is hard to put in place and retain there.
As to using a wax ball in place of a glass one after
removal of an eye, the wax does not change its shape
to any marked degree. It will keep the lids separated
and is very comfortable to wear until the soft parts
settle down and then an ordinary artificial eye can be
Vforn without any trouble. It is simply a temporary
affair put in a few days after the eye is removed and
used until the socket is in good condition for the glass
eye. I have used it as an implant, but it failed to stay.
It might be used under very favorable circumstances.
In cicatrical contraction of the orbit I do not be-
lieve it has any great effect. The ball is changed in
size as the case demands and the orbital cavity is thus
maintained. The amount of scar tissue depends on
the kind of operation performed. It is assumed all
raw surfaces have been covered.
This material does not seem to be an irritant. One
of the features is that it will mold easily. If you make
splints out of it all you need to do is to hold it over
a gas jet and you can mold any size or shape you want.
If it is too large you can make it smaller, and you
can make it into so many different shapes that it is
admirable to use.
The reason I put in the name of the manufacturer
is that if you do not know where to get it, all this
discussion is of no avail.
One thing further in regard to irritation and pain :
you put it into the nose and with all the contortion of
the nasal cavity it may cause pain ; but the body tem-
perature is sufficient to soften it enough so it will con-
form to the shape of the nose and the pain will cease.
At the same time it is hard enough so it will not melt
but will retain its general shape.
To sterilize it you simply bring it to the boiling
point. I simply take a little aluminum vessel and put
in the quantity I want and hold it over a gas jet and
let it come to the boiling point for a few minutes.
In the case of occlusion of the epcternal auditory
canal, the scar tissue was bound down so firmly after
the long period of inflammation, that I ctvetted out
as much as I could with safety. This case had been
operated for mastoid trouble and a brain abscess and
they had drained the abscess through the external
auditory canal. The opening or canal after the curett-
ment was about 1/12" toj^" in diameter which ex-
tended down to the middle ear. A small plug was
made and pressed down into the canal firmly, causing
some pain. As the canal became larger I made the
plugs larger.
In the treatment of the ear I used the ordinary treat-
ment for any chronic middle ear trouble. The plugs
were changed daily for a long time until suppuration
ceased, and then every other day, and later every week.
There were no complications. The eustachian tube
must have been opened to an extent that it took care
of some of that drainage, for the ear would go for
maybe a week or two and then the pus would appear
at the surface. By cleaning the ear out every day and
putting in boric acid the amount of pus that would
form in twenty-four hours was not so great.
I trust this preparation will be of some value to all
who may try it.
LENTICONUS*
(with the report of two cases)
GEORGE W. MACKENZIE, M.D.
PHILADELPHIA
Judging from the space allotted to the subject
by the average textbook writer, it would seem
that lenticonus is either an exceedingly rare con-
dition or one of minor importance. Roemer,'
who gives the subject the most space, devotes
forty-five lines to it, the American Encyclopedia
of Ophthalmology* allows thirty-three lines, de
Schweinitz' sixteen and one-half lines, Ball* thir-
teen lines, Posey' three and one-half lines,
Swanzy & Werner* three and one-half lines,
Fuchs' (Fifth Edition, English) but two lines.
A glance through the literature on the subject,
as it appeared in the journals devoted to the eye,
convinces one of the fact that lenticonus is
neither so rare a condition, nor one of such
minor importance as would seem to be indicated
by the scant attention given to it by the textbook
authors.
According to the definition found in the'
American Encyclopedia of Ophthalmology, len-
ticonus, or lentoglobus, is a conical projection of
the lens surface. When it occurs in front it is
known as anterior lenticonus; at the posterior
pole it is called po.sterior lenticonus. It is a rare,
usually congenital anomaly of the lens, which
presents a conical prominence upon its anterior
or posterior surface (Fuchs'). Swanzy credits
•Read before the Section on Eye, Ear, Nose and Throat.
Diseases of the Medical Society of the State of Pennsylvania,'
Pittsburgh Session, October 7, 1920.
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878
THE PENNSYLVANIA MEDICAL JOURNAL September, 1921
it with being a congenital anomaly of the lens in
which the anterior, or still more rarely, the pos-
terior surface is cone-shaped. The view of most
authors, however, is that the posterior form is
found oftener than the anterior. Swanzy adds
that the derangements of vision are very similar
to those caused by conical cornea..
The first case of lenticonus to be described was
the one reported by Wester* in 1875. The same
case was also studied by Knapp.* It was that of
a twenty-four-year-old man whose vision had
always been poor in both eyes. Quoting from
Knapp, the ophthjilmic examination revealed the
same appearance as that found in keratoconus.
Oblique illumination showed, however, a normal
curvature of the cornea, as well as a decidedly
pronounced conical curvature of the central part
of the anterior capsule. There was found a
slight posterior polar cataract. This affection
■ was the same in both eyes. According to Knapp
it was either hereditary or acquired in early life.
Leopold Mueller" is undecided as to whether
lenticonus is congenital or acquired, but is in-
clined to believe that it develops after birth.
Placido," who with Van der Laan reported the
second case in 1880, believes that it is of gradual
development, beginning at early puberty. Fuchs
places lenticonus among the list of congenital
anomalies of the lens. Eiseck" assumes that his
case was one of congenital origin. F. Meyer,*'
who reported the third case of lenticonus, is of
the opinion that if lenticonus develops first at
the stage of puberty, as claimed by Van der Laan
and Placido, it cannot be a formation anomaly.
The only anatomical findings existing up to then
were those of Becker," whose exp)eriments con-
sisted of examinations made of rabbits' eyes af-
fected with lenticonus. The results obtained ap-
parently speak for a formation anomaly. Meyer
further claims that lenticonus is neither a forma-
tion nor a developmental anomaly, but rather the
result of a pathologic process, supported by the
fact that the posterior capsule of the lens in his
case showed a distinct haziness or clouding. The
frequency in which lenticular opacities occur as
an incident in lenticonus, has been referced to by
Pergens.'' He mentions that of twenty eyes af-
fected with lenticonus collected from the litera-
ture, the lens was transparent in only seven;
otherwise cataracta polaris posterior or other
cloudiness was present. More recent estimates
tend to show a lower rate of cataract associated
with lenticonus. Since this haziness is not found
in all cases but only in those of long standing,
it would rather point towards the conclusion that
it is a secondary change, and tends thereby to
support the contention of Meyer that the whole
process is founded on a pathologic basis.
Summarizing from the cases reported in the
literature the writer desires to present the his-
tory, symptoms and signs of an average case of
posterior lenticonus.
The history in the average case is that for a
number of years the vision has been poor, espe-
cially for distance. The patient is generally able
to read but poorly with the naked eye, while the
vision is slightly improved with a minus lens
(-5Dto-i2D) and occasionally even stronger.
This improvement, however, is considerably less
than is generally obtained in a case of uncom-
plicated myopia. The impaired vision is occa-
sionally limited to one eye ; more often both eyes
are affected. In other cases, though the vision is
poor in both eyes, it is markedly more so in one
than the other. Comparing the unilateral with
the bilateral cases, there seems to be a slight ex-
cess of the unilateral. Of the eighteen cases re-
ported in the literature up to 1902, Pergens men-
tions that only two were double-sided. Upon close
inquiry the average patient relates that though
the vision has been diminishing perceptibly for
a number of years, it was never excellent at its
best as far back as his memory reaches. The
average history shows that the impairment of
vision has been progressive, again suggesting a
pathologic process rather than a congenital con-
dition which was fixed prior to birth. ,
Refracting with or without a mydriatic after
the subjective method, the average patient selects
a minus glass, which he claims sharpens his
vision ; however, in the majority of cases it will
be found that the visual acuity has not been im-
proved to the extent the patient at first believed.
It is not altogether rare where the opportunity
is afforded to compare the patient's refraction
over a number of years, to observe a change
from that requiring a plus to one requiring a
minus correction ; in other words, a tendency to
an increase in the myopia comparable with that
which occurs in progressive myopia, the resuk
of posterior staphyloma. This tendency to
myopia, or increase of myopia where it had al-
ready existed, may be more apparent than reql,
at least in some cases. For instance, one may
examine a case under a mydriatic and find the
patient's vision improved with a plus 1.50 D.
Sph. for distance: whereas at a postmydriatic
examination a week later, the plus correction is
refused, the patient preferring a -8.00 D. Spasm
of accommodation does not explain this dispar-
ity, for it was observed in one of my patients at
the age of 62 years, in another at 70 years. Had
cither of these cases been seen by two different
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LENTICONUS— MACKENZIE
879
observers at wide intervals the first observer
might have prescribed glasses while the patient
was under the mydriatic and thereby have writ-
ten his prescription f or a + i .50 D. The second
observer some time later, fearing to use a mydri-
atic, might have prescribed a — 8.00 D. A third
observer seeing the patient still later and com-
paring the two prescriptions might jump to the
conclusion that myopia is advancing rapidly,
whereas in fact there has been little or no
change in the actual refraction covering the en-
tire period. This might explain the apparently
changing refraction toward myopia in some
cases, but the writer has sufficient reasons for
doubting that it explains every case. In one
exceptional case marked improvement in vision
with a strong minus glass was obtained. These
patients not infrequently report that their case
has been previously diagnosed as one of cataract.
The external examination of the eyes as a rule
reveals a grayish pupillary reflex, suggestive of
cataract. After dilating the pupil it will be ob-
served that this apparent cataract is central with
a peripheral clear zone surrounding it (L. Muel-
ler). With oblique illumination and with the
closest scrutiny the lens is found to be trans-
parent, clear to the posterior pole in the majority
of cases. Furthermore, there is the absence of
the iris shadow which is quite definite in an im-
mature cataract. In other cases with oblique
illumination a cloudiness may be observed of a
definite shape, as in one of Salzmann's'* cases,
cited by Mueller. This cloudiness took the form
of a short-stemmed T. The cloudiness of the
lens found in posterior lenticonus is due to the
reflex from the posterior surface of the lens,
rather than to opacities in the lens substance. In
some few cases of Iong-st£inding there occurs a
complicating posterior polar cataract which, when
sufficiently pronounced, can be detected by ob-
lique illumination. In other less pronounced
cases it can be detected only with the aid of the
ophthalmoscope.
The study of the Purkinje-Samson images
with the candle flame in a dark room is rather
difficult to make, for the reason that the small
reflex from the posterior surface becomes even
smaller in the region of the conus. It is there-
fore advisable to use a larger source of illumi-
nation, such as a gas flame, as was used by Salz-
mann in the study of his case. Where a smaller
source of illumination is used, a magnifying
loupe is a necessary aid.« In moving the source
of illumination about, it will be observed as it is
brought nearer to the axis of the eye that the
image, reflected from the posterior surface
changes its shape. It becomes elongated radially
and then diminishes perceptibly in size ; further-
more, it appears to come from a greater depth
than in the case of the normal eye. It is well in
making this test to use the other eye of the pa-
tient, if normal, as a control, or else the eye of
a normal individual.
Divergent strabismus occurs not infrequently
in these cases, as was first noted by Webster and
later by other observers.
It is with the ophthalmoscope that the most in-
teresting features of lenticonus are to be ob-
served. With either the plain or concave mirror
at a distance of ten inches with a + 4 Ds lens,
the lenticonus is most readily recognized, ac-
cording to the description of Meyer, Knapp, and
other authors, "as a drop of oil in water." Per-
haps the most graphic description yet oflFered is
the one by Leopold Mueller, from whom I quote
in abridged form as follows : "The right eye of
an eighteen-year-old male was examined with a
plain ophthalmoscopic mirror. There appeared
a dark disc in the middle of the illuminated pupil,
which was not due to any clouding of the lens,
but to a 'Schatten-phenomena' (shadow phe-
nomenon). Upon turning the mirror there ap-
peared no longer a complete dark shadow, but a
red sector, the apex of which lay in the middle
of the pupil ; the base of the sector corresponded
to the edge of the dark disc. By changing the
inclination of the ophthalmoscopic mirror the
sector changed its position. The sector did not
disappear from its first position and reappear in
the second, but was seen to move directly from
one to the other. It was observed that even by
relatively slow movements of the mirror the
illuminated sector would jump rapidly in a circle
about the central point."
Lawford Knagg's" description is as follows:
"On examination with the ophthalmoscope at a
distance of three or four feet, by the direct
method, a clear uniform red reflex was obtain-
able. With slight manipulation of the mirror,
dark shadows could be made to play around the
central point of the lens, but always leaving a
narrow zone of red reflex between the periphery
of the shadow and the margin of the pupil. Ap-
proaching to about twelve inches distant, a disc
with a diameter of 5.5 nim. was seen centrally
placed in the pupil. It was of a slightly duller
red than the peripheral part of the reflex, from
which it was marked off by a faint circular
shadow, which varied somewhat on movement
of the mirror, and sometimes took a reddish
tinge due to the retinal vessels. The shadows al-
ready described as circling round the central part
of the lens were formed entirely within this
disc, and a more careful observation showed that
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880
THE PENNSYLVANIA MEDICAL JOURNAL September, 1921
they were similar to those formed by keratos-
copy in a myopic eye, viz, moving with the mir-
ror ; but instead of the edge of the shadow be-
ing straight, it was crescentic, and the two ends
of the crescent embraced the centre of the disc."
Sym" describes the disc as it appears in the
lens when viewed with the concave ophthalmo-
scopic mirror, as follows: "The pupillary field
divides itself into two parts, one a central, dim,
faint, circular area having a diameter of 4 mm,
and the other a clear annular portion surround-
ing it, in which the ordinary appearances of an
eye affected with moderately high myopia are
presented. The two areas are sharply divided
from one another. Inside the central area the
retinal vessels are seen to pursue pretty much
their usual course, though in a rather erratic
fashion, but on a slight movement of the eye
they twist and twirl about in a most bewildering
manner, the part of a vessel seen within the cen-
tral area pursuing the same apparent (myopic)
course as the part in the surrounding ring, but
in a much more rapid and erratic way, so that
occasionally a vessel looks as if it were looped
or knotted on itself."
About half the cases of lenticonus of consid-
erable d^ree (8 to 14 diop.) show vitreous
opacities. Knaggs reports such findings in his
case, and the writer found "it in one of his.
The writer desires to report the following
cases:
Case I. E. M. H., physician, aged 62 years,
was first seen by the writer September 11, 1910,
at which time he furnished the following his-
tory : patient began to wear glasses at the age of
thirty-five, when he was beginning to train for
the practice of ophthalmology. His chief at the
time pronounced his eyes perfect in spite of the
fact that the patient observed that he could not
study for more than one hour without becoming
nervous, which was the particular indication that
prompted the patient to seek the examination.
The examination was made under homatropin,
and it revealed, according to the patient's ac-
count, a mild grade of hyperopia with astigma-
tism ; the exact amount was not ascertainable
since his chief had died in the meantime, thus
preventing us from recovering the records. The
patient claims to have had good results from the
refractive correction made at the age of thirty-
five, and only the usual slight modifications were
necessary until five years ago, when he discov-
ered he could not see well with his right eye.
The lenses were then changed several times at
short intervals. The first change was to a weaker
plus glass ; a short time later he required a minus
correction. He complains of no severe pain, but
has a feeling of unrest, a consciousness of dis-
comfort short of pain, but sufficient to be notice-
able. If it were not for the fact that he does not
see well with the eye he feels that he would
hardly pay any attention to this discomfort.
At the present time (September 11, 1910,) he
reports that he is wearing a plane glass before
the right eye. The vision in left eye with pres-"
ent correction is good for distance and for near.
Neither a plus nor a minus glass improves the
vision of the right eye. The patient claims that
he had floating vitreous opacities two years ago.
At the present time he complains of diplopia
with right eye open and left eye closed (monocu-
lar diplopia). When looking at a light (Wels-
bach light in the office) with the right eye, it
appears very much enlarged as compared to its
normal size as seen with the left eye. The light
looks large and round, like a cart wheel with
three radiating spokes, one spoke appearing to
correspond with two o'clock, another with three-
thirty, and a third with five-thirty; and three
lesser spokes, one at nine-thirty. (Unfortu-
nately, the remaining two were not recorded).
At night when looking at gas or electric light,
bright lines are seen which are very constant and
very annoying. Vision in the right eye has been
progressively diminishing. When first attempt-
ing bifocals he could not wear as strong a plus
addition before the right eye as before the left
eye. Vision of O. D. taken at this first \'isit re-
vealed 2/22 ; at four inches and somewhat closer
the patient is able to read 37 cm. type without
a glass before the eye. Vision of O. S. taken
with present correction (-|- 2.50 D»0-f .25 D^'
ax. 70°) gives 6/4.5 scant. The external ex-
amination reveals normal mobility of the eyes,
divergent squint, the patient fixes with the left
eye while the right deviates outward approxi-
mately 20 degrees. The pupils are equal in size
and react promptly to all stimuli. Tension taken
with the fingers normal O. U. After instilling
cocain in right eye for closer study, the cornea
is observed to be brilliant, transparent and other-
wise normal. Anterior chamber is of normal
depth. Iris normal in texture, the left eye being
used as a control. A slight haze is noticeable in
the central portion of the lens of O. D. that is
not present in the lens of O. S.
With the ophthalmoscope at 20 cm. using a
.concave mirror and + 5 D lens, a sharply de-
fined dark disc is visible in the centre of the red
reflex. The diameter of the dark disc appears to
be about one-third that of the whole pupillar)'
diameter after cocain mydriasis. The disc is not
uniformly dark, but is darker at the edge tlian
toward the centre. The darkness of the disc
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LENTICONUS— MACKENZIE
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varies with the distance at which the ophthal-
moscope is held from the patient's eye; for in-
stance, at one distance the circle of greatest
darkness is larger, and for another distance
smaller, but at all times the outline of the lenti-
conus is sharply defined. At 20 cm. distance it
looks very much like the drop of, oil that others
have likened it to. When looking from a level
below the horizontal or by having the patient
look upward, the observer maintaining the one
jjosition, the shadow appears to move downward
in its setting of red reflex, as noted by a narrow-
ing of the peripheral margin of normal red re-
flex below and a widening of the reflex above
the shadow. On viewing the dark disc from
above the appearances are reversed. The direc-
tion and amoimt of parallactic movements, there-
fore, establish the fact that the shadow is cast
from a curved surface just far enough behind
the plane of the iris to correspond to the poste-
rior surface of the lens, somewhat bulged ; con-
sequently a posterior lenticonus.
From the date of this first examination the
patient has reported many times, at first at closer
intervals (a few months apart) latterly at wider
intervals. He is still living. To report his case
in every detail would make too long a story. It
is better, therefore, to summarize from the fur-
ther observations.
At odd times the patient complained of slight
pains in the right eye, together with tenderness
noticeable during attempts at taking tension with
the fingers. A few months after the first exami-
nation the patient reported slight improvement
in vision (doubtful). With naked eye his best
vision O. D. is 37 cm. type at four inches. This
is equivalent to a myopia of about 10. diopters ;
however, with undilated pupil he sees quite as
well with — 10. as he does with a -|- i. At a
still later date he reports that while trying out
his vision he observes with the naked eye a dark
horizontal line dividing his vision ; he can see
60 meter type at 2 meters, but the capital letter B
seems to be truncated or jammed together (pa-
tient's o.wn expression). The upper half of the
B seems to be in its normal proportion but the
lower half is very squatty. On inclining the
head to right or left 45 degrees all becomes a
blur ; vision is better with head erect (possibly
due to sagging down of a pendulous lenticonus),
for the patient has a fluid vitreous with numer-
ous small floating opacities. With the pupil di-
lated it is possible to obtain only a fair view of
the fundus details, hindered in part by several
delicate lenticular riders. It is probably these
riders that account for the presence of the "cart
wheel spokes" referred to by the jjatient, for
they appear to correspond in number, size and
extension to the patient's description.
December 7, 1915, about five years after his
first visit, patient reports that he is able to see
the clock dial effect which he referred to as a
cart wheel with spokes at his first visit. ?Ie was
asked to make a drawing of it as he had done
on some of his earlier visits. A comparison of
the drawings show them to be quite uniform.
At this visit he seems to be less myopic than he
had been a few years before. Without a cor-
recting lens his vision is 2/60 with — 1.25 D'G
I — 3.00 EKy' ax. 70° he is able to see 6/20.
With his head inclined slightly backward (about
25 deg.) he observes a bright red horizontal line
dividing his field into two, the lower half is bet-
ter illuminated than the upper.
There is no question in the writer's mind but
that this is a case of posterior lenticonus which
began some time between his thirty-fifth and
sixty-second year, advancing rapidly for five
years prior to his sixty-second year, without any
pronounced changes between his sixty-second
and his seventy-second year. The lenticular
riders observed in the right eye may be of senile
origin ; however, there are no changes of a cor-
responding character in the left eye which per-
mits one, therefore, to surmise that they are the
result of stretching of the posterior capsule of
the lens. The lenticonus in this case is of the
posterior variety. It is probably pendulous, for
changing the position of the head works a change
in the patient's vision, better with the head up-
right or tilted slightly backward than in any
other position. The fluid condition of the vitre-
ous with the floating opacities rather suggests a
pathologic basis for the lenticonus, at least in
this particular case.
Case 2. Mrs. J. B. K., age 48, referred by
Dr. Weston D. Bayley, of Philadelphia, was .seen
for the first time May 11, 1920, when she
presented the following history: The patient
claimed to have enjoyed good health up to five
years ago, when she began to suffer from neu-
ralgic pains above the left eye. Later it ex-
tended to the region of the left cheek and lasted
for several months, and then subsided. For a
year or more prior to two months ago the patient
was quite free of pain, when the pain became
quite acute again, and it was because of this pain
that she was referred to the writer. This part
of her history is quoted not because it had any-
thing to do with her eye condition, but for the
reason that the case report would be incomplete
without it. Her neuralgia was evidently due to
intranasal conditions which cleared up promptly
after intranasal operations, the details
Digiti ■ ■
882
THE PENNSYLVANIA MEDICAL JOURNAL Sei'Tkmber, 1921
are not essential for our present purpose. The
c)'e condition to be reported was discovered only
incidentally after the patient had requested an
examination of the eyes, because of her glasses
liaving been broken a day or so before. She re-
ports further tliat the vision of her left eye has
been poor as far back as she can remember and
that she has never been able to secure a glass for
the left eye to help her see much better. Her
])resent correction neutralized
C). D. + 1.75 sphere
O. S. — 4.00 sphere O — .62 cylinder, axis 180°
External examination : eyes move well and to-
gether in all directions, convergence good ; O. D.
is out under cover i mm. for distance, O. S. like-
wise. About the same amount of outward devi-
ation is noted for near vision by the cover test.
Tension normal O. U. Ocular and palperbral
conjunctiva slightly congested, O. S. more so
than O. D. Cornea brilliant and transparent O.
U. Anterior chamber normal depth. Irides blue
and of normal texture. Pupil of O. D. larger
than pupil of O. S. Both react promptly to
light, accommodation and convergence. Pupils
normally black by oblique illumination.
Ophthalmoscopic examination : Examination
of the refractive media with the Morton oph-
thalmo.scope, concave mirror, and + 4.00 lens at
about 10 inches distance reveals normal trans-
parency in O. D. Examination of O. S. is rather
unsatisfactory, because of a faintly dark shadow
in the pupillary area. The pupils of both eyes
were then dilated with homatropine, when the
media were again examined after the same man-
ner as before. The shadow previously observed
with the natural pupil is seen to better advan-
tage, and appeared to occupy the central area of
the dilated pupil, when viewed from in front ;
that is, when the patient looks directly at the mir-
ror of the ophthalmoscope, the diameter of the
dark area appears to be about two-thirds that of
the widely dilated pupil and is fairly well de-
fined. The intensity of the shadow increases
perceptibly toward the center. Observation
through the peripheral zone shows the brilliancy
aitrl coloration of the red reflex to be the same
;ts that observed throughout the pupillary area
of O. D. Since the ophthalmoscopic findings in
O. D. are normal in every particular, further
reference to them will be omitted except where
comparison may be necessary. Further observa-
tion of the dark .shadow seen in the pupillary
area of O. S., varying the distance of the oph-
thalmoscope from the eye, reveals a small lighter-
colored glistening area in its very center. The
color of this glistening area compares with that
of the moon-stone ; there is practically no tint
of red in it. This highly refractile area is ob-
served to best advantage at a definite distance
(estimated to be about 10 inches). On increas-
ing or diminishing the distance, the most central
area becomes dark again, even darker than the
rest of the dark area. When the most central
area is observed light in color, it is surrounde<l
by a dark zone, and this again surrounded with
the normal red reflex. Slight movements of the
ophthalmoscopic mirror causes the shadow to
play rapidly about the central spot of the pupil
in a tortional manner. The shadow is observable
at distances from 4 to 20 inches, less distinct
however as the distance is diminished or in-
creased beyond 10 inches. Retaining the -|- 4
lens in the ophthalmoscope and increasing the
distance beyond 10 inches, the shadow enlarges
and becomes paler. When the patient is directed
to look to the left, the shadow moves to the left,
assuming a position eccentric to the temporal
boundary of the pupil. When the patient looks
to the right, the shadow moves to the right and
assumes a position eccentric to the nasal bound-
ary of the pupil. These movements of the
shadow establish the fact that it must lie in a
plane anterior to the plane of the iris ; in other
words, in front of the pupil.
The findings up to this stage suggest the pres-
ence of either an anterior lenticonus or kerato-
conus necessitating the inclusion or elimination
of the latter. In the ultimate diagnosis accord-
ingly a Placido's disc was used for the purpose
of studying the reflection from the anterior sur-
face of the cornea. With the aid of this valuable
instrument no change in the contour or size of
the white circles reflected from the cornea is ob-
servable when the reflection is made to play over
its surface; besides there are no variations ob-
servable when comparing the cornea of the af-
fected eye with that of the patient's normal right
eye. The exclusion of keratoconus leaves lis
with but one possible condition capable of ex-
plaining the phenomena present in this ca.se.
namely, anterior lenticonus.
Examination of the fundus by the indirect
method — O. D. normal ; O. S. without mydri-
atic, un.satis factory. After the use of mydriatic
the optic disc is observed to be quite round,
sharply defined, scleral crescent on temporal
edge, the physiologic cup is fairly well defined,
the lamina cribrosa is somewhat obscured be-
cause of the presence of a slight amount of con-
nective tissue which extends along the vessels
but is limited to the disc. There is one tiny
cilioretinal artery present; otherwise the size
and di.stribution of the vessels are normal. The
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Skptember, 1921
LENTICONUS— DISCUSSION
883
rttina, including the macular region, appears to
be normal.
With the direct method the fundus of O. S.
is seen clearest with a minus lo. D lens in the
scope, so long as one studies the fundus through
the central area of the lens. If studied some-
what peripheralward or by having the patient
look slightly to one or the other side, the fundus
can be seen quite as well with a less minus glass
in the scope. It is impossible to note any paral-
lactic movements as has been observed by the
writer in cases of posterior lentoconus or lenti-
globus. A further distinguishing feature is that
in the several cases of posterior lenticonus
studied by the writer by oblique illumination
there was observable a more or less gray reflex
in the central portion of the pupillary area which
is absent in this case of anterior lenticonus. The
writer is especially pleased to report this case of
anterior lenticonus since it is the first of the kind
that he has had an opportunity to study. On
looking over the literature of reported cases of
lenticonus, the writer finds the vast majority to
be of the posterior variety.
An apology is offered for what to the writer
appears to be rather incomplete reports of two
interesting cases of lenticonus ; however, enough
data is presented to establish the diagnosis to
his satisfaction.
In preparing the case reports herewith cited,
it was necessary for the writer to study not only
the records of the cases but the patients them-
selves a second or third time most carefully in
order to satisfy himself that nothing was omitted
to mar the reports, in spite of which he finds that
improvements are possible.
BIBLIOGRAPHY
1. Roemer. Translation by Foster, Textbook of Ophthalra.
Rebman Co., New York, 1913, pp. 273-274.
2. American Encyclopedia of Opbthalm. Cleveland Press,
1917, Vol. X, pp. 7417, 7418.
3. de Schweinitz. Diseases of the Eye. 8th Edition. W. B.
Saunders Co., 1916, p. 394.
4. Ball. Modern Ophthalni. F. A. Davis Co., Phila., 1913,
pp. 438, 439.
5. Posey. Diseases of the Eye. Lea Bros., Phila. and New
York, 1902, p. 478. .
6. Swanzy & Werner. Diseases of the Eye. nth Edition.
P. Blakiston's Son & Co., 19 15, p. 295.
7. Fuch's Textbook of Ophtbalm. 5th edition by Dtiane. J.
B. Lippincott Co., Phila., 1917, p. 558.
8. Webster. Archiv. of Ophth. & Ofol. (Knapp). Band iv,
p. 382.
9. Knapp. Archiv. f. Augenheilk., 1891. Bd. xxii, p. 28.
10. Mueller. Klinische Monatsblaet f. Augenheilk. 32 Jahr-
gang, 1894, P- 178.
11. Placido & Van der Laan. Una nuova anomalia de con-
formacav de cristallino & Period de oftalm. prat.; rivista bim.
No. 3 Lissboa. 1S80.
12. Eiseck, klin. Monatsblat. f. Augenheilk., 1892, Vol. xxx,
p. 116.
13. Meyer. Centralblatt f. Augenheilk., 1888, Bd. xi, Cen-
tralblatt f. prakt. Augenheilk., 1888. Bd. xii, p. 41.
14. O. Becker, zur Anatomic der gesunden und kranken
Linse, Weisbaden, 1883, p. 126.
15. Pergens, Zeitschrift f. Augenheilk.. 1902. Vol. vii, p. 451.
16. Saltzmann, cited bv Leopold Mueller, Klinische Monats-
blaet. f. Augenhrilk.. 32 Jahrgang. 1894, p. 184.
17. Knaggs. Lancet, Vol. ii, 1891, p. 657.
18. Sym, Ophthalmic Review, Vol. xiv, 1895, p. 76.
DISCUSSION
Dr. Edward Stieren (Pittsburgh) : Doctor Mac-
kenzie is to be commended for bringing before this
Section such an excellent paper on this little discussed
topic of ophthalmology. I am strictly in accord with
him in his statement that it is a condition prone to be
overlooked or improperly diagnosed as nuclear or pos-
terior polar cataract, the salient features of the un-
usual curvature of the surface of the lens being over-
looked.
The posterior surface of the lens in lenticonus is
usually the side affected, but that it may occur in the
anterior surface and in a marked degree is admirably
illustrated by the case presented by de Schweinitz be-
fore the Section on Ophthalmology of the American
Medical Association last year.
The cause of lenticonus is shrouded in darkness
and while there is "usually a concomitant posterior
polar cataract yet this condition is by no means al-
ways present and when so, has happened as a result
of a rupture of the posterior capsule. That this may
be the result of traiuna at any period subsequent to
birth is illustrated by the case reported by Fisher in
the Ophthalmic Review, April, 1913. A concussion in-
jury had caused a minute rupture of the capsule at
the posterior pole. Gradually a small hernia of the
lens substance through the rupture produced the pos-
terior lenticonus. The explanation given by Collins
and Mayo that the capsule of the posterior pole of the
lens is so thin that it ruptures easily and that it is a
developmental defect, seems most logical. These
lenses examined microscopically showed the posterior
lens capsule had not already ruptured.
Dr. Waid E. Carson (Pittsburgh) : I should like to
ask the doctor if he tried the visual acuity by the pin-
hole test, and if so, with what results?
Dr. Mackenzie (in closing)- : I want to thank Doc-
tor Stieren and Doctor Carson for discussing the
paper. I might say that the etiology is uncertain.
Some of the cases I have seen reported have had in-
juries, and some have not. Of course a negative his-
tory does not necessarily exclude injury. In practically
all cases studied there has been found a stretching of
the posterior capsule and a displacement backward of
the nucleus of the lens.
The pin-hole test was made, but not recorded. We
could not find that it improved the vision any.
One thing I wish to speak of which has been quite
frequently observed by others as well as tjie writer is
that a patient is refracted with a mydriatic and appar-
ently requires a plus correction ; later on refuses the
plus and prefers a minus glass. In these cases the pin-
hole test was tried but we could not see that the
vision was improved. In fact, the vision was about
the same with a relatively strong minus lens as with a
plus lens.
That rats desert a sinking ship is proverbial. But it
now appears that they berth in life boats, as if in
preparation for sinking. Of 100 rats destroyed by
fumigation on a steamship arriving at San Francisco,
says the U. S. Public Health Service, 89 were killed
in the four life boats.
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884
THE PENNSYLVANIA MEDICAL JOURNAL Septkmber. 1921
THE PHARYNGEAL TONSIL— IMPOR-
TANT CONSIDERATIONS IN
ITS TREATMENT*
C. M. HARRIS, M.D.
JOHNSTOWN, PA.
The faucial tonsil has been the subject of so
many articles and discussions that it would seem
we should expect little improvement over pres-
ent day methods in its treatment. On the other
hand, however, the pharyngeal tonsil, commonly
termed "adenoid" when discovered, has appar-
ently not excited the same serious attention re-
garding the underlying factors or the operative
technic, as it would appear to be only an incident
in the operative treatment of the adjacent faucial
tonsil.
My object in presenting this brief paper is not
tt offer anything new, but to emphasize the im-
portance of intelligently treating this more
prosiac variety of tonsil.
As my hearers no doubt know, this tonsil is
present at birth and within certain limits is
strictly physiological, and proceeds to progres-
sively atrophy after five or si.x years of age
under normal circumstances. At times it is, no
doubt, abnormal at birth. It is composed of
lymphoid and connective tissue elements which
are covered with mucous membrane, and in
many instances the gland is invested with crypts
and openings which dip well into its substance.
That it may be the seat of acute or chronic in-
flammation somewhat like its faucial neighbor
cannot be denied. It may be pathological early
in life, but the surgeon is usually consulted after
the subject is three years of age.
Several varieties of pathologic enlargement
have been described. The simplest and most
easily dealt with is of soft consistency, due to
overgrowth of the lymphoid elements and often
covers a wide area, extending into the fossae of
Rosenmuller and down the posterior pharyngeiil
wall. A second variety is congestive in type and
secondary to systemic disorders; little hyper-
j)lasia is observed. Another type is of firm con-
sistency with actual hyperplasia of all its ele-
ments, the connective tissue predominating. Fre-
((uent inflammation is .said to promote this condi-
tion. Such a gland is more circumscribed in its
outline and makes a fine specimen when removed
witii a sharp curette.
What concerns us most is the obstruction
caused by the enlargement of this gland. That
its enlargement may be caused by extension of
inflammation from the nose may be quite true,
•Read before the Section on Eye, Ear, Nose and Throat
Diseases of the Medical Society of the State of Pennsylvania.
Pittsburgh Session, October 7, 19^0.
but I believe that in most instances it is the pri-
mary factor. It is observed that nasal disorders
commonly clear up after its renwval. It is un-
doubtedly an important contributing factor in
most ear disease during childhood and my ob-
servation causes me to believe that much deaf-
ness which becomes apparent in adult life, began
years before when the pharyngeal and faucial
tonsils were perniciously active. Owing to the
proximity of the eustachian orifices, either vari-
ety of tonsil when disordered may cause acute or
chronic tubal inflammation, but the adenoid is
the prime offender. It is but a short distance to
the middle ear, and practically all middle ear and
mastoid disease is secondary to that in the
pharynx. In the acute contagious diseases, the
adenoid contributes to the seriousness of the
situation.
To avoid facial, nasal and palatal deformity,
the gland should be dealt with early for, as has
been repeatedly stated, mouth breathing causes a
narrowing of the entire face and jaws, associated
with misplaced teeth, highly arched palate, con-
stricted nasal passages and frequently a bent and
obstructive septum. When such deformity ex-
ists, removal of the tonsillar structures alone will
not give all the relief desired unless other radical
corrective procedures are carried out.
Wliile comments like the foregoing may justi-
fiably be stated with frequency, it was my chief
object to draw particular attention to the oper-
ative methods and their outcome.
It may be presumed that the average operator
uses a curette of the Stubbs or Barnhill type. It
the growth is circumscribed, a proper width of
curette is chosen and skill is exhibited, a ver)'
clean pharynx is the result with no injury to the
adjacent parts, and smooth healing may be antici-
pated ; if the growth happens to be of more firm
consistency and widely distributed, much of it
may be left or in further attempts at removal, in-
jury to the tensor palati, levator palati, or supe-
rior constrictor muscles may occur. It is sur-
prising what the examining finger will on occa-
sions find after the initial sweep of the curette.
In fact, I could hardly get along without the use
of the finger as a guide and adjunct to the cu-
rette, especially when deposits are found in the
fossae of Ro.senmuller. If one will wait for the
cessation of hemorrhage and inspect the parts,
not infrequently will a fragment of the gland be
found hanging as though by a hinge which, if
left, would annoy the patient very much during
the healing .stages. This can be avoided by using
an instrument with a blade which slides forward
such as the LaForce and Braun devices. In my
hands they have their shortcomings as they are
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September, 1921
PHARYNGEAL TONSIL— HARRIS
885
more cliinisy, and frequently do not encompass
the adenoid with the same facility as the otiier
tyi^e of instrument.
The nearest approach to intelligent attack in
my operations has been the method of Dr. J. C.
Beck, which consists of passing the free ends of
a rubber tube through either nostril and bring-
ing them out through the mouth, thereby draw-
ing the soft palate well forward. By using good
light and throwing the patient's head well back,
a good view can be gotten in many cases and in-
struments can be carefully used ; hemorrhage
can also be stopped by direct pressure.
As the form and consistency of the gland vary
in different patients along with their general
physical processes, so will our immediate and re-
mote operative results vary. Who can say that
he always removes all the glandular tissue, or
that the muscles are left intact? In occasional
instances obstructive symptoms will return and
examination reveals a mass which may be lymph-
oid in character and which has proliferated from
minute deposits which remained after the gross
removal. In other instances, it may prove to be
a mass of scar tissue. In two cases I have seen
this fibrous mass return after careful and com-
plete removal, and can offer no suggestion as to
its prevention.
I have examined many postnasal spaces at
varying periods after operation and find all sorts
of appearances. Many are all that could be de-
sired, some show scars and contracture, while
quite a few have lymphoid deposits in one form
or another. My conclusion is that some of these
unsatisfactory results are due to unskillful oper-
ating, while some could not have been prevented
by any known precaution. Where possible, post-
operative douches and astringent applications
should be used, with attention to palatal and
nasal deformities later.
I would not have you assume that I condemn
the present day adenoid operation. It does a
world of good and the unsatisfactory results are
relatively few, but I believe that improvement is
possible and I trust that in time a technic may be
formulated which will compare favorably with
that practiced in removal of the faucial tonsil.
DISCUSSION
Dr. GEORce M. CoATES (Philadelphia): I am glad
that Doctor Harris has brought this subject before us
as I agree with him that surgery of the adenoid has
been somewhat neglected, most operators considering
it by far the least important part of the dual T. & A.
operation. I agree with almost everything the doctor
has said and desire only to emphasize certain points.
We have all, I dare say, seen some pretty raw ade-
noid surgery, or its results. These latter are because
of an incomplete operation, from whatever cause.
and are not of the destructive type seen in bungling
tonsil surgery, but nevertheless they are deplorable in
that the patient fails to get the relief expected. Of
course we all have disappointments and adenoid
masses do recur in the pharyngeal vault, but I am
rather convinced that when such happens in my own
cases it is because I have failed somewhere in my
technique. Most of our cases do well; it is only the
exceptions that we are concerned with, but I think
they should be loo per cent successful. In recently
examining several hundred ex-service men I was sur-
prised to find that in many of those who had had
tonsil and adenoid operations, there remained small
detached masses and tags of adenoid tissue, not only
in Rosenmuller fossae but in the midline as well.
Doctor Harris is correct in his statement that the
infected adenoid is frequently the aggravating factor
in nasal infections, particularly in the sinusitis of in-
fants and young children, as brought out by Dean and
Armstrong. There can also be no controversion of
the fact that many cases of impaired hearing function
have their inception in the diseased adenoid of child-
hood even though the offender may have atrophied be-
fore the aural condition became marked enough for
notice.
Adenoid surgery is limited, like that of the faucial
tonsil, to three broad methods: cutting downward
with the curette, upward with a sliding knife of the
La Force type, and avulsing with forceps. Adjuncts
are the use of the curette through the nose, and the
finger through the mouth.
There are certain points "in the surgery of this re-
gion that, if followed, will materially aid in obtain-
ing success. I personally operate with a curette. My
preceptor, Walter Roberts, of Philadelphia, long ago
taught me the most important factor in the use of this
instrument — it must be of razor sharpness. If selected
of a proper width to go between the eminences of the
eustachian tube orifices and as sharp as it can be made,
the mass can be readily removed at one sweep, leaving
a clean, uninjured zone where recurrence is most un-
likely to take place. A curette loses its extreme and
necessary sharpness after one or two operations and
is habitually used in only a semi-sharp or dull condi- -
tion.j The average curette seen in the usual hospital
instrument case is worthless. The up-cutting blade is
not needed if the curette is sharp and used skillfully.
It may be avoided in any case by incising the mucous
membrane just below the adenoid prior to the sweep
downward of the curette and the whole operation is
much facilitated by the use of either a single or double
soft rubber catheter through the nose, under the soft
palate and out through the mouth as described by Doc-
tor Harris as Beck's method. It enables one to oper-
ate with greater certainty and precision and, with the
aid of good illumination (no operation should be at-
tempted without this), renders the outcome much
more secure. A method that I have employed at times
with profit is thus to raise the velum palati, excise the
adenoid with one or two clean sweeps, palpate the "
vault with the bare forefinger to search for adenoid
remains, particularly in Rosenmuller fossae, and if
found, smooth them down with the forefinger covered
with two thicknesses ofgauze. This all takes but a few
seconds, and a gauze tampon of proper size, coated
with bismuth subnitrate, or moistened with iodine and
benzoin, is hastily tucked into the vault and firm pres-
sure made for a short time. This checks all bleeding
and the faucial tonsils can then be removed at leisure.
By the time this is accomplished and bleediiig arrested.
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886
THE PENNSYLVANIA MEDICAL JOURNAL September. 1921
the postnasal plug is easily removed by retracting the
soft palate, when the vault will be dry. Where the
tonsils are large and prominent they interfere too
much for this reversal of the usual procedure. '
I believe the exploring finger should always be used
after removing the adenoid. Forceps in my hands
have not proved effective, leaving a ragged and uneven
field, but are useful to finish up with after an oper-
ation with a dull curette. The La Force method is
good but not sufficient in itself, as it is not readily
adaptable to all sized and shaped vaults.
As a routine last step, I always dilate the nose with
a Lewis dilator, introduced straddling the septum, so
that pressure on the handles crtishes the inferior tur-
binate the lateral nasal walls and squeezes them out.
In many cases of marked adenoid hypertrophy we
may be disappointed in obtaining prompt restoration
of nasal breathing after operation on account of the
enlargement, engorgement or misplacement of these
bodies. Dilatation gives us physiological breathing at
once with manifest good results.
After treatment, I believe, is impracticable and not
worth the trouble as, if a clean operation is done,
healing is usually prompt and painless. Free nasal
breathing is to my mind more important.
Dr. Watson Marshall (Pittsburgh) : I am much
gratified to hear Dr. Coates' remarks about the re-
moval of adenoids before the removal of tonsils. I
think this is an important point. Blood is blood, no
matter whence it comes, and its loss should, in every
case, be prevented if possible. The idea of packing
the nasopharynx, I think is excellent. There is one
slight modification to what Dr. Coates said that I
should like to suggest, namely, to tie a silk thread to
the postnasal pack and after inserting, to anchor the
end to the mouth gag. The bleeding stops at once and
a clear, dry field results for the removal of the tonsils.
There is thus no difficulty in removing the pack.
We all know that the tonsils are mechanically wrong.
If they were free of crypts and the mucous membrane
were a continuous sheet over the exposed surface of
the tonsils few, indeed, would require surgical inter-
ference. The crypt is the element at fault and I be-
lieve the same principle applies to adenoids. If one
removes the adenoid body en masse, in the majority
of cases one finds deep slits or sulci, from one to five
in number, extending from the surface to the base,
analogous to the crypts of the tonsils. I feel that
middle ear and other complications due to adenoid
tissue in the nasopharynx owe their presence, in large
part, to the role played by these sulci.
Dr. Matthew S. Ersner (Philadelphia) : When
the I^a Force first came into vogue I naturally fol-
lowed suit but I found that by removing the adenoids
before the tonsils there was less danger of disturbing
the pillars which usually adhere from three to five
minutes, thus avoiding hemorrhage from manipulation.
In case the pillars are sutured on account of hemor-
rhage one is less apt to tear them out during the
manipulation while removing the adenoids. This
method of procedure is especially recommended for
beginners as they have no bleeding to contend with
after the adenoids are removed as a gauze pack may
be inserted into the nasal pharynx and tonsillectomy
performed without having any bloody interference.
The only bleeding the surgeon is confronted with is
purely tonsillar, if there is any. There is, however,
one disadvantage especially when the pack in the nasal
pharynx is too large, which causes a puckering of the
soft pillar and disturbs the natural anatomical rela-
tions ; but with a little practice and patience one is
soon able to judge the size of the pack and avoid any
serious hemorrhage that may have been overlooked
on account of the adenoid bleeding.
Dr. George B. Jobson (Franklin): For twenty
years I have removed the adenoids, alone, in children
in whom the tonsils were not diseased, even though
the latter were enlarged.
In my opinion adenoids should always be removed,
whether they be large or small, as they are not only a
fruitful soil for the cultivation of infectious organ-
isms which harm the host, but the hearing and facial
form are endangered by their presence. Not so with
tonsils, which may be large, and if not infected, and
not covered with a plica triangularis will seldom do
any harm.
No doubt I will be censured by the professional
anesthetist, when I tell you I use ethyl chloride for
general anesthesia in my adenectomies. The method is
as follows: the child is seated on the nurse's lap. a
gag placed in the mouth, and a conical shaped mask
of felt, with both ends open, and containing three or
four layers of gauze is placed over the mouth. The
ethyl chloride is sprayed upon the gauze, through the
small end of the mask, and in a few moments the pa-
tient is asleep. Great care must be taken not to overdo,
but to stop as soon as anesthesia occurs, even though
the body is rigid, as the reflexes will be sufficiently
abolished to remove the adenoids completely with a
La Force instrument, followed by curettement with
the gauze covered finger or adenoid curette. No
doubt there are more cases of acute adenoiditis than
we are aware of. I have had two such cases in my
practice in young women, upon whom I could use the
pharyngoscope. The symptoms were similar to those
of acute tonsillitis except the soreness was referred to
the postnasal space and "stuffiness" of .the ears com-
plained of. An interesting case of adenoids was re-
ferred to me, in a six-weeks-old baby, supposedly for
stricture of the esophagus, because it could not swal-
low when it attempted to nurse. Removal of the ade-
noids caused a wonderful transformation in the child
in a few weeks.
Dr. Harris (in closing) : I want to thank the gen-
tlemen for their generous discussion of this subject
I am very glad to agree with them in all their remarks,
especially as to the sharpness of the curette and the
means taken to avoid hemorrhage, although I, person-
ally, have not been accustomed to operate on the ade-
noids first.
One important point is the age of the patient Sonte
have advised against operating at an early age. I have
not been in the habit of doing it, although I have had
occasion carefully to weigh the question as to whether
it was better to continue with the evils we had, or to
try to get rid of them in spite of this objection, where
the health of the child was being seriously affected by
obstructed breathing. I have sometimes operated re-
gardless of age and have not had occasion to regret
it so far.
The high price of arsphenamine (salvarsan) is a
constant incentive to marketing useless fake substi-
tutes, says the U. S. Public Health Service. Large
quantities of such have recently been detected in New
York City and elsewhere. These products should not
be bought from unknown persons.
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September, 1921 SKIN ERUPTIONS— KNOWLES AND CORSON
887
SELECTIONS
OCCUPATIONAL OUTBREAKS OF THE
SKIN INCLUDING NOVOCAINE
ERUPTIONS
FRANK CROZIER KNOWLES, M.D., and
EDWARD FOULKE CORSON, M.D.
PHILADELPHIA
Eczema or dermatitis comprises a large number of
all cases of diseases of the skin. There were observed
from the years 1902-1912, 24,459 dermatological cases,
and of this number 4,142 were classed as eczema or
dermatitis.' In a paper read before the American
Dermatological Association in 1912,2 the external ori-
gin of eczema or dermatitis was discussed at length
and it was determined that one-fourth of these cases
is of external origin and almost one-sixth caused by
the trade of the individual.
Irritants causing an outbreak on the skin are almost
innumerable and therefore it has been decided best to
select only a few instances from our hospital dispen-
saries and private practice. During the last two
months (February and March, 1921), out of 228 new
cases coming for treatment to the Skin Dispensary of
the Jefferson Hospital, 12 were well marked examples
of trade dermatitis. The occupations represented in
this number were as follows : fisherman, cooper, fruit
dealer, cloth cutter, fumigator, tailor, manufacturing
jeweler, printer, machinist, driver, bronze worker and
candy maker. During the same period two dentists
employing novocaine and four women using hair dyes
have been under observation in private practice.
The hands, as would be expected of the portions
of the body coming most intimately into contact with
the various agencies employed in the several trades,
were involved in all the hospital cases. Indeed, with
the exception of the fumigator and the bronze worker
they were the only regions affected among the 12 in
that group.
According to R. Prosser White, "The 'catchment
points' of the skin's surface are its stomata and the
hollows between the ridges. This proposition is quite
obvious if the agent is black, such as soot, or darkened
by dirt or impurities, such as petroleum." The same
writer called attention to the fact that workers who
sweat profusely were much more liable to trade der-
matoses than those who perspired less freely. This
has been our own observation. Perspiration collects
the dust, fumes or other form or irritant, retains it in
contact with the skin and ofttimes, by dissolving it,
makes its action more severe.
The hands, besides being the most exposed portion
of the body, afford many special "catchment points"
as, the webs of the fingers, around the nails and the
furrows and creases of each of the numerous small
joints of those parts, in addition to the pores, hairs
and furrows common to most skin surfaces. Unless
special attention is given to rigid cleanliness this ma-
terial is apt to leave traces which later may irritate or,
indeed, the measures taken to remove the stains them-
selves prove the exciting cause of an outbreak. The
right hand, obviously, is usually worse than the left,
even when both are engaged in the same work. Occa-
sionally the functions of the two members differ, as
was noted in two of our cases, the printer and the cut-
ter, where each hand suffered from a separate cause.
The fumigator over an extended period of time had
been employed in liberating formaldehyde vapors.
For several years his skin withstood the action of the
fumes but finally became irritated and showed a gen-
eralized erythemato-squamous and vesicular eruption.
This repeatedly disappeared following treatment and
recurred when he resumed his work as a disinfector.
The bronze worker exhibited a vesicular outbreak on
the face, hands and forearms, both regions exposed to
acid fumes in the foundry, where he was accustomed
to keep his sleeves rolled up. The dentists showed a
decided inflammation of the hands and fingers, par-
ticularly the third and fourth fingers of the right
hand and the index finger and the thumb of the left
hand. There was marked vesiculation and pustulation,
fissuring, oozing, crusting and redness. This erup-
tion was apparently due to novocaine, as other irri-
tants seemed to have been excluded. With the syringe
held in the right hand, any leakage ran down on the
lower fingers of that hand, while the left thumb and
index finger were close to the field being anesthetized
and liable to be in contact with the solution used. The
four women using the hair dye showed a marked
edematous redness, extending down the face from the
hair line, with closure of the eye lids by swelling. The
outbreak was mostly dry, although there was some
slight vesiculation. Later in the outbreak the skin
was red and scaly. The itching was intolerable and
quite persistent. In some of these cases the eruption
and itching continued over many weeks.
There is no one who has written more completely
on the subject of "Occupational Affections of the
Skin" than R. Prosser White and the exact irritant
provocative of an outbreak in the present cases, will
be largely gleaned from his excellent book. Alkalies,
and especially caustic alkalies, have a rapid and most
deleterious action upon the skin. The strong solution
of caustic soda used by coopers in "barrel-washing"
was evidently the cause of outbreak in one of our
cases. The eruption occurring in fruit dealers appar-
ently is caused by the essential oil which exudes from
cutting the rind of oranges. Our patient frequently
had his hands wet with the juice of citrus fruits.
Outbreaks occurring amongst those handling fish are
usually due to the salt in the "fish-curing" industry.
The greater the concentration of the brine, the more
irritation is produced. The eruption in our case was
evidently produced by the irritation of the fish scales,
the lines and the prolonged immersion of the hands in
cold water, as the patient was not a "pickler." Potas-
sium cyanide used for the cleansing of silver, gold and
less precious metals and quick "rouge," a red powder,
containing ferric oxide and mercury, employed for
"dry polishing" were undoubtedly causal in two of
our cases.
The cases observed in trades dealing with cloth
handling, one in a tailor and the other in a cutter,
would suggest that the mordants or other chemicals
still remaining in the cloth were to blame. The latter
worker exhibited on the fingers an itchy, vesicular and
erythemato-squamous outbreak. In addition, a scaly,
reddened patch ran diagonally across the palm of his
right hand, corresponding to the region pressed by the
shears when at his work. The eruptions occurring in
candy workers may develop from an inferior quality
of sugar in which there is an acartis. The old-fash-
ioned brown sugar was apparently more apt to cause
an outbreak than those doubly refined. Sugar is fre-
quently a cause of eczema in those who handle it
largely, mainly grocers, candy workers, pastry cooks,
etc. Our patient handled an inferior grade of candy
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THE PENNSYLVANIA MEDICAL JOURNAL Sei'TEmber, 1921
in a confectioner's shop. She developed the outbreak
after a month's employment at this work. On chang-
ing her form of occupation she was much improved.
It is rather difficult to come to a conclusion as to
the special irritant causing an outbreak in the me-
chanical trades, as to whether a high grade of petro-
leum oil or the cheap oils siKh as heavy coal tar, shale
or refuse where employed. The outbreak occurring
on the hands and forearms of mechanics is undoubt-
edly of local origin. Dirty lubricating oil, full of sedi-
ment and impurities as encountered in automobile
crank cases by repair men is more irritating than the
clean stock. Also the various agents used to remove
grease from the hands, containing as they usually do,
free alkali and grit, are quite apt to be badly tolerated
by the skin. The driver of a delivery wagon used
brass polish and cleaned the harness with a soapy
preparation. His hands were the seat of a red, scaly,
itchy outbreak, especially marked on the fingers.
Oozing and vesiculation were occasionally present.
The printer used a hand press. His left hand bore a
stigma characteristic of his work — a heavily calloused
ridge across the palm and two fingers where he
grasped the wheel. His right hand showed a vesicular
eruption, largely limited to the fingers, the nails of
which were rimmed with ink. The ink was daily
cleaned off with benzine, following which a soft soap
with grit and free alkali was thoroughly rubbed in and
washed off.
An interesting account of novocaine dermatitis is
described by Guptill. In this personal example, the
writer's hands became highly irritated, chapped,
cracked and at times badly swollen, especially the
third and fourth fingers of the right hand. Later the
face and lips became swollen. There was vesiculation
and a considerable number of pustules, much crusting
and intolerable itching. The eruption on the face was
thought to have been caused by the bursting of air
bubbles as they were expelled from the syringe held up
close to the face. Others* have reported somewhat
.similar types of eruption in dentists using procain and
apothesin.
Although various irritants used in scalp preparations
and hair dyes may be causal of a dermatitis, the hydro-
chlorate of paraphenylene diamin is particularly to
blame.* This chemical under the influence of oxygen
is converted into quinone. This property has led to
its being used as a hair dye, as tints from auburn to
jet black may be produced. An aqueous or alcoholic
solution of the diamin is first brushed or sponged on
and a few seconds later oxygenated water is similarly
applied with immediate effect. Quinone gives off most
irritating vapors which cause the outbreak.
Pusey has likened the differential diagnosis of ec-
zema and dermatitis to that difference which exists be-
tween natural and artificial ice. Some few points help
to a slight degree in distinguishing the externally pro-
duced eruption. The history of a trade commonly
producing such a condition, a pruritis more intense
than ordinary, the grouping and location involved, a
sudden onset, sharper outline and more rapid course,
all are suggestive. The initial type of lesion is apt to
be retained throughout and careful observation early
in the case may note a beginning in any spread from
"catchment points."
This brief paper points out the relatively common
occurrence among skin diseases of eruptions caused
by occupational hazards. Selecting, as we have done,
the new cases coming to a dispensary over a short
period of time, we found over s'/c of the patients to
be included in this class. Our few cases exhibited an
unusually wide diversity of trades and consequent!)' an
equal variety of special irritants. The exact agent
responsible for the eruption in a given case is some-
times difficult to distinguish and a knowledge of work-
ing conditions in the trade involved is essential both
for diagnosis and treatment.
2022 Spruce Street.
2039 Chestnut Street.
1. Knowles, F. C. Jour. Cut. Dis. 31: 11, Jan.. 191 3.
1. Hazen, H. H. Jour. Cut. Dis. 32:487, July, 1914.
3. I.ane. C. ('•. Arch, of Derm, and Syph.. 3: 235. March,
1921. Mook, W. H. Arch, of Derra. and Syph., 1:65. June,
•921
4. Knowles, F. C. Penna. Med. Jour., 19:897, Sept., 1916.
PITTSBURGH ACADEMY OF
MEDICINE
ABSTRACTS
HEADACHES AND EYE STRAIN
DR. W. E. CARSO.V
Headaches may be defined as pain in the cranial
part of the head. When we attempt to elaborate such
a definition and to explain just what we mean by the
word pain, we are met with difficulties.
It will suffice for our purpose, however, to say that
the pain of headache is the result of perception
of the irritation of ordinary sensory nerves carried
through the trigeminus resulting from irritation of the
nerve endings of the meninges, particularly those of
the dura, as the arachnoid has no nerve supply and
the pia mater receives only sympathetic twigs accom-
panying the blood vessels. It is highly probable that
the sensory endings of the sympathetics running in
the vessel walls in many parts of the dura, play an im-
portant role.
These sources of irritation may be grouped as physi-
cal, chemical and reflex, acting in different localities
resulting from chemical, thermal, mechanical or nutri-
tional stimuli beyond a certain maximum point of in-
tensity. Of the physical causes of irritation, the most
important are mechanical injuries, a good example of
which is the increased intracranial pressure resulting
from cerebral tumors. The headaches here may be
due to direct pressure, irritation on the nerve endings,
by either compression or dilatation of the blood and
lymph vessels surrounding them. Hyperemia may
cause mechanical irritation of these nerve endings
from pressure. Anemia may cause irritation from nu-
tritional or chemical influences. Other chemical irri-
tants are the toxins of febrile diseases, absorption of
putrefactive products from the bowel, retained urinary
constituents in nephritis, and drug poisons such as
alcohol, lead, opium, amyl nitrite, etc. Some of these
drug poisons act directly on the nerve endings in the
dura as irritants, others, such as alcohol and amyl
nitrite, act by causing a vascular paresis and resulting
increase in intracranial pressure.
The 'headache resulting from excess of bodily and
mental exertion is doubtless due to the irritant effect
of accumulated fatigue toxins, associated also ustlally
with hyperemia. Here belong most headaches of eye
strain. In the matter of diagnosing the cause of head-
aches, we may say that headache is a svmptom asso-
ciated in many cases with di.seases which are readily
recognized, s»ich conditions being self-limited by either
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September, 1921
PITTSBURGH ACADEMY OF MEDICINE
889
recovery or death. In another class, however, are
headaches which are present as the symptom, fre-
quently the only symptom of morbid conditions, which
morbid conditions may present no evident signs and
which also are not self-limited but may persist
throughout the life of the individual. Such headaches
were considered in former times as in themselves dis-
eases and even in more recent times the best diagnosis
available in the case of many such headaches was
neurasthenia, hysteria or migraine.
In guiding patients in the matter of determining the
cause of persistent headaches our endeavor should be
of course, for the sake of economy of time and ex-
pense, to use the best possible judgment in attacking
and either proving responsible or eliminating the most
probable cause for the headaches. The routine his-
tory and general medical examination may at once
suggest that the trouble is systemic or that the cause
is in the head itself. As to the systemic causes for
persistent headache, time will not permit a considera-
tion of even the more common causes such as consti-
pation, nephritis, arteriosclerosis, gastric hyperacidity,
et cetera.
Of the sources of headaches located in the head it-
self by far the most common source is eye strain, and
from the standpoint of frequency would be the first
possible cause to be eliminated. However, there may
be characteristics about headaches from local causes
which will at once suggest some other origin, such as
diseases of the sinuses of the ear or of the teeth.
Just what proportion of all headaches are due to eye
strain would be difficult to approximate, but it can be
safely stated that eye strain accounts for more head-
aches than any other one cause, a fact which has been
appreciated only within comparatively recent times.
Even at the present time some authors have seemed to
fail to grasp the true importance of the subject and,
in reading over the discussion of possible causes of
headache in some of the well known standard test-
books by European authors, one is struck by the casual
mention of ocular anomalies as causal factors in head-
aches. To ophthalmologists whose daily practice in
many cases is concerned with patients, 50% of whom
come complaining of headaches, such practical neglect
of ocular affections as a cause of headaches is un-
accountable.
While a completely satisfactory explanation of the
pain associated with eye strain headaches, like the
pain of any other type of headache, is not in the pres-
ent state of our knowledge available, nevertheless the
mechanics involved in the cause of such symptoms
are well understood. Such headaches should be put in
the class of fatigue headaches, and are due to con-
tinued effort to overcome an accommodation or mus-
cular abnormality of the ocular apparatus either on
the part of the muscle of accommodation to keep the
lens in proper adjustment in order to compensate for
refractive error present, and by so doing to produce
an accurate focus on the retina, or to continued effort
on the part of the external ocular muscles to keep the
two globes so properly converged and accurately
placed, as to allow light rays to fall on corresponding
portions of the retinse, i. e., coordination. The first
named condition is designated accommodative asthe-
nopia, the latter as muscular asthenopia.
While it would be impossible at this time to go with
any detail into the nature and variety of ocular anom-
alies which constitute undue strain upon the visual
organs, it may be well to recall the more important
anomalous conditions, and to note how they differ
from the normal physiologic standard. This normal
physiologic standard is to be foimd in two healthy
eyes with normal vision, having a focusing apparatus
such that parallel rays are brought to a focus on the
retina without effort, having also accommodative
power in each eye for near objects corresponding to
age, and the same in proper coordinate relation to the
power of the external ocular muscles required to prop-
erly direct the two eyes.
Refractive errors in either eye or a tendency to
overaction or underaction in one or more of the 12
external ocular muscles required to properly direct the
two eyes in order to obtain binocular vision, consti-
tute the important variations from our - physiologic
standard. The important refractive errors may be
briefly recalled by reviewing a few facts in elementary
physiological optics.
A hyperopic eye is an eye which is too short so that
the focus lies behind the retina except when by special
abnormal action of the ciliary muscle the focus is
brought forward by a thickening of the lens. It is this
constant action on the part of the ciliary muscle re-
quired to obtain a sharp image on the retina that pro-
duces strain in hyperopes.
When astigmatism is present the focal distance is
shorter in one meridian than in another so that images
on the retina are blurred and the continual effort on
the part of the ciliary muscle to overcome the error
and thus obviate the blurring results in fatigue or eye
strain. Astigmatism may be responsible for the most
aggravated symptoms of eye strain and it is estimated
that fully 60% of functional headaches are caused by
this type of refractive error, either alone or in asso-
ciation with some other form of refractive error. The
headache may vary from a moderate frontal headache
to violent explosions of pain and may be situated in
any portion of the cranium. Pains may be strangely
and persistently situated in the nape of the neck, be-
tween the shoulder blades, in the precordium and deep
in the mastoid. Reflex nervous disturbances may re-
sult, such as pseudo chorea, vertigo, habit-spasm,
epileptiform convulsions, neurasthenia, dyspepsia and
indigestion.
A myopic eye is a long eye and hence with the
focus already too far forward there is no tendency
for overaction on the part of the ciliary muscle for
the vision, already much reduced, is only made worse
by any increase in the thickness of the lens. Hence
the fact that headaches do not result from simple
myopia per se. Certain less definite asthenopic symp-
toms do, however, occur in myopes which have their
explanation partly in the congested membranes of the
stretched tunics of the elongated eyeball and partly in
the difficulty such eyes have in effecting convergence
of the two eyes.
The most common exciting cause of ocular head-
ache is some form of near work that requires long
continued use of the muscles of accommodation and
convergence, such as reading, sewing, stenography
writing, drawing, et cetera. The pains do not always
follow immediately upon indulgence in excessive near
work; they are sometimes nftt noticed until early
morning. It is more frequent, however, for the eyes
and head to begin to ache after a certain number of
minutes or hours of close work and with such regu-
larity that the sufferer himself associates the head-
ache with some trouble in his eyes. Patients with
astigmatism, hyperopia and muscle imbalance also
suffer when called upon to use the eyes more than
usual for distance vision such as is required in shop-
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890
THE PENNSYLVANIA MEDICAL JOURNAL September, 1921
ping, at theaters, in museums, riding on the street cars,
et cetera. In general it may be said that stx:h head-
aches are worse toward evening in contradistinction
to sinus headaches which are worse in the early morn-
ing and tend to pass off as the day advances.
The site of the headache is important. Vertex pain
is comparatively rarely due to eye strain. In point of
frequency ocular headaches are most frequently
frontal, then fronto-occipital, in the back of the neck,
deep orbital and temporal. Simple eye strain due to
some error of refraction (e. g., hyperopic astigmatism
in children) will usually give rise to brow pain. If
there is also an associated muscular imbalance there
may be also' occipital pain.
Because in certain cases headaches are relieved by
wearing properly fitting glasses it must not always be
assumed that the headaches were solely due to the eye
strain. Headaches are frequently due to a combina-
tion of causes only one of which may be eye strain.
The removal of any one of the causes in siich cases
may give relief from the headache. Such combined
causes of headaches are, for instance, certain forms
of sinusitis plus eye strain, indigestion plus eye strain,
and neurasthenia and eye strain. A patient with a
chronic sinusitus and astigmatism may have headaches
during an exaccerbation of the sinus condition which
are promptly relieved by wearing his glasses. When
his sinus condition quiets down he may be able to dis-
pense with his glasses and still remain free from
headaches. So the fact that in a certain case head-
ache may be relieved by glasses should not cause us
in all cases to cease further search for another cause
if there is probability of any serious condition of
which the headache might be a warning symptom.
In presenting a few cases to illustrate these points
the aim has been to present not spectacular specimens
but rather cases typical of the large class seen by all
occulists, namely, those who have symptoms of eye
strain relieved by correction of a low or only mod-
erate refractive error.
Mrs. S. (2050). Age 33. Oc. house work. Gen-
eral health good. Headaches for the past two years.
Practically continuous. No relation to near ' work or
time of the day. Worse back of right eye. Wearing
R. E., C + 0.25 ax 90; L. E., S — 0.50 = C+ 0.75
ax 90. Ordered, R. E., S — 0.25 = C -f 0.50 ax 93 ;
L. E., S — 0.50 = C -I- 1.25 ax 85. Reports that head-
aches were entirely relieved.
Mr. M. (1807). Age 31. Oc. insurance salesman.
Seems in robust health except for headaches. About
5 weeks ago woke up with a headache which con-
tinued after he went to work. Had frequent and very
severe attacks during the month following but has
been better since receiving treatment from Doctor
Wright during the past ten days. At first the head-
aches were all through the front part of the head,
now they seem to involve the entire right side of the
head. Because of the sudden onset, severity and ap-
parent non-relation to near work his doctor did the
logical thing in referring him to a neurologist. A
peculiar and striking condition of both discs was found
by Doctor Wright which, however, was finally deter-
mined to be a congenital anomaly. Refraction: Has
been wearing for the past two years R. E. C — 0.50
ax 17s; L. E., C — 0.7S ax 175. Ordered, R. E., C -f-
0.37 ax 100; L. E., C -|- 0.50 ax 90. Headaches were
promptly relieved and had remained so when last
heard from. The error in this patient was quite small
and, though his natural error was increased by im-
proper glasses, the same were of low power so that
the total error was not large. Yet the symptoms were
marked, and promptly relieved by correcting the error.
Miss D. (i4SS). Age 25. Oc. teacher. General
health good. Has been having headaches for the past
four years which come on in the afternoon and seem
to be worse after near work. Never wore glasses.
Was referred by her rhinologist who stated that
enough trouble had been found in her nose to seem
to be a probable cause of the headaches and operation
had been tentatively decided upon but, as it was not
convenient to have the same at the present time, it
was thought well to have the' eyes examined.
After examination lenses were ordered as follows
to be worn constantly : R. E., C -|- 0.25 ax 55 ; L. E.,
C + 0.50 ax 130. Two weeks later her rhinologist
reported that her headaches had entirely cleared up
and that the proposed operation had been indefinitely
postponed. This is an example of a patient in whom
persistent headache was relieved by the correction of
a very small error.
TETANY
DK. H. H. DONALDSON
Occurrences of tetany after operation on the thyroid
gland were first recognized in 1880. About three years
later Kocher called attention to the condition since
known as myxedema which he showed was a sequel
of complete thyroidectomy. For some time these two
conditions were supposed to be due to functional in-
sufficiency of the thyroid gland. It was then advised
that total removal of the thyroid should not be prac-
ticed and this rule which is still followed accounts for
the relative infrequency of myxedema. In animal ex-
perimentation it was then discovered that in herbivora
total removal of the thyroid was followed by pro-
tracted myxedema while in camivora fatal tetany fol-
lowed. This apparent inconsistency led to the discov-
ery of the parathyroid bodies and it was found that in
cats and dogs the parathyroids are buried in the thy-
roid glands and removal of the thyroid included also
the parathyroids and resulted in tetany.
The tetanic spasm which is present in tetany is the
one symptom which alone makes it a dreadful dis-
ease. Great variations in localization occur. It is
most often observed in the hands and is symmetrical.
Flexion at the wrist and extension at the joints of the
fingers is the characteristic position. The spasm is
painful and in our case was controlled only by opiates.
When the lower extremities are affected the foot is in
an equino-varus position with toes drawn plantarward.
Involvement of the muscles of the larynx is common,
especially in children. Great anxiety and fear of com-
plete closure is associated with this spasm. The dura-
tion of the spasms varies. In our case the spasm was
of a definite tonic type, remaining so almost from day
to day. Weakness and stiffness of the involved mus-
cles is a common sequel and lasts for weeks. In
adults the sensorium is usually uninvolved. In chil-
dren it is frequently clouded and there may be com-
plete loss of consciousness. There is a slight rise in
temperature and a slight increase of pulse rate. The
facial expression is lost to some extent and there is a
tendency to ptosis of the lids.
Severe tetany is usually the result of surgical re-
moval or injury of the parathyroid. Tetany may fol-
low operation on the thyroid even when no parathy-
roid tissue is removed. Such complication would in-
dicate that the subject was one of deficient parathyroid
function. Injury due to traumatism of the parathy-
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September, 1921
PITTSBURGH ACADEMY OF MEDICINE
891
roids or hemorrhage into these bodies in such cases is
sufficient cause for temporary insufficiency. Such tem-
porary insufficiency may also be due to removal of
one or more parathyroids when the condition of the
patient is one of relative insufficiency. One or more
parathyroids may be removed from patients with nor-
mal parathyroid function, during thyroidectomy with-
out producing symptoms of tetany.
We believe that surgeons recently have been little
concerned about the welfare of the parathyroids and
since there is a tendency to remove more and more
of the thyroid there is surely more danger of injury
or removal of sufficient parathyroid to disturb their
function. Sub-capsular dissection of the thyroid pos-
teriorly has always been practiced to protect the nerve
and the parathyroids.
The case to be reported showed the upper parathy-
roids in such position that such practice did not pro-
tect them and two were removed. Since all the para-
thyroids receive their blood supply from the inferior
thyroid arteries it would seem better to sacrifice the
superior thyroid vessels on both sides rather than both
vessels on the same side. More careful examination
of our patients may exclude from operation those in
which unstable parathyroid function is suspected.
'Report of patient. Admitted Dec. 3, 1920. Mrs. B.
Age 38 yrs. German. Mother of 4 children. Referred
by Dr. T. A. Miller of Bellevue. Dr. George Wright
was associated in the treatment of this patient. Chief
complaints: nervousness, palpitation, excessive fatigue
and headache.
Operation for goiter January 3, 1921. Under ether.
Operation consisted in removal of the upper poles of
both lobes. Inferior not ligated. The lower poles
of both lobes were left and also a thin layer over the
trachea, about three-fourths of the gland being re-
moved.
Almost immediately following operation she com-
plained of pain in her arms but spasm of muscles of
arms did not occur until sixty hours after operation,
at which time there was numbness also. Temperature
on sixth day after operation reached loi degrees.
Wound showed no infection. At this time she first
showed spasm of larynx, complained of choking,
coughed a great deal and was very anxious and rest-
less. There was some spasm of masseter muscles.
Medication, when tetany developed, consisted' in cal-
cium lactate, grains ten, every four hours and para-
thyroid extract, grain i/s, every four hours and mor-
phine, grain 14, to control pain. Sodium bicarbonate
given freely. When the tetany was most active pa-
tient could not retain food and at times choked when
she tried to swallow. An attempt to pass duodenal
tube caused so much distress that it was discontinued.
Tympanites always seemed to be most pronounced at
height of the muscular spasms, and great difficulty
was experienced in trying to relieve this condition,
and in getting the bowels moved. During the second
week some improvement was noticed and the muscular
spasms became more easily relieved by sedatives.
Luminal was used with success.
Twelve days after operation she had another severe
laryngo spasm in which she became cyanotic and her
pulse became weak. About this time the equino-varus
condition of both feet was first seen. Morphine was
again used to control the spasm. Following this at-
tack there was gradual improvement and patient was
allowed out of bed three weeks after operation. She
was discharged four weeks after operation with still
a suggestion of contraction of the flexor muscles of
the forearms. Administration of parathyroid gland
was discontinued at the end of the second week. Cal-
cium lactate was g^Iven regularly and was continued
after the discharge of patient. Within a few days
after patient returned home she had two slight at-
tacks which lasted only a few minutes and each at-
tack was apparently brought on by over-exertion.
The extremities only were involved. She has now had
no attacks for five weeks. The only sequel of the
tetany is numbness of the hands with stiffness and
weakness. Her general condition is improved, she is
less nervous and eats and sleeps well. She had slight
headache, but is much improved in this respect.
CHRONIC INFECTIONS IN THE FEMALE
LOWER GENITAL TRACT
DR. B. Z. CASHMAN
Leucorrhea is the most frequent and persistent
symptom of which gynecological patients complain.
The two great causes of leucorrhea are infection with
the gonoccoccus and infections of the cervix, second-
ary to cervical tears and puerperal infections. In the
chronic cases, the surface inflammation has disap-
peared and the infection is located in the deeper struc-
tures. The common sites of persistence of gonorrheal
infection in the lower genital tract are Skene's glands,
Bartholin's glands, and the cervix. It is in these
structures that the so-called latent infections smolder,
to flare up and extend later to the uterus and tubes
when favorable conditions arise, such as after child-
birth, abortion, or during or following menstrual pe-
riod. These deep glands are responsible for the gon-
orrheal carriers, latent chronic infection in the pa-
tient, but with activity and virulence readily increased
on transmission to new soil, producing acute gonor-
rhea. Aside from the importance of these latent in-
fections in their tendency to flare up and extend to
the upper genital tract, and their action in producing
gonorrheal carriers, the morbidity which they produce
is not generally appreciated. We frequently see pa-
tients complaining of frequency and burning on urina-
tion, whose bladders have been irrigated for weeks
with no relief of symptoms. On examination, the
bladder urine is free of pus and organisms and there
is no evidence of cystitis, but all of the signs of
chronic infection of Skene's glands are present at the
external urethral meatus, and the symptoms are re-
lieved with the treatment of this condition.
The majority of cases of chronic leucorrhea are due
to chronic cervicitis. This alone would stamp it as a'
big morbidity producer, for what is a more common
complaint in women than leucorrhea? But while leu-
corrhea is the most readily recognizable sign of
chronic cervicitis, there are other important symptoms
and signs — sacral backache, pain and dragging sensa-
tions in the pelvis, especially when the patient is on
her feet or when she strains, and painful sexual inter-
course. These symptoms are all readily explained on
a pathological basis. The lymphatics of the cervix
pass upward and outward through the parametrium,
on each side, and backward through the sacro-uterine
ligaments. It is especially these latter structures th'at
produce symptoms when involved in the inflammatory
process. In cases of chronic cervicitis, in palpating in
the vault of the vagina behind the cervix, these sacro-
uterine ligaments are usually found as tender, inflamed,
shortened, band-like structures, feeling like cords run-
ning back from the cervix. Cervicitis also lessens the
chances of pregnancy, and is one of the causes of
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THE PENNSYLVANIA MEDICAL JOURNAL September, 1921
sterility. Cervicitis predisposes to chronic metritis,
and chronic inflammatory processes in the body of the
uterus tend to disappear if permanent changes have
not taken place. If the foci are removed in which the
infection persists, namely, the cervical mucosa and the
fallopian tubes if they are involved, the indications
for removal of the uterus because of infection are less
frequent than formerly. Many'of the menstrual dis-
orders of chronic metritis will disappear after removal
of the cervical infection.
The role played by chronic cervicitis in producing
cancer of the cervix is undoubtedly prominent as can-
cer of the cervix seldom, if ever, occurs in a cervix
which is not the site of a chronic inflammatory process
either gonorrheal or secondary to cervical lacerations,
the infrequency of carcinoma of the cervix in patients
who have not borne children is evidence in favor of
this.
The diagnosis of these infections is a matter of look-
ing for them. If we do only bimanual examinations,
we will seldom find them, but if we get our patients in
a good light and carefully inspect the orifices of
Skene's and Bartholin glands for the red areola around
them and strip them with the finger in order to ex-
press pus, and insert a speculum into the vagina to in-
spect the cervix in addition to palpating it for evi-
dence of cystic changes, and increased fibrous tissue,
we will finW these chronic infections very prevalent.
The differential diagnosis of gonorrheal infection
and the other infections is not always easy. Infections
of Skene's and Bartholin's glands are practically al-
ways due to gonoccoccus and this is an important dif-
ferential point. The demonstration of gonoccocci in
the discharges from chronic gonorrheal cervicitis is
often difficult or impossible, so that its differentiation
from the chronic cervicitis tliat so frequently follows
laceration of the cervix, is by no means simple.
Whether or not we are able to differentiate in an in-
dividual case the gonorrheal infection from the sec-
ondary infections following lacteration of the cervix,
we can recognize the cervicitis and we must remember
that too prolonged chronic inflammation in the cervix
may produce irreparable changes in the form of in-
creased fibrous tissue with hypertrophy, and Nabothian
follicle cyst formation so that finally the only hope of
cure is in amputation of the cervix.
The number of women treated in the doctor's of-
fices for months and years for chronic cervicitis by
means of applications, tampons, etc., is a tribute to its
persistence and chronicity and the inadequateness of
the treatment. Local applications of antiseptics and
caustics by means of applicators or instillations are
valuable in surface infections, but are inadequate in
many of the deep chronic infections. In some of these
cases, we have as much chance of cure by local sur-
face applications as we have for the cure of chronic
tonsillitis by application of antiseptics to the tonsillar
surface. It is very often evident at the first examina-
tion that the inflammatory changes are too deep seated
to hope for a cure by surface applications and radical
treatment is economical in expenditure of time, energy
and money. In doubtful cases where the cystic and
fibrous changes are not prominent there should be a
reasonable time limit to local treatments, and if these
are not successful radical treatment should be advised
instead of dragging on for months with a hopeless
procedure.
By radical treatment, we mean destruction of the in-
volved tissues by means of the cautery, or when the
changes are too marked, amputation of the cervix.
We also feel that the cervix should not be neglected
ii; our routine oi)erative work for pelvic infection. It
is disappointing, to sajr the least, to do a supravaginal
amputation of the uterus and removal of the tubes for
pelvic infection and have the patient return in a month
complaining of the same old leucorrhea which she has
had for so long became the cervix with chronic infec-
tion has been left behind.
The most efficient treatment of chronic infection of
Skene's glands is cauterization. For cauterization of
Skene's ducts probes heated in an alcohol flame, or
preferably electro-cautery, can be used. For this pur-
pose Downes has made an instrument which can be in-
serted cold, and the current then turned on and the
gland cauterized. Infected Bartholin glands are dis-
sected out. For chronic cervicitis, dilatation of the
cervix and destruction of the mucosa with the electro-
cautery, or if there is extensive laceration or exten-
sive cystic changes amputation of the cervix is neces-
sary as the depth to which cauterization would be nec-
essary would surely result in stenosis. The advan-
tages of cauterization are its effectiveness in destroy-
ing the infected tissue and the rapidity with which it
can be done so that it can be applied to all cases of
pelvic inflammatory disease without unduly prolonging
the operation.
The disadvantage of the operation is the narrowing
of the cervical canal if it is necessary to cauterize ex-
tensively, producing subsequent dysmenorrhoea. If
this is borne in mind, however, and these patients seen
within a few weeks after operation, and the patulence
of the cervical canal insured, there is no trouble. The
constriction occurs usually at the external os, and if a
sterile dressing forcep is carefully passed into the
canal, thus dilating it, no further treatment is neces-
sary, and it shows no further tendency to contract as
a rule.
COMMUNICATION.
WELCOME TO THE ^ESCULAPIAN
CLUB
The .(Esculapian Club of Philadelphia takes
pleasure in extending to the members of the
Medical Society of the State of Pennsylvania
for the duration of its meeting in Philadelphia.
October 3 to 6, 1921, the use and privileges of
its Club house.
The membership of the .^sculapian Club is
limited exclusively to physicians. Its purposes
are social and not scientific.
It is the only Club in the United States, and
perhaps in the world, with such a membership
and with such purposes.
It has one of the most beautiful Club houses
in Philadelphia at the S. E. Cor. of Tenth and
Clinton Streets (Clinton Street is between
Spruce and Pine) .
The members of the State Society are urged
to make the Club their headquarters for the
meeting of friends, forwarding of mail, resting
or the holding of small meetings. Platter lunch-
eon may al.so be had between twelve and two.
Dr. Norman L. Knipe,
Chairman House Committee.
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FRANK G. HARTMAN
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September, 1921
EDITORIALS
893
THE PENNSYLVANIA
Medical Journal
Published monthlr under the supcTTuion of the Publication
Committee of the Trustees of the Medical Societj of the Sute
of Pennsylvania.
Editor
FREDERICK L. VAN SICKLE. M.D Harrisburg
AnliUnt Editor
FRANK F. D. RECKORD Harrisburg
AiBoclato Editor*
JosErH McFakland, M.D Philadelphia
Gtoici E. PfAHLts, M.D Philadelphia
LAwaiNCB LiTCMnsLO, M.D., Pittsburgh
Gtoaci C JoHNSToK, M.D., Pittsburgh
J. Stewait Rodham, M.D Philadelphia
John B. McAustkk, M.D Harrisburg
BxKHAXD J. Myxrs, Esq Lancaster
PnbUoatloii Oommltto*
Ira G. Shoeuaxu, M.D., Chairman Reading
THinDoits B. Appii,, M.D., Lancaster
FiAHK C. Hahuohd, M.D., Philadelphia
All communications relative to exchanges, books for review,
manuscripts, news, advertising and subscriptions are to be ad-
dressed to Frederick L. Van Sickle, M.D., Editor, aia N.
Third St., Harrisburg, Pa.
The Societjr does not hold itself responsible for opinions ex-
pressed in original papers, discussions, communications or ad-
vertisements.
Subscription Price— $3.00 per year, in advance.
September, 1921
EDITORIALS
PRESIDENT-ELECT HARTMAN
Frank Gast Hartman, President-elect of the
Medical Society of the State of Pennsylvania,
was born in Lancaster, Pa., December 29, 1869,
being the son of Daniel and Catherine (Gast)
Hartnian and representing a family that has for
many years been prominent in the business, finan-
cial and political life of that city. His early edu-
cation was received in the public schools. After
graduating from the high school in 1885, he be-
came a drug clerk and later entered the Phila-
delphia School of Pharmacy. He graduated there
in 1891 and immediately entered the Medical De-
partment of the University of Pennsylvania, be-
coming a classmate of his predecessor in the of-
fice of president of our society. After securing
his degree in 1893, for one year he managed a
drug store in Philadelphia and in 1894 started
the practice of medicine in Lancaster. Devoting
himself from the start to internal medicine, he
early won recognition and laid the foundations
for a practice which has developed throughout
the years and he stands now one of the leading
general practitioners of his locality. He early
identified himself with the Lancaster General
Hospital and contributed much to the upbuild-
ing of that institution and now occupies the posi-
tion of Chief of the Medical Service of the Staflf.
He has always been interested in the Medical
Society of Lancaster City and County, and
served as its president. He was one of the or-
ganizers of the Lancaster Medical Club in 1917
and has been its vice-president since then. His
activities in the State Society began in 1904 with
his appointment as a member of the Committee
on Pharmacy. In 1905 he was appointed a mem-
ber of the Committee on Asylums for Inebriates,
and in 1910 he was appointed a member of the
Committee on Legislative Aflfairs, of which he
was a valuable member during the period when
the present laws governing the Bureau of Medi-
cal Education and Licensure were developed.
He was one of the original members of the Leg-
islative Conference Committee. He became a
trustee in 1917, holding that position for two
years until the reorganization of the Board under
the new constitution. He was elected delegate
to the State Society in 1907 and was regularly
continued in that position until he became a
trustee, serving frequently on reference commit-
tees of that body. t
He has always been interested in civic af-
fairs and for years has been a member of the
Select Council of Lancaster and president of
that body, and is regarded as one of the men of
prominence and responsibility in the city admin-
istration. For a number of years also he has
been a trustee of the State Institution for Feeble
Minded at Pennhurst and served as alternate
delegate to the Republican Convention in 1920.
He has been prominent in Masonry, is Past Mas-
ter of Lodge No. 476, and this year is serving as
Most Puissant Grand Master of the Grand
Council of the Royal and Select Masons of
Pennsylvania.
In 1898 he was married to Miss Lillie Herr,
a daughter of Franklin and Sarah (Frantz)
Herr, of Lancaster. They have one daughter,
now a senior as Vassar. T. B. A.
JOHNS HOPKINS AND FIXED
MEDICAL FEES
The dictum of the Board of Trustees of Johns
Hopkins Hospital that : "The maximum fee that
any surgeon ought to charge for an operation,
no matter how wealthy the patient, is $1,000.
The maximum charge that any physician ought
to make for attending patients in a hospital is
$35.00 a week," will be felt not only in Johns
Hopkins, but all over the United States.
The question of limiting medical fees is not
a new one. It has been tried before in many
countries and at many times, but always with-
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THE PENNSYLVANIA MEDICAL JOURNAL September, 1921
out success. In the end, the states, the courts
and all bodies concerned, as well as the profes-
sion and the general public, concluded that
physicians should be allowed to charge fees pro-
portionate to the means of their patients.
The medical profession has the right to feel
resentful at the layman's attempt to fix his fees.
It is another act in the many legislative enact-
ments menacing the freedom of physicians. The
continued attempts to dictate to, and prescribe
limitations for the profession have a discourag-
ing eflfect upon the number of young men who
enter into it. If the fees, which are the legiti-
mate rewards for skillful and efficient accom-
plishments are limited, then, indeed, the ambi-
tions of both students and practitioners will nat-
urally be diminished.
It is true that the love of money is a great
danger which confronts the profession to-day
and lowers its standard before the public. Over-
charging has been frequent in the medical pro-
fession, just as in a hundred forms of endeavor.
But the question of professional fees is a matter
lying wholly between the physician and his pa-
tient. An operation, which saves his life, is
worth to a very rich man proportionately more
than to one not so rich.
Why should the medical profession be the
subject of so much "Thou shalt not"? No one
would think of cutting down or limiting the fee
of the lawyer, and surely doctors are quite as
important to human happiness as are lawyers.
Men of exceptional skill in any walk of life have
the right to larger fees than the average man.
Another feature of the Johns Hopkins ruling,
which is certainly unjust, is to set such a differ-
ence in value between surgical and medical serv-
ice. It is true that the surgeon's achievement is
more spectacular, but for much of his work he
gives no more valuable or precious service than
does the medical man.
Is a severe case of pneumonia, successfully
guided through a short but critical illness, worth
only $35.00 to the same individual who would
pay $1,000 for an appendectomy? Thirty-five
dollars a week may be sufficient in the average
illness, but it is not enough where difficult diag-
noses are required. It is often as important and
;is delicate to diagnose a case as it is to perform
the oj^eration whic'.i the diagnosis calls for, and
may require quite as much studv, experience and
skill.
The Johns Hopkins dictum adds to the al-
ready, too large variance between the fees of
surgeons and physicians. While it is true that
the ruling of the hospital applies only to that
institution, it will have a far-reaching, sentimen-
tal effect and other hospitals may take similar
action, with their own judgments as to proper
fees on the part of their staffs, which would lead
to endless discussion, discord and inefficiency.
The Johns Hopkins' dictum will, however, ex-
ercise an influence for moderation in the profes-
sion, and establish a precedent for court cases
arising from disputes of such origin.
J. B. McA.
RECIPROCITY OF MEDICAL
LICENSURE
CAN THE PRESENT CONDITIONS BE IMPROVED?
Since the early days in the United States, the
practice of medicine as an art has been one of
progression, gradually increasing in the length
of curriculum required to perfect men and
women to fill this field of occupation. Accom-
panying this increased requirement of medical
knowledge has been state requirement of ex-
amination and licensure, giving tests which
would accord with the college standards of each
state. When limited knowledge of medical sci-
ence made a two-year course in college sufficient,
the laws relative to medical practice were equally
lenient. As time went by legislation affecting
medical practice became more stringent, keeping
step with the need of protecting the public
against those who might inflict their inferior at-
tainments upon the people, and these legislative
requirements were regulated many times in ad-
vance of the real conditions which prevailed.
Occasionally, it was found that some states
had the tendency to open their doors of licensure
to those not as well qualified as they should have
been, and the result was that steps were taken to
guard the entrance of illy qualified persons into
those states where requirements were more rigid.
This has brought about the tendency for each
state to act independently in relation to examina-
tion and licensure for medical practice. There
was a time when a college diploma was all that
was required in any state to practice the healing
art, and no special attention was paid to those
persons who were in this particular field of en-
deavor. Eventually, those who had the matter
of examination and licensure in charge in some
states set up barriers against other states of lesser
requirements, so that a feeling of antagonism
prevailed to a limited degree. Later on a cen-
tralized effort was made to establish a plan of
reciprocity which might cover the United States,
rendering examination and licensure equitable to
all parts concerned. There is yet much that is
faulty in the method of application and it is be-
lieved that the subject has been far from solved.
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September, 1921
EDITORIALS
895
as to how this interchange of licensure can be
acconipHshed.
In view of the fact that many middle-aged
medical practitioners have found it advisable
from time to time to move from one state to an-
other, it became apparent to those who sought
admission into another state, having different
standards from those of the state from which
they came, that much embarrassment ensued.
Reciprocal standards were not well understood
by the average medical practitioner and although
proficient in the art of medical practice these
men were unable to meet the requirements of
preliminary medical education and could not
pass the required examinations which were then
prescribed for the recent graduates. We can-
not deny the fact that each state has the inherent
right to establish its own standards and require-
ments for medical practice, yet there appears to
be the tendency to favoritism, to some extent,
when one from another state seeks admission
and asks the right which others can receive with-
out serious encumbrance.
The point which is so patent to those who have
made the effort to move from one state to an-
other leads to the thought that this problem
should be solved in a better way in the future,
so that those who have been in practice for a
decade or more may, through bedside examina-
tion or other tests, be allowed the privileges en-
joyed by others of equal standing. National
centralization can hardly be looked to as the
gateway through which this may be brought
about, as experience has taught us that it is im-
possible to create flexible standards that would
be humane in their application, .as well as pro-
tecjive to those who would recieve the ministra-
tion of those licensed.
Legislatures are apparently becoming im-
pressed with the viewpoint of cult-practice to
such an extent that on one hand the old line
medical practitioner is bound around with steel-
clad protective armor to keep him from injuring
the dear public, while on the other hand those
v/ho set up the new thought and standards of
cult-practice can easily gain admission through
legislative enactments. Can we not draw some
solace from the thought that this is only tem-
porary and that eventually right-minded law-
makers will recover from this infatuation and
listen to the mature advice of those who have
for many years conscientiously cared for the
people's ills ?
Reciprocity of medical licensure, we believe,
should receive more attention on the part of
boards and bureaus of examination and a gen-
eral getting together should occur to help, aid
and assist all those who have for legitimate rea-
sons need to move from one state to atiother to
practice the art for which their earlier training
has qualified them.
SCIENTIFIC PROGRAM, PHILADEL-
PHIA SESSION
The Committee on Scientific Work has tried
hard this year to arrange a practical program
for the Philadelphia Session, and one that will
prove of interest to our members in whatever
line of work they are engaged. This has been
made possible by consulting a large number of
doctors to learn from them, titles that are timely,
and also subjects that require elucidation. We
hope in a modest way we have succeeded. To
further stimulate the interest of our members,
eleven men — outside the state — prominent in
their respective localities, and men of national
reputation, have been invited to read papers and
open discussions, namely, Drs. Lewellyn F.
Barker, of Baltimore, and J. J. R. McCleod, of
Toronto, Canada, in the Medical Section; Drs.
George W. Crile, of Cleveland, and M. S. Hen-
derson, of Rochester, Minn., in the Surgical
Section ; Drs. Charles Gilmore Kerley, of New
York City, and John Lovett Mors, of Boston,
Mass., in the Pediat;-ic Section; Drs. P. H.
Fridenberg, of New York City, Robert Scott
Lamb, of Washington, D. C, and Prof. J. Va(n
der Hoeve, of Leyden, in the Eye, Ear, Nose
and Throat Section. The management and
treatment of diabetic patients will be well han-
dled by Drs. Ellicott Joslin, of Boston, and
Frederick M. Allen, of Morristo\yn, N. J., and
no one interested in this subject can afford to
remain away from the General Section, Thurs-
day afternoon. Dr. Harry C. Solomon, of Bos-
ton, Mass., will present a paper in the Syphilis
Symposium, the Treatment of Neuro-syphtlis,
Wednesday morning, in the General Session.
Dr. Lewis Ziegler, of Philadelphia, will read a
paper, Wood Alcohol Toxaemia, and the Rem-
edy, at the oi)ening General Session, Tuesday
morning.
In view of the bootlegging, "home brew" and
"rastn mash" concoctions placed on the market
since National Prohibition went . into effect, it
behooves us all to become familiar with the
deadly wood alcohol toxaemia, and render timely
aid before our patients lose their eyesight. The
Committee on Scientific Work feel they are of-
fering our members a great opportunity to hear
this subject presented by Dr. Ziegler, and can-
not understand how any of the doctors can af-
ford to miss hearing his p.iper. Ninety-six
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THE PENNSYLVANIA MEDICAL JOURNAL September, 1921
papers — 96— are being prepared for this Session
of the State Society, by men well qualified to
handle the subjects, and if you will only take the
time to look over the program published in the
August number of the Journal, then ask your-
self, can I aflford to remain at home this year?
The answer will be. No, I can not. You should
look on the time spent at the meetings as three
days of postgraduate work, combined with pleas-
ure. A vacation in which I met old acquaint-
ances, and formed new friends, and resolved to
get out of the rut, and my shell. The program
has been prepared with • a view of giving you
what you want to hear in the line of papers, and
subjects presented that will be helpful in your
daily work. Is it fair to the invited guests who
are taking the time to come to our meetings, that
they should appear before a small audience?
Some doctors will not even sacrifice an office
hour to come and hear them ; while they will
miss one, two or three days away from their
practice. Think it over. Engage accommoda-
tions for the entire three days of the Session.
Raster, and attend all the meetings. Swell the
section, and session attendance, and when the
Philadelphia Session has passed into histpry, you
can say to yourself without regret : / was there.
T. G. S.
ATTENTION OF DELEGATES
The attention of delegates is called to the fact
that the first meeting of the House of Delegates
will be held at three o'clock Monday, October
3d, in the Bellevue-Stratford Hotel. Delegates
must present their credentials and be enrolled
before they are seated.
Important business should be presented to the
House early so that it may receive proper con-
sideration. It is desirable that a session shall
be held Monday evening in order that business
may be expedited and the attendance of dele-
gates at the Scientific Session not be interfered
with.
The election of officers is the first order of
business Wednesday morning, October 5th.
Henry D. Jump, President.
THE NATIONAL BOARD OF MEDICAL
EXAMINERS
The National Board of Medical Examiners
has just completed the first five years' work and
with it the trial period of its usefulness. The
principle which this board has stood for, namely,
the establishment of a thorough test of fitness to
piactice medicine which might safely be accepted
throughout this country and abroad, has been
widely accepted. Since this board was organized
by Dr. W. L. Rodman, in I91 5, eleven examina-
tions have been held. These examinations have
been conducted on the plan of holding at one
sitting, a written, practical and clinical test for
candidates with certain qualifications, namely, a
four-year high school course, two years of col-
lege work, including one year of Physics, Chem-
i.<>try, and Biology, graduation from Class A
medical school and one year's internship in an
acceptable hospital. These examinations have
covered all the subjects of the medical school
curriculum and have been conducted by mem-
bers of the board with members of the profes-
sion resident in the place of examination ap-
pointed to help them. Such examinations have
been held in Washington, Philadelphia, New
York City, Boston, Chicago, St. Louis, Roches-
ter (Minnesota) and Minneapolis. During the
war a combined examination was held at Fort
Oglethorpe and Fort Riley. There have been
325 candidates examined, of whom 269 have
passed and been granted certificates.
Starting with the endorsement of the Council
on Medical Education of the American Medical
Association, American Medical College Associa-
tion and various sectional medical societies, the
recognition of the Army, Navy and Public
Health Service Medical Corps of the United
States and certain state boards of medical ex-
aminers, the certificate is now recognized. Also
by twenty states, as follows: Alabama, Arizona,
Colorado, Delaware, Florida, Georgia, Idaho,
Iowa, Kentucky, Maryland, Minnesota, Ne-
braska, New Hampshire, New Jersey, North
Carolina, North Dakota, Pennsylvania, Rhode
Island, Vermont and Virgina, the Conjoint
Board of England, the Triple Qualification
Board of Scotland, the American College of
Surgeons and the Mayo Foundation of the Uni-
versity of Minnesota.
There has been such a widespread demand for
an opportunity to secure this certificate by ex-
amination, that the board has now adopted and
will put into eflfect, at once, the following plan:
Part I, to consist of a written examination in
the six fundamental medical sciences: Anatomy,
including histology and embryology; Physi-
ology ; Physiological Chemistry ; General Pathol-
ogy ; Bacteriology ; Materia Medica and Phar-
macology. Part II, to consist of a written ex-
amination in the four following subjects : Medi-
cine, including pediatrics, neuropsychiatry, and
therapeutics; Surgery, including applied anat-
omy, surgical pathology and surgical specialties;
Obstetrics and Gynecology; Public Health, in-
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September, 1921
EDITORIALS
897
eluding hygiene and medical jurisprudence.
Part III, to consist of a practical examination in
each of the following four subjects: Clinical
Medicine, including medical pathology, applied
physiology, clinical chemistry, clinical microscopy
and dermatology; Clinical Surgery, including
applied anatomy, surgical pathology, operative
surgery, and the surgical specialties of the dis-
eases of the eye, ear, nose and throat ; Obstetrics
and Gynecology; Public Health, including sani-
tary bacteriology and the communicable diseases.
Parts I and II will be conducted as written ex-
aminations in Class A medical schools and Part
III will be entirely practical and clinical. In
order to facilitate the carrying out of Part III,
subsidiary boards will be appointed in the fol-
lowing cities : Boston, New York, Philadelphia,
Minneapolis, Iowa City, San Francisco, Denver,
New Orleans, Baltimore, Galveston, Cleveland,
St. Louis, Chicago, Washington, D. C, and
Nashville, and these boards will function under
the direction of the National Board. The fee of
$25.0x3 for the first part, $25.00 for the second
part and $50.00 for the third part will be
charged. In order to help the board the Car-
negie Foundation has appropriated $100,000.00
over a period of five years.
At the annual meeting held June 13th of this
year, in Boston, the following officers were
elected : M. W. Ireland, Surgeon General, Pres-
ident; J. S. Rodman, M.D., Secretary-Treas-
urer; E. S. Elwood, Managing Director.
Mr. Elwood will personally visit all Class A
schools during the college year to further explain
the examination, etc., to those interested. Fur-
ther information may be bad from the Secretary-
Treasurer, Medical Arts Building, Philadelphia.
J. S. R.
"SOCRATES REDUX'
A GLIMPSE OF THE CARDINAL'S ROBE
"No, not a voice seems to be raised in pro-
test !"
He was so terribly in earne.st that it was im-
possible not to become aroused. He leaned for-
ward aggressively, his bald head shining, and his
bright eyes beaming behind his spectacles, while
lines appeared in his usually smooth, cleanly
shaven face.
When he began we were apathetic and as he
enumerated the donations amounting to millions
that had been distributed by the trustees -of a
great fund, we followed casually, feeling that
the whole matter was none of our business. But
when he reached the point of the ten million dol-
lars appropriated for a medical college and hos-
pital in Peking, China, he spoke with rare fervor
and we suddenly found ourselves sitting up and
taking notice. The loss of such a sum from the
educational institutions of our country was a
matter meriting consideration. He paused as we
turned it over, giving us plenty of time and evi-
dently pleased that the light was beginning to
dawn upon us. After reflection we said:
"Ten millions is a great sum."
"Certainly it is. It is enough to endow ten
large medical colleges in our own country with
enough income, when added to their present re-
sources, to enable them to found new chairs, em-
ploy additional instructors, build and equip labo-
ratories and more carefully select the student
body."
"Ten million dollars," we repeated, emphasiz-
ing the words as we did so. "Think what that
would mean to the medical institutions of this
state alone. Pennsylvania has the oldest and
some of the best in the country — ^the University
of Pennsylvania with its new postgraduate
school, the University of Pittsburgh, Jefferson
Medical College, the Woman's Medical College,
Halinemann Medical College of Philadelphia;
all old, well established and high-grade institu-
tions bent on doing the best possible work, all
manned by capable and devoted men and all
struggling to meet expenses, and annually con-
fronted by increasing deficits."
"Did you say anything about Temple Univer-
sity?"
"No, that institution may close its doors at
the end of this year."
"But who will close it ? Why should it close ?"
"Well," we said, "It is presumed that Temple
is not needed, and the graduates are so ill-pre-
pared ( ?) that very many of them disgrace it by
failing to pass state boards or, passing them, en-
ter upon some nefarious line of practice."
"Who says so?"
"Well, that is the assumed consensus of opin-
ion."
"Ah! the cardinal is behind it."
"The cardinal?" We asked this question
with a surprise that printer's ink cannot reflect.
"Certainly, the cardinal is behind all these
things. When you hear that there are still too
many medical colleges, that is the cardinal talk-
ing ; when it is said that there are too many doc-
tors, that is the cardinal ; when certain institu-
tions are acceptable while others are not, that is
again the cardinal ; whan certain institutions are
given large donations and others refused, it is
still the cardinal ; when ten millions of good
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THE PENNSYLVANIA MKIDICAL JOURNAL September. 1921
American dollars go to China, it is again the car-
dinal."
"We do not follow you. The Church and its
cardinals have nothing to do with medical edu-
cation."
"You are fortunate in belonging to an insti-
tution that is not yet in his control. In this state
the shadow of his hat has fallen upon two insti-
tutions; one went out of existence by amalga-
mating with another, the second may close its
doors. You are to be congratulated."
"But you are so cryptic that we don't under-
stand. What cardinal do you mean?"
"If your university were to receive a million-
dollar donation you would soon find out. It
would no longer be your university, it would be
his. No new office or program could be elected
without his consent, and you would soon find
that many of the old and best-known professors
would be unseated. Thank your lucky stars that
you have not been thus favored."
"Now, see here! If you talk like this, we will
have to stop, for we can't follow you. What do
you mean ? Who is the cardinal ?"
"I'll explain. Once in old England they had
a king who is known in history as Henry the
Eighth. As adviser, he had a cardinal named
Wolsey. In the early days of their association
he was very useful to the king and gave him
good advice, thus saving him from much disa-
greeable work. But as the years went on, the
cardinal assumed more jmd more power ; people
left him money, he did a great deal of business
on his own account and became richer and richer,
and more and more powerful. At last he de-
cided to assume kingly style and built himself a
great palace at Hampton Court, where he reigned
so magnificently as to make the king look like
thirty cents. When any one wanted anything, he
called on the cardinal and forgot all about the
king. At last he even began to rule the. king. It
was only then that the king aroused himself, de-
stroyed the cardinal, appropriated his property
and did his own reigning."
"As a synopsis of history that is all well and
good, and quite accords with what we have read,
but how in the world can it have anything to do
with the matter under discussion?"
"Don't you see ? The king is the medical pro-
fession ; the great 'foundations' are the cardinal.
We, the profession, have permitted certain indi-
viduals composing these foundations to take pos-
session of us body and soul, to tell us what we
ought to do, how much we ought to know, where
we ought to study, how many of us there ought
to be. The cardinal is reigning instead of the
king. We must destroy the cardinal or the car-
dinal will make us do his will."
"Ah ! ha ! Very good, indeed ! We now un-
derstand the metaphor but we doubt its appro-
priateness."
"How so?"
"Why, the men in control of these funds are
most reputable, honorable, sagacious and well
meaning."
"So was the cardinal."
SCHOOL FOR MIDWIVES
The profession of the midwife is at last being rec-
ognized as a legitimate field of woman's work. This is
the oldest profession of women and in Pennsylvania
alone, about one-fifth of the population — its foreign-
born fraction — seek the services of a midwife. In
many of the home lands the male physician is un-
known, and the emigrant husband, as well as the wife
herself, flatly refuses to have the "man doctor" de-
liver the child.
The Board of Directors of the Maternity Hospital.
734 S. Tenth Street, Philadelphia, has opened a school
for midwives; the period of instruction to be twelve
months, and the entrance fee $50.00. They state that
since only six pupils will be admitted in any one year,
it will be clearly seen that this course is not intended
to materially increase the number of midwives in the
state, but since the life of the mother and child fre-
quently depends upon her skill, it is felt that she
should be properly trained so as to recognize such
symptoms or complications requiring the services of a
physician.
The Maternity Hospital of Philadelphia was estab-
lished in 1872, has a capacity of ,35 beds, and is one of
the leading institutions of its kind in Philadelphia.
Judge William H. Staake is president of the Board of
Directors, and the superintendent in charge is Helen
L. Kelly, R. N.
Personal responsibility for the transmission of vene-
real disease has been upheld by both civil and criminal
courts, says the U. S. Public Health Service. In Okla-
homa a man has been sentenced to five years in the
penitentiary for infecting a girl with syphilis. In Ne-
braska the court upheld a doctor who warned a hotel-
keeper that one of his patients, a guest at the hotel,
had syphilis and had refused treatment and was con-
sequently a menace to the public health. In North
Carolina a woman has been awarded $10,000 damages
against her husband for a similar infection, and the
Supreme Court upheld the judgment.
PROPAGANDA FOR REFORM
PouLEN Anticen-Lederle (Ragweed). — A liquid
prepared by extracting the proteins from the pollen of
the ragweed.
Pou,en Antigen-Lederle (Timothy). — A liquid
prepared by extracting the protein from the pollen of
the timothy. The Lederle Antitoxin Laboratories. New
York (Jour. A. At. A., June 18, 1921, p. i7S3)-
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THE Medical Society of the State of Pennsylvania
OFFICERS' DEPARTMENT
WALTER F. DONALDSON. M.D.
Secretary
8014 Jenkins Arcade BIdg.
Pittsburgh, Pa.
•1921 SESSION
We are confident that all previous registration
and attendance records will be shattered at the
coining annual session in Philadelphia, October
3 to 6. This opinion is based upon the following
facts : First, the scientific program arranged for
this meeting has never been excelled in its di-
versity of standardized subjects and its wealth
of native and foreign talent. Second, interest
in postgraduate work was never keener than at
jiresent among our members. Third, the busi-
ness men represented at our annual scientific
exhibits have never before displayed such con-
cern in the early choice of reservation ; and
finally, the Philadelphia County Medical Society
is exerting itself as never before to make pleas-
ant the time spent by visiting members and their
f;unilies in the city of which they are so justly
proud.
The highways, improved and unimproved, of
Pennsylvania are in their best condition during
October. The Lincoln Highway at present is
without a detour from Pittsburgh to Philadelphia,
and it is superfluous to remind any Pennsylva-
nian of the incomparable beauty of our own
mountains during the autumn season. We re-
gret that it is impossible to obtain reduced rail-
road rates, but we are sure that the money ex-
pended by whatever method you choose to travel
will be many times repaid if you will faithfully
attend upon the scientific meetings, the social en-
tertainments and the scientific exhibit as pro-
\ ided for you.
ANNUAL REPORTS
Judged by several standards, our organization
has grown to large proportions. Judged by the
popular standard of dollars and cents, we have
with our gross annual income of nearly $50,-
CKX).oo, attained considerable size. This number
(if the Journal under the heading of Official
Transactions carries the reports of Officers and
Committeemen of the Society for the twelve
months just concluded, September ist to Sep-
tember 1st. Those of our members who desire
lo review the Society's past activities, have their
opportunity in these published reports. Those
members sufficiently interested to compare the
recorded results with their own conception of
proper results, may commend the year's work or
protest against same through Delegates to the
192 1 House. If, after careful study and having
acquainted yourself with all the facts, you find
evidence of extravagance or lack of aggression
in certain policies, you should come to Philadel-
phia prepared to offer constructive suggestions.
FOR SERVICES RENDERED
Apropos of having your income for services
rendered regulated by outsiders, whether it be a
hospital Board of Trustees or lay members of a
health insurance panel, we offer for the guidance
of all true physicians and their patients the fol-
lowing advice given to the graduating class in
medicine from the University of Pennsylvania,
Philadelphia, in 1789, by Benjamin Rush, M.D.,
Professor of the Institute and Practice of Medi-
cine and Clinical Practice:
"When we consider that sickness deprives men
of the means of acquiring money ; that it in-
creases all the expenses of living ; and that high
charges often drive patients from regular-bred
physicians to quacks, we should make our
charges as moderate as possible and conform
them to the following state of things :
"Avoid measuring your services to your pa-
tients by scruples, drachms and ounces. On the
contrary, let the number and time of your visits,
the nature of your patient's disease, and his rank
in society, determine the figures in your ac-
counts. It is certainly just to charge more for
curing an apoplexy than an intermitting fever.
It is equally just to demand more for risking
your life by visiting a patient in a contagious
fever than for curing a pleurisy. If a rich man
demand more frequent visits than are necessary,
and if he impose the restraints of keeping to
hours by calling in other physicians to consult
with you upon every trifling occasion, it will be
just to make him pay accordingly for it. As this
mode of charging is .strictly agreeable to reason
and equity, it seldom fails of according with the
reason and sense of equity of our patients.
"I shall only add under this head that the poor
of every description should be the objects of
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900
THE PENNSYLVANIA MEDICAL JOURNAL September, 1921
your jjeculiar care. Dr. Boerhave used to say
'they were his best patients because Qod was
their paymaster.'
"There is an inseparable connection between a
man's duty and his interest. Whenever you are
called, therefore, to visit a poor patient, imagine
you hear the voice of the good Samaritan sound-
ing in your ears: 'Take care of him, and I will
repay thee.' May the blessings of hundreds and
thousands that were ready to perish be your por-
tion in life, and your comfort in death, and your
reward in the world to come."
FREDERICK L. VAN SICKLE. M.D.
Executive Secretary
212 North Third Street
Harrisburg, Pa.
CHANGES IN MEMBEBRSHIP OF COUNTY
SOCIETIES
The following changes have been reported to Au-
gust 15:
Adams: Death — John C. Felty (Univ. of Penna.,
'73), of Gettysburg, August 6.
Clearfield: Reinstated Member — H. Albert Blair,
Curwensville.
Chester : New Member — E. V. Kyle, Pa'rkesburg.
Columbia: Death — Charles F. Altmiller (Medico-
Chirurg. Coll., Phila., *oi), of Bloomsburg, August 2,
aged 44.
Erie: Reinstated Member— John K. De Tuerck,
261 E. Eighth St., Erie.
Fayette : Reinstated Member— Edgar K. Wells, Ma-
sontown.
Greene: Reinstated Member— CWnlon E. Bane, Jef-
ferson.
LuzERN'E : Reinstated Member — Frederick A. Musch-
litz, 18 N. Main St., W. Pittston.
Philadelphia: Deaths — Charles Hermon Thomas
(Univ. of Penna., '65), of Philadelphia, June 28, aged
82; Frank I. Hurlock (Jeff. Med. Coll., '81), of Phila-
delphia, July 24, aged 62.
Union: Reinstated M embcr—Edga.r T. Shields, c|o
National Tuberculosis Assn., 370 Seventh Ave., New
York.
Venango: Reinstated Member — Winnie K. Mount,
Odd Fellows BIdg., Oil City.
Westmoreland: Reinstated Member — James F.
Trimble, Greensburg.
Wyoming! New Member — Frank J. Austin, Lacey-
ville.
PAYMENT OF PER CAPITA ASSESSMENT
The following payment of per capita assessment has
been received since July 21. Figures in first column
indicate county society numbers; second column, state
society numbers :
For 1920
Aug. 2 Fayette 125 7200 $5.00
For 192 I
July 21 Berks 131 7208 5.00
Venango 58 7210 5.00
July 25 Clearfield 61 721 1 5.00
July 26 Erie 124 7212 5.00
Aug. 2 Fayette 117 7213 5.00
Aug. 4 Westmoreland 149 7215 5.00
Aug. 8 Greene 26 7216 5.00
Aug. 12 Union 19 7217 5.00
Aug. 13 Luzerne 230-231 7218-7219 10.00
The following new members have paid for one-half
year (July i to Dec. 31, 1921) :
July 21 Wyoming 14 7209 $2.50
Aug. 4 Chester 77 7214 2.50
A TRIP THROUGH THE COMMERCIAL
EXHIBIT
OF THE 7IST ANNUAL SESSION OF THE
MEDICAL SOCIETY OF THE STATE OF
PENNSYLVANIA, OCTOBER 3-6, 1921
"Good morning. Dr. U. C. Sharp, you are just
ihe man I am pleased to meet. I want your criti-
cal judgment upon our Commercial Exhibit and
wish you to take a trip with me. Will you ?"
"De-lighted," said Dr. Sharp.
Taking the elevator in the Bellevue-Strat f ord
Hotel we make our entrance on the first floor,
which has been reserved for this ses.sion, and find
that we are right at the beginning of the exhibit.
"Knowing your interest in the mechanical side
of the profession we will first visit the booths
devoted to
APPARATUS
"In booths 5 and 6 we find the A. S. Aloe
Company of Saint Louis, who are exhibiting,
among other things, a new model of microscope
and their famous Lighting Cabinet. They are
also displaying a large assortment of European-
made instruments just received from their for-
eign buyer." (See advertisement, page xv, this
Journal.)
"The American Surgical Specialty Com-
pany of Chicago, occupies booth 38 and is show-
ing Cameron's complete Electro-Diagnostoset,
together with the special attachments for mastoid
transillumination and removal of foreign objects
from the eye.
"The Bard-Parker Company, Inc., of New
York, at booth 52 is oflfering an exhibit particu-
larly attractive and worth while to the surgeon
who is interested in modern scientific equipment.
Here we see on display the well-known Bard-
Parker Operating Knife, with its detachable
blades. This remarkable instrument solves the
surgeon's problem of dull knives in a very clever
and efficient manner. Charles R. Bard also in-
vites you to examine his very complete line of
urological instruments. They are the best that
can be produced by expert workmen and careful
selection of material..
"The W. a. Baum Company, Inc., of New
York, with its staff of experts to assure efficient
and courteous service, is at booth 76. The
Baumanometer represents the ideal in blood
pressure apparatus and is entitled to careful con-
sideration on file part of all physicians, for cor-
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September, 1921
OFFICERS' DEPARTMENT
901
rect blood pressure findings are essential to effi-
cient diagnosing and can be assured only with a
truly scientific instrument.
"Becton, Dickinson & Company of Ruther-
ford, N. J., have a fine display in booths 54 and
55. Here we see equipment that will furnish the
surgeon with the latest surgical specialties. This
firm is also to be congratulated upon their exhibit
of thermometers, -sjnringes, needles, atomizers
and leather goods.
"The Devilbiss Manufacturing Company
of Toledo, Ohio, are occupying booth 69, where
we find the latest in atomizers, nebulizers, etc.,
too numerous to mention, and well worth seeing.
"In spaces 43 and 44 Hanovia Chemical
and Manufacturing Company of Newark, N.
J., exhibit the latest models of their Alpine Sun
Lamp and Kromayer Lamp. A feature of the
exhibit is the practical demonstration given. It
is very convincing ! We must be sure to call.
"At William H. Horn & Brother's (Phila-
delphia) booth, numbers 50 and 51, are Trusses,-
Abdominal Supporters and Elastic Hosiery. The
'Curtis' Support and 'Hombro' Seamless Sur-
gical Elastic Hosiery particularly attract our at-
tention.
"The Keystone Surgical Instrument Co.,
Inc., of Philadelphia, at booth 41, are showing
their Ferguson's Eye, Ear, Nose and Throat In-
struments. Furniture for physicians' offices and
hospitals invites our attention. Let's sit down
and be comfortable !
"Then as we start out again, we see our old
friend E. Leitz, Inc., of New York, at booth 32.
Their exhibit includes a full line of microscope
models, one of the most interesting of which is
the microscope for binocular and monocular
vision. They also show a new line of microtome
models; the 'Thoma-Metz' blood counting ap-
paratus, an instrument simple in manipulation
and at the same time guaranteeing greatest accu-
racy; the 'Edinger' drawing and projection ap-
paratus which permits drawing of microscopic
images, reconstruction work, projection of micro
slides, projection of lantern slides, micro-pho-
tography and many other means of demonstra-
tion and teaching; a modified pattern of 'Du-
bo.scq' colorimeter whose modified construction
permits its sale at a moderate price ; and a new
type of bath which is a combination model per-
mitting the Wassermann test and inactivating to
be carried out simultaneously within the same
apparatus. The features enumerated are only
a few of the points of interest which may be ex-
pected at the Leitz exhibit." (See advertise-
ment, page xiii, this Journal.)
"Charles Lentz & Sons, well known sur-
gical instrument makers of Philadelphia since
1866, are at booths 73 and 74. They are display-
ing a representative line of 'Noco' (non-corro-
sive) steel instruments, as well as late develop-
ments of instruments and appliances of their own
manufacture. In addition they are demonstrating
the 'American' Sterilizer, being special agents of
the American Sterilizer Company of Erie,
Pa. Their electrical department is exhibiting a
liberal line of cystoscopes, diagnostic-illuminat-
ing instruments, x-ray and high-frequency appa-
ratus of the manufacture of the Wappler Elec-
tric Company, for whom they are sole distribut-
ing agents in the State of Pennsylvania. The
Burdick Quartz Lamp will also be demonstrated..
"We must be sure to call at the Lungmotor
Company's exhibit, booth 39, for this Boston
firm give a very graphic demonstration of the
exact action of the Lungmotor when used in
cases of collapse, asphyxiation, drowning and-
electric shock. Their apparatus is designed to
treat the case from the newborn to the largest
adult. This exhibit appeals to us as being of
immense value to the first-aid operator and in-
dustrial surgeon.
"The Physicians Supply Company of
Philadelphia occupies booths 13 and 14, with
their usual high grade surgical instrument line
and specialties. Nose, throat and ear specialists
will wish to see this exhibit of latest instruments
and receive one of the new catalogs.
"The exhibit of the Harvey R. Pierce Com-
pany of Philadelphia, is unique and instructive.
Those interested in surgery will find it profitable
to inspect their special lines, viz: Stille Cutting
and Bone Instruments, New Alloy Feather-
weight Splints, Albee Table and General Indus-
trial Equipment. Genial Mr. Pierce is busy wel-
coming old and new friends at booths 45 and 46.
"Basal Metabolism apparatus is featured by
the Sanborn Company of Boston, at booth 70.
The Sanborn Benedict, a closed-circuit instru-
ment for determination of the basal metabolic
rate is in use in most of the large hospitals and
medical schools of the country. The Sanborn
Handy is a portable apparatus which functions
on the Benedict principle. The Sanborn Blood
Pressure Outfit, with the new non-leak release
valve, will also be demonstrated, as well as the
Sanborn Pulse Wave Recorder, a new poly-
graph, which is essentially an instrument for the
busy practitioner. An increasingly large num-
ber of physicians are becoming interested in de-
termination of the vital capacity of the lungs as
a diagnostic aid and as index of the patient's
condition in heart disease and pulmonary tuber-
culosis. Thus interest in the Sanborn Vital
Capacity Spirometer is assured.
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THE PENNSYLVANIA MEDICAL JOURNAL September, 1921
"In booth 35 the Toledo Technical Appli-
ance Company, Toledo, Ohio, are showing Mc-
Kesson Anesthetic and Metabolism Appliances,
including nitrous oxid-oxygen appliances for
analgesia and anesthesia in surgery, obstetrics
and dentistry, also anesthetic accessories and
oxygen regulators. Very interesting are the spe-
cial plans and equipment for piping gas-oxygen
to multiple operating rooms in offices and hos-
pitals."
So many anesthetics are beginning to have an
effect upon Dr. Sharp and me, so we wander
along to find new features to divert ourselves.
The placard over the next section reads
BOOKS
and we are delighted to see the fine displays be-
fore us.
"P. Blakiston's Son & Company of Phila-
delphia, at booth 28, have many new books and
each contains new knowledge, new technique, or
new methods of value. Let's look them over!
There are the 'Compend of Human Physiology'
by Albert P. Brubaker, Binnie's 'Manual of
Operative Surgery,' Schamberg's 'Compend of
Skin Diseases,' Deaver and Ashurst's 'Surgery
of the Upper Abdomen,' Stewart's 'Manual of
Surgery' — new books on Diagnosis, on Surgery,
on Obstetrics, on Pathology, on Anesthetics and
a large group of other subjects.
"Booth 40 is occupied by that old friend of the
profession, F. A. Davis Company, of Philadel-
phia, who are presenting a large number of the
latest publications on medical subjects. Among
these you will find A. Edward Davis on 'Nursing
in Eye, Ear, Nose and Throat Diseases,' 'Ra-
tional Treatment of Pulmonary Tuberculosis' by
Sabourin, 'Heart Affections, Their Recognition
and Treatment,' by S. Calvin Smith, 'Practical
P.sychology and Psychiatry' by C. B. Burr, 'Re-
gional Anesthesia' by B. Sherwood Dunn,
'Operative Surgery' by John J. McGrath, and
the Fitch 'New Pocket Medical Formulary.' Be
sure to see their representative !
"The J. B. LiPPiNCOTT Company, another
Philadelphia firm, is at booth 66, and here the
visitors are enthusiastic over Rehberger-Lippin-
cott's 'Quick l^eference Book of Medicine and
Surgery,' with its 151 illustrations, 33 colored
plated, 3 folding manikins, and with one thou-
sand pages of information divided for quick ref-
erence into eleven parts — each disease or dis-
order is treated alphabetically and all instru-
ments and drugs have been catalogued. And
other new books and new editions are here: a
'Gynecology' by Brooke M. Anspach, M.D.. a
new edition of Shears-Williams 'Obstetrics.' Dr.
Karsner's 'Principles of Immunology,' White
and Martin's 'Genito-Urinary Surgery' and the
new twelfth edition of Dr. Sharpe's famous
book on 'Brain Injuries,' together with many
other notable books by eminent writers of the
medical profession.
"Here we have a special feature in the exhibit
of the W. F. Prior Company, Inc., of Hagcrs-
town Md. (booth 2) — a demonstration of the
time-saving blue print plan by which their ten-
volume, loose-leaf Tice's 'Practice of Medicine'
was written, a plan which makes their publica-
tion different from any previous eflfort. In ad-
dition to their ten-voliime set of Tice they will
exhibit their medical services, supplementary to
this work, viz: the International Medical Di-
gest, and the Research Service.
"The W. B. Saunders Company of Phila-
delphia, at booth 16, are showing a number of
new books and new editions of unusual impor-
tance to the medical profession. Among these
may be mentioned : two new volumes of Keen's
'Surgery,' a volume of Mayo Foundation
Theses, a new edition of de Schweinitz's 'Dis-
eases of the Eye,' Bandler's 'The Endocrines,'
Osborne's 'Therapeutics,' a new edition of
Tousey's 'Electricity, X-ray and Radium/ a new-
edition of 'American Illustrated Medical Dic-
tionary,' Boyd's 'Preventive Medicine,' Grif-
fith's 'Pediatrics,' Moynihan's work on the
Spleen, Norris and Landis' 'Chest Diseases,' and
a new edition of Stengel and Fox's 'Pathology.'
Thsse are only a few ; let us stop and see the
others." (See advertisement on front cover of
this Journal.)
We have had much food for thought in the
Book Section, so we are quite ready to partake
of other varieties, for here we are at the
FOODS AND BEVERAGES
"The Horlick's Malted Milk Company, at
booth 62, has come from Racine, Wisconsin, to
exhibit Horlick's — ^the Original Malted Milk in
both powder and tablet form, and other products,
which have been perfected by the experience of
over a third of a century and are known for
their reliability and highest quality. The repre-
sentative in charge will distribute samples and
printed matter and gladly answer your inquir-
ies." (See advertisement, page xiii, this Jour-
nal.)
"The Kalak Water Company of New
York, Inc., has an abundant supply of Kalak
Water at booth 47. Let's try it!
"At booths 56 and 57 Mead Johnson &
Company of Evansville, Indiana, are exhibiting
a full line of Infant Diet Materials. For the
baby with diarrhea, the baby that does not gain,
the baby that cannot digest starch, the baby that
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September, 1921
OFFICERS' DEPARTMENT
903
has constipation — let the Mead Johnson and
Company's representative show you how simple
it is to select one of their diet materials to suit
the individual requirement of each baby." (See
advertisement, page xii, this Journal.)
"Melun's Food Company of Boston, Mass.,
are occupying spaces 17 and 18. Physicians who
desire information relative to the composition of
Mellin's Food and its application as a mo<lifier
of milk or who wish to take up the matter of
management of an infant's diet will have every
opportunity, for representatives well qualified to
discuss the subject will be present at every ses-
sion of the meeting." (See advertisement, page
xxii, this Journal.)
"The Philadelphia Interstate Dairy
Council have some interesting charts at booth
I, showing the nutritional value of milk, and this
point is being stressed throughout their exhibit.
The various ways in which milk is of importance
to the medical profession are being discussed.
Samples of the Interstate Dairy Council's prod-
ucts are being submitted. Good, pure milk is
very important and we will stop for an inter-
view.
"The Welch Grape Juice Company of
Westfield, N. Y., are demonstrating Welch's
Grape Juice and also Grapelade at booth 12.
Free drinks, of course !"
Dr. Sharp and I feel so well satisfied after vis-
iting the last section that we are ready to tackle
the next, which is the
MISCELLANEOUS
"The Americal Institute of Medicine of
New York, has booth 75, where we find mem-
bers of their staff who are pleased to explain
their methods of special service in keeping physi-
cians in touch with the latest developments in
medicine. Let us stop and make their acquaint-
ance ; they may be able to help us with some of
our difficulties.
"Booth 63 brings us to Colgate and Com-
pany of New York City, an ethical business
concern, established in 1806, whose products
have a world-wide reputation. It is well to ex-
amine carefully the goods they have especially
for the profession.
"At booths 8 and 9 interesting bacteriological
experiments demonstrate the properties of
KoLYNos Dental Cream, made by the Koly-
nos Company of New Haven, Conn.
"The Medical Protective Company of
Fort Wayne, Indiana, is occupying booth 3.
This company is exclusively engaged in the busi-
ness of furnishing protection against the mal-
practice risk of the profession." (See advertise-
ment, page ii, this Journal.)
"C. D. Williams & Company of Philadel-
phia, are in booth 64. These exhibitors are tail-
ors and manufacturers of cotton and linen cloth-
ing for hospital surgeons, resident physicians,
nurses and orderlies, naval officers, U. S. Public
Health Department, dentists, etc. Established
in 1876, they have developed garments from sug-
gestions of members of the medical profession,
and have standardized them to such an extent
that they ship their products to all parts of the
United States and to surgeons and hospitals in
some foreign countries."
"Now that I have purchased my hospital sup-
plies," said Dr. Sharp, "suppose we visit the
OPTICAL INSTRUMENTS
"D. V. Brown of Philadelphia, has a full dis-
play at booth 33 of ophthalmological instruments
and other accessories pertaining to the testing of
vision and the filling of oculists' prescriptions.
"At spaces 29 and 30 are McIntire, Magee
& Brown Company of Philadelphia, Wholesale
Prescription Opticians, displaying a complete
line of eye testing apparatus and ophthalmic
office equipment, also a large assortment of the
best in eye textbooks and charts. This firm gives
a cordial invitation to every dispensing oculist
to visit their home office at 723 Sansom Street,
only two squares below Jefferson College Hos-
pital, where there will be found in their plant
of about 15,000 square feet, one of the most
complete optical factories in the country.
"E. B. Meyrowitz, Inc., of New York, Paris
and London, are in spaces 21 and 22. They are
manufacturers of ophthalmological apparatus
and eye, ear, nose and throat instruments and
are exhibiting many specialties in this line. At-
tention is particularly called to their 1920 model
ophthalmometer, a new trial frame and a very
practical portable perimeter. While their ex-
hibit ai)peals mostly to specialists in the lines
mentioned, many things are shown which are of
interest to the general surgeon and practitioner
— electric operating and diagnostic instruments,
fine scissors, scalpels, curettes — ^that are fre-
quently extremely useful in some of the finer
surgery.
"Booth 42 is occupied by the White Haines
Optical Company of Pittsburgh, Pa.; Colum-
bus, Ohio; Indianapolis, Indiana, and Spring-
field, Illinois. This firm has a reputation for
high-class prescription work and efficient service.
They have recently developed the new 'Korectal
Lens' and are demonstrating this at their booth.
Be sure to call and see them." (See advertise-
ment, page x, this Journal.)
"The WooLF Instrument Corporation of
New York, are this year demonstrating at booth
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THE PENNSYLVANIA MEDICAL JOURNAL Skptkmbp.r. 1921
13 tlie improvements which they have made upon
their eye testing apparatus, and we are very much
fascinated with the methods employed mechan-
ically to diagnose defective vision. This firm
is very painstaking in their explanation and'
demonstration and one should not fail to spend
some time at their booth.
Since Dr. Sharp says he has an eye full, we
will pass on and see the next section —
PHARMACEUTICALS
"The Abbott Laboratories of Chicago, are
at space 34. This firm is showing many interest-
ing products, among which are: Acriflavine,
Argyn, Benzyl Benzoate, Cinchophen, Chlora-
zene, Calcalith, Chlorcosane, Digipoten, Pitui-
tary Solution, Parresined Lace-Mesh Surgical
Dressing and Sodoxylin, beside many others.
"The well-known Paris house of P. AsTiER
are again exhibiting their Arheol Capsules, which
represent the active principle of sandalwood oil ;
likewise their Riodine Pearls, an excellent sub-
stitute for iodide of potassium. Both prepara-
tions have been favorably passed upon by the
Council on Pharmacy and Chemistry and are
presented to the profession and marketed to the
trade in the most ethical fashion. Mr. Albert
Thouin of New York, their American represen-
tative, and his assistants, will be pleased to have
you visit his exhibit at space 53, where he will
supply interesting data covering the Astier prod-
ucts." (See advertisement, page viii, this Jour-
nal.)
At booth 58 the Calco Chemical Company
of New York and Bound Brook, N. J., are
this year featuring Cinchophen Calco, Tolysin,
Acetannin Calco, beside the usual standard Beta
Naphthol and Creosote group. This firm are
pioneer manufacturers in the newer chemical
prescriptions, so it is essential that we stop a
moment and give them an opportunity to explain
the latest thing in their line.
"Fairchild Brothers & Foster of New
York, are exhibiting at booth 59 well-known
j)roducts of tlie gastric and pancreas glands. The
newer products evidence continued progress in
the apph'ed chemistry of the digestive ferments
— (lastron, for instance, an entire extract of the
gastric gland ti.ssue juice, in fluid form, sugar
free, alcohol free. Fairchild Culture Pepton. a
time-saver in the laboratory, enables the physi-
sian to prepare culture media instantly — simply
with water and this desiccated pepton-broth-
media Optolactin, the bacillus acidophilus and the
bacillus bulgaricus in the convenient and 're-
sistant' tablet form.
"The GiLLiLANi) Laboratories, Inc., of
Ambler, Pa., are displaying a comjjlete line of
biological products at booth 25, and have repre-
sentatives there to explain and give physicians
any information in regard to them." (See ad-
vertisement, page ix, this Journal.)
In booth 23 Hynson, Westcott & Dunning
of Baltimore, are exhibiting their standard
pharmaceuticul specialties, including the more
recent Mercurochrome-220 Soluble and the
Benzyl Benzoate preparations. This firm is
handling the new products and is well worth a
half hour's consideration." (See advertisement,
page xvii, this Journal.)
"The Keasbey & Mattison Company, with
factories at Ambler, Pa., and offices throughout
the United States, take pleasure in recalling to
the profession their Granular Eflfervescent Salts,
particularly Alkalithia, the ideal renal eliminant
for over forty years; Salaperient, the effective
purgative ; and Phoso Benzoate of Soda, a com-
bination of unusual merit and deserving of the
serious consideratoin of the physician and sur-
geon. They are occupying booth 60.
"The McKennan Pharmacy of Pittsburgh,
occupies booths 19 and 20, and are showing us
the professional side of the Druggist's calling.
How the druggist can render professional serv-
ice to the physician and the public by analyses,
assays, etc., is well demonstrated. This firm is
in a position to furnish to the profession the
many newer preparations in organotherapy,
among them being Corpus Luteum Substance,
Ovarian Substance, Ox Bile Keratin Coated.
Pitutiary Substance, Suprarenal Substance —
desiccated. They are the manufacturers of
Glenicals, Dakin's Solution freshly prepared,
Liquor Calci Creosoti, Gelose products and a
host of others." (See advertisement on back
cover of this Journal.)
"At booth 61 the Maltbie Chemical Co.m-
PANY of Newark, N. J., are having an attractive
exhibit in charge of Mr. H. J. Somerville, their
.salesmanager. Mr. D. H. Smith and Mr. G. J.
Hall are also gracing the occasion with their
presence and demonstrating some of the new
things this house has to offer, such as Calcreose
in tablet, powder and solution, as well as other
tablet preparations." (See advertisement, page
viii, this Journal.)
"The Maltine Company has a display of
various materials at booth 24. Among these are
Malt, Cod Liver Oil, Cascara Sagrada, Olive
Oil, etc., which enter into the composition of the
Maltine preparations, together with the fini.shed
j)roducts. The company's representatives are
glad to furnish visiting lists, sets of memoran-
dimi books, tongue depressors, blotters, etc.. to
visiting physicians.
"The exhibit of the H. A. Metz Laborato-
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September, 1921
OFFICERS' DEPARTMENT
905
RiES, Inc., of New York, at space 4 is particu-
larly of interest to the medical profession be-
cause of their principal products: Salvarsan,
Neosalvarsan, ■ Silver Salvarsan, Novocain, Su-
prarenin, Orthoform, Pyramidon, Holocain, etc.
Members of their scientific staff are in attend-
ance." (See advertisement, page x, this Jour-
nal.)
"H. K. MuLFORD Company, Inc., of Phila-
delphia, the pioneer biological manufacturers, in
booths 71 and 72, are showing the Collapsible
Tube Syringe with various formulas of sterile
solutions ready to use, as well as their One Hun-
dred and Sixty Plus products, serums and bac-
terins for the treatment and prevention of Pneu-
monia, Diphtheria Antitoxin and a multitude of
other interesting therapeutic agents.
"The splendid specialties of William H.
RoHRER of Philadlephia, will be featured at
booth 78. The wonderful growth and service
displayed by this manufacturer of superior
pharmaceutical preparations has attracted the
medical profession throughout the State and we
are particularly pleased to have this house, which
is serving so many of the members of our So-
ciety, represented at the Philadelphia Session
this year."
"Well, my friend, the exhibits of the pharma-
ceutical houses have interested me very much,
as I have desired for some time to learn of the
new preparations for the internist," said Dr.
Sharp, "but I have also a great desire to see the
latest things in
X-RAY AND RADIUM
"The first booth that attracts our attention is
occupied by Campbell Electric Company of
Lynn, Mass., exhibiting their X-Ray and High
Frequency Coil, which delivers a current of high
and low voltage and high and low frequency.
This x-ray and electro medical apparatus is of
the latest design and adapted to the use of the
practitioner as well as the specialist. We are
pleased to find this firm in booths 10 and 11.
"The Engeln Electric Company of Cleve-
land, Ohio, occupy booths 36 and 37. They are
exhibiting a complete line of modern x-ray
equipment and accessories which include some
recent developments in the x-ray field. Mr. H.
B. Denny, of the Philadelphia Branch, and Mr.
F. Pollard, of the Pittsburgh Branch, are in at-
tendance.
"The LiEbel-Flarsiieim Company of Cin-
cinnati, Ohio, are exhibiting at booth 65 some
very handsome x-ray and electrical apparatus of
the latest design, adapted to the electric current
found in every city, and a careful examination
of this firm's display will reveal through their
demonstration the newer metliods of applying
electricity.
"The Raijium Chemical Company of Pitts-
burgh, this year are exhibiting their patented
Glazed Plaques for superficial conditions and
tube and needle applicators for deep therapy.
This firm, being one of the pioneers in radium,
are in a position to demonstrate the benefits of
radium in the treatment of cancer and other dis-
eased conditions. We find their exhibit in booths
48 and 49 extremely interesting.
"We next find in booths 67 and 68 the Ra-
dium Company of Colorado, Inc., with an ex-
hibit of tubular applicators, needle applicators,
flat applicators and applicators of special design.
Their demonstration reveals many interesting
facts concerning radium treatment of diseased
conditions." (See advertisement, page x, this
Journal.)
"Thompson-Plaster Company, Inc., of
Leesburg, Va., are comfortably situated in spaces
26 and 27, where we see models of their type
F O machines for treatment of malignant dis-
ease and other electrical appliances, as well as
their latest type of x-ray machines."
"I'll say," said Dr. Sharp, "this is one of the
best exhibits I've seen!"
"Then our attention was called to the United
States Radium Corporation of New York,
formerly the Radio Chemical Corporation, in
booth 7. This company produces its radium
from ore mined in Colorado and Utah, the re-
duction process being accomplished in their
works and laboratories in Orange, N. J. Their
representatives demonstrate to us the advanced
methods of radium work of all kinds, and the
results of their study of methods of treatment,
dosage and effects. They tell us that they will
be glad to have physicians who are interested in
radium inspect their reduction and laboratory
operations at Orange, and gladly offer assistance
and cooperation in aiding those who seek infor-
mation relative to radium and radium treat-
ment." (See advertisement, page xxiii, this
Journal.)
As we emerge from the Commercial Exhibit I
notice a twinkle in Dr. Sharp's eye and surmise
that he has something to say. I am not long in
waiting to hear his verdict. "My friend, I have
visited many exhibits of state medical societies
and have always found them instructive and of
scientific value, but I am free to confess that this
year your exhibitors have excelled anything I
have previously seen and I want to congratulate
your Society, as well as the exhibitors, up)on the
excellent and painstaking display which I have
had the privilege this morning of viewing." .
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THE PENNSYLVANIA MEDICAL JOURNAL September, 1921
NEW AND NONOFFICIAL REMEDIES
Armour & Co. :
Suprarenalin Solution-Armour.
The Diarsenol Co.:
Silver Diarsenol.
" " 0.05 Gm. Ampules.
o!is " "
0.2 "
0.2S "
Hynson, Westcott & Dunning:
Mercurochrome-220-Soluble.
Beebe Laboratories, Inc.:
Beebe Protein Milk.
Beebe Modified Buttermilk.
Benzyi, Bekzoate. — Van Dyk.— A brsind of benzyl
benzoate (see New and Nonofficial Remedies, 1920, p.
49), complying with the N. N. R. standards. L. A. Van
Dyk, New York, N. Y.
Benzyl Benzoate.— Van Dyk 20 per cent.— Each
100 Cc. contains benzyl benzoate — Van Dyk, 20 Cc, and
alcohol 80 Cc.
Benzyi. Benzoate.— Van Dyk 20 per cent Aromatic.
— Each 100 Cc. contains benzyl benzoate — Van Dyk,
20 Cc. ; oil of orange, 0.74 Cc, and alcohol, 79.26 Cc.
Benzyl Alcohol-Ipco. — A brand of benzyl alcohol
(see New and Nonofficial Remedies, 1920, p. 27), com-
plying with the N. N. R. standards. Intra Products
Co., Denver, Colo.
Ven Sterile Solution Benzyl Alcohol 4 per cent
2 Cc. — Each ampule contains benzyl alcohol Ipco 4
per cent in physiological solution of sodium chloride,
2 Cc. Intra Products Co., Denver, Colo.
Varcol. — A compound of silver and a derived al-
bumin containing not less than 20 per cent of silver.
For the action and uses of Vargol, see general article
on Silver Preparations under Silver Protein Prepara-
tions, Argyrol Type, New and Nonofficial Remedies,
1920, p. 310. Heyden Chemical Co., New York, N. Y.
(Jour. A. M. A., Nov. 27, 1920, p. 1499).
Arsphenamine — Squibb. — A brand of arsphenamine
N. N. R. (see New and Nonofficial Remedies, 1921, p.
41). Arsphenamine-Squibb is marketed in ampules
containing, respectively, 0.1 Gm., 0.2 Gm., 0.3 Gm., 04
Gm., 0.5 Gm., 0.6 Gm. Arsphenamine. E. R. Squibb &
Sons, New York.
Neoarsphenamine — Squibb. — A brand of neo-
arsphenamine N. N. R. (see New and Nonofficial
Remedies, 1921, p. 45). Neoarsphenamine-Squibb is
marketed in ampules containing, respectively, 0.15 Gm.,
0.3 Gm., 0.45 Gm., 0.6 Gm., 0.75 Gm., 0.9 Gm. Neo-
arsphenamine.
Sodium Arsphenamine — Squibb. — A brand of so-
dium arsphenamine N. N. R. (see New and Nonoffi-
cial Remedies, 1921, p. 48). Sodium Arsphenamine-
Squibb is marketed in ampules containing, respectively,
o.is Gm., 0.3 Gm., 0.45 Gm., 0.6 Gm., 0.75 Gm., 0.9 Gm.
sodium arsphenamine. E. R. Squibb & Sons, New
York {Jour. A. M. .4., April 9, p. 1007).
"Aspirin Bayer" and the Sterling Products Co. —
Shortly after the United States entered the war, the
Alien Property Custodian took over the property of
Bayer and Co., Inc. The Sterling Products Co. ac-
quired the pharmaceutical end of the Bayer concern.
After that the Winthrop Chemical Co. was incor-
porated and seemingly secured control of all the Bayer
pharmaceutical specialties, except "Aspirin." The
Bayer Co., it was announced, had been merged with
the Sterling Products Co., and "Aspirin-Bayer" added
to the latter firm's list of "patent medicines" Cm-
carets, Danderine, Pape's Diapepsin, California Symp
of Figs, Neuralgine and Dodson's Livertone. Just
what relationship exists between the Winthrop Chemi-
cal Co. and the Sterling Products Co., we do not
know ; the "Bayer Cross" is used on the label of the
Winthrop products. As the court has ruled that on
prescriptions calling for "Aspirin" the Bayer prodnct
must be dispensed, physicians should prescribe acteyl-
salicylic acid and not "Aspirin" (Jour A. M. A., June
II, 1921, p. 1697).
PROPAGANDA FOR REFORM
More Misbranded Nostrums. — The following prep-
arations have been the subject of prosecution by the
Federal authorities charged with the enforcement of
the Food and Drugs Act, chiefly because the curative
claims made for them were unwarranted: Hoffman's
Celebrated Mixture (Solomons Co.), essentially in
alcoholic solution of copaiba and opium. Aspironal
(Aspironal Laboratories), essentially a solution of
sodium salicylate, cascara, a small amount of mydri-
atic alkaloids and a trace of menthol. Lozon Pills
(Lafayette Co.), consisting essentially of ferrous car-
bonate, nux vomica, damiana, arsenic and a laxative
plant drug. La Nobleza and Sin Igual (Juan Can-
dara), the first, a solution containing plant extractives,
including saponin (sarsaparilla), a plant laxative,
sugar, akohol, water and traces of alkaloids ; the sec-
ond, a watery solution containing gum, a plant laxa-
tive, licorice, and faint traces of alkaloids. Silver-
stone's Internal Remedy (H. Planten and Son), cap-
sules containing resins and volatile oils, including
copaiba and cubebs. Yellow Pine Compound (Yellow
Pine Extract Co.), consisting of turpentine mixed
with magnesium oxid and a small amount of jalap.
Thomas Emmeragogue Pills (Palestine Drug Co.),
consisting essentially of ferrous sulphate, aloes and an
unidentified alkaloid. Kyal's Prescription "23" and
Nyal's Prescription "23" Pills (Nyal Co.), the first, a
liquid consisting essentially of zinc sulphate, boric
acid, (}olden Seal, glycerin and water; the second,
consisting essentially of ferrous sulphate, copaiba
balsam, oleoresin of cubebs and alkaloidal material
(Jour. A. M. A., Aug. 6, 1921, p. 481).
Cod Liver Oil in Rickets. — For many years cod
liver oil has been regarded almost as a specific against
rickets in children. During recent years it has been
made reasonably certain that the administration of cod
liver oil alters the calcium balance in such a manner
that calcium will be retained in the body and that it
increases the capacity of rachitic children to take op
and hold calcium. Since the beneficial effects of cod
liver oil on rickets may be due to its liberal content
of vitamine A, frequently described as the Fat-Soluble
food accessory, it is interesting to know that crude
unrefined cod liver oil may be 250 times as rich as
butter in vitamine A and that samples of refined oil
although not so active as the crude oil, were also far
superior to butter in their vitamine potency. The ease
with which the Fat-Soluble A Vitamine of cod liver
oil is destroyed by reagents and drastic manipulations
make the various "refinements" of cod liver oil prod-
ucts sold as proprietary preparations even more repre-
hensible than they have semeed in the past (Jour. A.
M. A., April 9, 1921, p. 1009).
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County Medical Societies
REPORTERS OF COUNTY SOCIETIES:
AoAMS — Henry Stewart, M.D., Gettysburg.
Alughxny— Lester Hollander, M.D., Pittsburgh.
AtHSTaoNG — ^Jay B. F. Wyant, M.D., Kittanning.
Bbav««— Fred B. Wilson, M.D., Beaver.
BEoroRD — N. A. Timmins, M.D., Bedford.
Bebks — Clara Shetter-Keiser, M.D., Reading.
Blair — James S. Taylor, M.D., Altoona.
Bradfom) — C. L. Stevens, M.D., Athens.
Bucks — Anthony F. Myers, M.D., Blooming Glen.
Bdtuu — L. Leo Doane, M.D., Butler.
Cambria — John W. Bancroft, M.D., Johnstown.
Carboh — Jacob A. Trexler, M.D., Lehightoo.
CsirriR — James L. Seibert, M.D., Bellefonte.
Chkstex — Henry Pleasants, Jr., M.D., West Chester.
Clasioh — Sylvester J. Lackey, M.D., Clarion.
Clxarfiild— J. Hayes Woolridge, H.D., Clearfield.
CliMTOn— R. B. Watson, M.D.. Lock Haven.
Colombia — Luther B. Kline, M.D., CaUwissa.
CRAwroRS — Cornelius C. Laffer, M.D., Meadville.
CuMBBRLAND — Calvin R. Rickenbaugh M.D., Carlisle.
Dauphih — F. F. D. Reckord, M.D., Harrisburg.
DtLAWARB— George B. Sickel, M.D., Chester.
Elk — Samuel G. Logan, M.D., Ridgway.
Eant — Fred E. Ross, M.D., Erie.
FayKTTB — George H. Hess, M.D.. Uniontown.
Frakklim — John J. Coffman. M.D., Scotland.
r.RBiuB— Thomas B. Hill. M.D., Waynesburg.
HoHTiRCDON — John M. Keichline, Jr., M.D., Petersburg,
Ihdiaha — C. P. Reed, M.D^ Indiana.
firnRSOif — W. J. Hill, M.D.. Reynoldsville.
cwiata — Benjamin H. Ritter, M.D., McCovsville.
.ackawamna — Harry W. Alhertson. M.D.. Scranton.
Lamcasier — Walter D. Blankenship, M.D., Lancaster.
Lawrence — William A. Womer. M.D., New Castle.
Lebanon — John C. Bucher, M.D., Lebanon.
Lehigh — Frederck R. Bausch, .M.D., AUentown.
Luzerne — Walter L. Lynn, M.D., Wilkes-Barre.
Lycoming — Wesley F. Kunkle, M.D., Williamsport.
McKean — Fred Wade Paton, M.D., Bradford.
Mercer — .\I. Edith MacBride. M.D., Sharon.
Mifflin — O. M. Weaver, M.D.. Lewistown.
Monroe — Charles S. Flagler, M.D., Stroudsburg.
Montgomery — Benjamin F. Hubley, M.D., Norristown.
Montour — John H. Sandel, M.D., Danville.
Northampton — W. Gilbert Tillman, M.D., Easton.
Northumberland — Charles H. Swenk, M.D., Sunbury.
Perry — Maurice I. Stein, M.D., New Bloomfield.
Philadelphia— John J. Repp, M.D., Philadelphia.
I'otter — Robert B. Knight, M.D., Coudersport.
Schuylkill — George O. O. Santee, M.D., Cressona.
Snyder— Percy E. Whiffcn. M.D., McClure.
Somerset — H. Clay McKinley, M.D., Meyersdale.
Sullivan — Martin E. Herrmann, M.D., Dushore.
Susquehanna — H. D. Washburn, M.D., Susquehanna.
Tioca — John H. Doane, M.D., Mansfield.
Union — Oliver W. H. Glover, M.D., Laurclton.
Venango — John F. Davis, M.D., Oil City.
Warren— M. V. Ball, M.D., Warren.
Washington — Homer P. Prowitl, M.D.. Washington.
Wayne — Edward O. Bang, M.D., South Canaan.
Westmoreland — J. F. Trimble, M.D.. Greensburg.
Wyoming — Herbert L. McKown. M.D., Tunkhannock.
York — Gibson Smith, M.D., York.
September, 1921
COUNTY SOCIETY REPORTS
ALLEGHENY— JUNE.
The regular monthly scientific meeting of the Alle-
gheny County Medical Society was held on June 21,
1921, 8 : 30 p. m., at the Pittsburgh Free Dispensary
Building, 43. Fernando Street, Pittsburgh, Pa. The
president, Dr. Carey J. Vaux, was in the chair. At-
tendance: 138. Pyloric Stenosis, presented by Dr.
W. B. Ray. Dr. Ray calls particular attention iti his
paper to the administration of belladonna in cases
which show retention, in order to rule out a spasmodic
contraction which is sometimes responsible for the
condition. He showed several roentgenograms to sub-
stantiate his point.
In a classical paper. Dr. H. E. McGuire took up the
subject of "Arthroplasty of Lower Jaw." He de-
scribed two types of ankylosis, intra-articular and
extra-articular or cicatricial. He called attention to
the difficulty in the diagnosis of the afTected side. Such
symptoms as flattening of the jaw, the elicitation of
lost motion with one's fingers, and the atrophy of the
muscles of the affected side are helpful in establishing
the diagnosis. He presented both pictures and patient
who was successfully operated upon for this condi-
tion. The patient was a thirteen-year-old female, in-
jured in 1912, receiving a fracture. Murphay's flap
operation was performed. Several helpful hints were
given by Dr. McGuire in the discussion of its tech-
nique.
In an informal way Dr. Theodore Diller presented
the subject of "The Prognosis of Disease in General,
and Nervous Disease in Particular." Telling the truth
fully either to the patient or friends or both was his
advice. In the discussion Dr. C. C. Wholey differed
quite materially in the method of procedure of prog-
nosis from the previous speaker and cited definite ex-
amples. He considered the art of prognostication in
much more important light. Dr. W. H. Mayer
thought that the prognosis should always be carefully
given. Dr. Diller closed the discussion.
The paper and discussion of Drs. W. H. Guy and
Fred M. Jacobs on Silver Arsphenamine, on account
of its timeliness will be published in full.
Pregnancy in Diabetes, Dr. Lawrence Litchfield. In
a highly scientific article Dr. Litchfield called attention
to the fact that the urine is not frequently enough
tested for sugar during pregnancy. The proportion of
glycosurea is one in ten to even as high as one in
three. Possibly this high ratio is due to the great
amount of food ingested but in all circumstances these
cases must be carefully watched as they are candidates
in the future for diabetes mellitus. Lactose may be
the reducing agent but it is very rare. Glucose is the
carbohydrate of frequency. A definite regime as to
the water balance, elimination of worry, and anxiety
and fatigue is important. Carbohydrate tolerance in-
creases during pregnancy. It is very important that
chloroform should not be used in these cases, gas be-
ing the anesthetic of choice. The patient should not
be allowed to put on weight. If symptoms of severe
acidosis occur the pregnancy should be interrupted.
We must always be on the lookout for acidosis and in
these cases the diet should be greatly diminished, large
amounts of water given to keep the kidneys flushed
and in case the presence of diacetic acid or acetone is
found in the urine, carbohydrates should be given by
mouth. Proteins should slowly be increased but never
give bicarbonate of soda. Administration of carbo-
hydrates in form of glucose intravenously is the best
treatment for acidosis. A maintenance diet should be
worked out for each individual patient, which is some-
thing lower than a tolerance diet. In discussing Dr.
Litchfield's paper. Dr. Paul Titus called attention to the
seriousness of diabetes in pregnancy and called atten-
tion to the fact that in severe cases pregnancy should
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THE PENNSYLVANIA MEDICAL JOURNAL September, 1921
be interrupted. If severe symptoms develop shortly be-
fore labor, Caesarian section under local anesthesia is
the choice of all procedure. The fermentation test
should be used in the differentiation of lactose and
glucose. Dr. Milton Goldsmith thought that the prog-
nosis of diabetes in pregnancy with the institution of
the Allen treatment is better than the tenure of the
paper and the previous speaker would indicate. Dr.
Geo. J. Feldstein thought that Caesarian section is
contra-indicated. In closing the discussion Dr. Litch-
field again spoke of the careful watching of the pa-
tient.
Cooperation Between the Physicians and the Depart-
ment of Health. Dr. August H. Eggers spoke on the
attitude of the physicians towards public health as the
determining factor of its efficiency. With the per-
sonnel, which had been very much reduced and with
the expenditure cut down to a minimum public health
officials are confronted with a very serious situation.
Unless physicians cooperate, especially in reporting
contagious diseases early and instituting quarantines
the work of the public health service is greatly handi-
capped, and may result in calamity.
What Constitutes a Surgical Appendix? Dr. E. S.
Montgomery stated that any appendix once attacked
by an inflammatory process is a surgical appendix.
Even a mild or catarrhal appendix which recovers
after a few attacks may become dangerous later. The
peritoneal coat being thicker at the base may account
for the frequency of rupture in that location. As soon
as a diagnosis of appendicitis is made cases become
surgical. Such symptoms as pain referred to the epi-
gastrium, nausea and vomiting, temperature, elevation
of the pulse, continued hypersensitiveness of McBir-
ney's point, and prostration may be due to a gangren-
ous appendix. A differential diagnosis must be made,
ruling out enteric colitis, nephritic colic, pneumonia
and diverticulitis. Cases which give symptoms but
never recur are not due to appendicitis but are due
to acute inflammation at the base of the jejunum or
ileum.
Dr. I. J. Moyer called attention to the fact that the
physician has a duty to perform in maintaining the
welfare of the community. This can be accomplished
only by close attendance to medical meetings, stimu-
lating public meetings, and by giving dignified instruc-
tion on medical subjects to the public. The success of
the various cults lies in the fact of their well organized
bodies and propaganda. It is absolutely necessary for
the medical profession to be well organized in order to
carry out the duty which they owe to the public.
Lester Hollander, Reporter.
BRADFORD— JUNE
The regular monthly meeting of the Bradford County
Medical Society was held at the Robert Packer Hos-
pital. Sayre, June 14, with the first vice-president, H.
C. Down, in the chair. Twenty-one members and ten
visitors were present. The delegate to the State So-
ciety session at Philadelphia and alternates were
elected, and a District Censor nominated.
Dr. Rufus S. Reeves, a member of the Methodist
Hospital staff in Philadelphia, and an intern at the
Packer Hospital in 1913, gave a carefully prepared
paper on Lethargic Encephalitis, giving full histories
of nine cases with report of the conditions one year
after the sickness in the seven cases that recovered.
These nine cases were all male adults seen in the serv-
ice of Dr. Reeves at the Methodist Hospital.
Dr. E. F. Butler, New York City, a guest of Dr.
Guthrie, who was a member of the first Red Cross
unit, consisting of six doctors and twelve nurses, to
go to Serbia, gave an interesting talk, relating some
of the experiences of the imit. They found twelve
hundred sick and wounded soldiers on their hands,
all crowded into one large concrete building with only
one room. The orderlies could not be trusted and the
Serbian officials were more interested in military af-
fairs than in sanitation or the care of the sick and
wounded. Every patient was lousy and most of them
had typhus fever. Dr. Butler thinks the mild cases
of typhus fever seen in New York City and in Mexico
and minus the lice is not more alarming than typhoid
fever, but with lice on all the patients, the lack of all
sanitary conveniences, indifference of patients and Ser-
bian help and the lack of sufficient medical and nurs-
ing force it was a far different task. All of the
twelve nurses contracted typhus, but fortunately re-
covered and returned to duty. They were .selected
women and not one shirked any laborious or distaste-
ful service, nor would one of them take advantage of
a quiet opportunity to withdraw from the field. Of
the sixteen American physicians entering the work ten
died of typhus.
Dr. Frank C. Neff, of Kansas City, Missouri, talked
upon the subject of "Interesting Conditions in Child-
hood," illustrated by lantern slides and specimens. To
those who practice obstetrics and pediatrics it is of
vital importance to recognize in the infant during the
first few days of life symptoms of meningeal or cere-
bral hemorrhage. Convulsions, refusal to nurse,
edema of the scalp and face, hemorrhages from
vagina, rectum, bladder, mouth, umbilicus and else-
where make up a picture which is demonstrative of
grave disturbances within the cranium. Rodda at the
University of Minnesota has shown by a study of the
newborn at that institution that there exists a delayed
coagulation time in the newborn and that this is foimd
especially in infants who have meningeal .hemorrhage.
A hemorrhagic tendency exists then in a high per-
centage of those infants whose brain hemorrhage has
previously been supposed to have occurred from birth
trauma. Dr. Neff showed specimens from an infant
dying of such a condition, revealing hemorrhagic areas
in the lungs, endocardium and kidneys which, with
large clots over the brain cortex, made up a picture
of an acute hemorrhagic process in the newborn. Such
processes, if extensive and progressive, cause deatK
but lesser degrees allow the child to live and, in cer-
tain instances, to cause in the child the spastic para-
lytic state which is recognized as Little's disease. The
value of early diagnosis rests in the use of serum and
in selected cases of surgical intervention for hemo-
stasis. Injections of the mother's or father's blood
from 30 to 100 c.c. intramuscularly, is indicated and in
certain instances stops the bleeding.
A photograph of a four-year-old boy was shown
illustrating a condition which has been described in
the past year, namely, acrodynia, a polynuritis of the
trophic type somewhat resembling pellagra. The
speaker has seen two cases of this in his practice, one
of which was typical in that the child's primary teeth
all dropped out in the course of a few weeks and even
some of the permanent ones came through and were
rapidly extruded. The gums were inflamed but not
hemorrhagic. Such a child is extremely restless, has
photophobia, buries his head in the pillow, has sym-
metrical lesions of a superficial ulcerative type on va-
rious portions of the body, especially the extremities
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September, 1921
COUNTY SOCIETY REPORTS
909
and the hands and feet are swollen and look as if
they might have just emerged from iintnersion in hot
water. Such a child is a pitiable sight. The speaker
remembers having seen in earlier years a few some-
what similar cases without having been able to classify
them. The condition is not proved as being due to a
deficiency in diet; it is not scurvy. However by care-
ful feeding of enough of an all-around diet and atten-
tion to the general welfare of the child, improvement
and sooner or later complete recovery occurs. The
utility of the examination for the commoner reflexes
was dwelt upon and the methods of eliciting these.
Roentgenograms of the thymus gland are sometimes
misleading. A plate made during forced expiration
will show a broader shadow than during inspiration —
a fact brought out by Gerstenberger of Cleveland.
There are other factors, such as enlarged auricles and
abnormalities of the great vessels, and distortions in
the picture due to technical differences in position dur-
ing exposure which change the width of the thymic
shadow. Therefore as shown by pictures of a case
in point one must not draw hasty conclusions.
A roentgenogram of an infant with absence of the
middle portion of the esophagus was shown and the
description of the case given. Operation to produce a
gastric fistula for feeding purposes was done and the
infant fed by this method for 2 days when death oc-
curred from hemorrhage of the liver. Partial or
complete absence of the esophagus has been recently
carefully described. No case living after attempted
relief by operation has as yet been reported.
Pictures of congenital lues, of rickets, scurvy, and
other more frequently encountered conditions in early
childhood were showif.
A rising vote of thanks to the visiting physicians
for their interesting talks was passed by the society.
C. L. Stevens, Reporter.
CHESTER— JUNE
The regular meeting of the Chester County Medical
Society was held at the Chester County Hospital for
the Insane on Tuesday, June 21, 1921, through the in-
vitation of Dr. James S. Hammers, superintendent of
the Institution. Following the regular order of busi-
ness Dr. Hammers gave an extremely interesting lec-
ture on the Mendelian Theory, and its application to
insanity. It is with great pleasure that the reporter
is able to publish Dr. Hammers's paper in the current
issue, for it represents the result of really high class
original research work — a type of work of which the
Society should be proud.
Dr. Hammers showed clearly in his paper the neces-
sity of the cooperation of physicians throughout the
country in securing the necessary data relative to the
heredity of the cases of insanity admitted to the Ches-
ter County Hospital for the Insane. At the close of
his paper, a general discussion was opened and it was
decided to further Dr. Hammers's efforts in his re-
search by appointing a committee consisting of twelve
members of the County Society, each located in a cer-
tain geographical section who would assist Dr. Ham-
mers in collecting the data which he required.
Upon adjournment the members enjoyed a delight-
ful collation on the lawn, prepared by Mrs. Hammers
and her associates.
Henrv Pleasants, Jr., Reporter.
CLARION— AUGUST
At a special meeting of the Clarion County Medical
Society held at Slego, August 23d, Dr. John W. Boyce,
of Pittsburgh, read a paper on The Importance of
Fluoroscopic Diagnosis in Internal Medicine. We had
a good turnout and all enjoyed the paper. The next
special meeting is to be held at Shippensville, on the
fourth Tuesday of September. We are having monthly
meetings during the summer months when the roads
are good. Charles C. Ross, Sec'y.
CLINTON— JUNE-JULY
The Clinton County Medical Society held its June
meeting at the Renovo Hospital, the physicians present
being Drs. E. C. Blackburn, R. B. Watson, W. J.
Shoemaker, A. B. Painter, D. W. Thomas, J. B.
Critchfield, S. J. McGhee and W. E. Welliver, of this
city; Dr. P. McD. Tibbins, Beech Creek, and Drs. F.
P. Dwyer, O. H. Rosser, C. L. Fullmer and T. E.
Roach, of Renovo.
An interesting paper on "Rheumatic Fever," was
read by Dr. F. P. Dwyer, following which there was
a general discussion of the subject.
Dr. R. B. Watson extended his thanks to the society
for flowers sent him while he was a patient at the
hospital.
An interesting paper on "The Intestinal Diseases of
Children," by Dr. R. B. Watson, featured the July
meeting of the Clinton County Medical Society, held
at the hospital on Friday evening. In the absence of
Dr. E. C. Blackburn, the president of the society. Dr.
W. E. Welliver presided. Drs. G. D. Green, W. E.
Welliver, P. McDowell Tibbins, J. E. Tibbins, A. B.
Painter, D. W. Thomas, S. J. McGhee, W. J. Shoe-
maker and R. B. Watson were present.
In the absence of Dr. J. M. Dumm, who had been
expected to read a paper on "Gastroenteritis," Dr.
Watson read his paper on "The Intestinal Diseases of
Children," showing that the death rate from such dis-
eases is decreasing in recent years. This fact he at-
tributed to more sanitary care of infants in feeding,
in preparation of the food before eating, and in the
increased knowledge of the laity. He asserted that
the proper treatment for such ailments was to empty
the whole intestinal tract promptly, and to abstain
from all food for 24 hours. The paper was generally
discussed.
As the West Branch Medical Society met at the
Clinton County Club on August 26, it was deemed ex-
pedient not to hold a meeting of the local society in
August.
ELK— APRIL-MAY- JUNE
The regular April meeting was held at the hospital
but was a decided frost. Only routine matters were
discussed. It was decided to have the next or May
meeting in St. Mary's, and to have the St. Mary's
doctors have entire charge of the program, so in May
we met in St. Mary's and Dr. Madara had the paper
on Public Health and Sanitation, and it was a hum-
dinger of a paper. Dr. Madara was to give us a
transcript or abstract, but has not done so. We will
not attempt at this date to abstract it, but take it from
me, it was some paper. Among other things Doctor
Madara pointed out some of the glaring inconsist-
encies and follies of our quarantine regulations, and
proved his point. The St. Mary's crowd was con-
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THE PENNSYLVANIA MEDICAL JOURNAL September, 1921
spiciioiis for the small minibcr, only the faithful Dr.
Wilson and Dr. Madara being on hand.
In June we met at Johnsonburg, and Dr. Warnick
had the paper or talk. You should have heard itt
We can not imitate Dr. Wamick's characteristic
speech, but if you have not heard him when he is
going right, you have missed something. Dr. McCabe
had some interesting cases to report.
In addition to that we had with us, Mr. Ziegler, ad-
juster for the Insurance Department of the Manufac-
turers' Association, with offices in Philadelphia. Mr.
Ziegler gave us a very nice talk, laying particular
stress on the desire of the insurance companies to deal
fairly and honestly with the doctors, to work together
in harmony, etc. Mr. Ziegler wanted to know frankly
any kick we had to make, to call a spade a spade, etc.
Our recollection is that the talk was frank and free,
precipitated no doubt by the reading of a few letters
about as follows:
Dear Doctor: Enclosed find Check for so and so
dollars in payment of bill or for services rendered
Mr. so and so. IVe have deducted so and so dollars
from your bill, as we find that so and so dollars is the
average fee, etc. We got one of their Kaiser letters,
and objected in no uncertain terms to any one, no
matter how nice a gentleman he might be, rtmning
our own particular business from a Philadelphia of-
fice ; that we thought we were fully competent to run
our own affairs without any outside influence, and that
we proposed to charge what we thought was right and
fair and just, and that if this company or any other
company did not want to do business with us on that
basis they could instruct their policyholders not to call
us ; that the Revolutionary War was fought as a mat-
ter of principle, and that it was the principle that was
at stake in this instance. To which Mr. Ziegler re-
plied, that if it was war we were looking for, we
could get it, that they would build industrial hospitals
and send the injured there (that is btink, of course;
it's not practical here), and none of us got scared.
We managed to get along before the compensation
act came into existence and we reckon we can get
along now, or we might be lined up right politically
and land one of these graft jobs in an industrial hos-
pital. Aside from the war talk, Mr. Ziegler did stress
what we most heartily approve, viz : not to charge the
insurance company any more than you would an ordi-
nary individual on the street. That is only just and
fair, but we resented and will resent the arbitrary
manner of some of the companies. Dr. Wamick, in
closing, may have hit the nail right on the head, when
he said he was glad Mr. Ziegler could be with us, etc.,
hut that he thought Mr. Ziegler would have a different
impression of us than he had when he came, that we
were not a bunch of cheap sports.
S. G. Logan, Reporter.
FRANKLIN— JULY
The society held its monthly meeting in Waynes-
boro, on Tuesday evening, July 19, 1921. The meet-
ing was preceded by a dinner at the Leiand Hotel.
Owing to the illness of the president, John W. Croft,
M.D., vice-president, presided. It was decided that
a committee should be named to make a survey of the
illegal practitioners of medicine in the county.
Frank N. Emmert, M.D., Chambersburg, was
elected a member of the House of Delegates. Samuel
D. Shull, M.D., Chambersburg, and Thomas D. White,
M.D., Orrstown, were elected alternates to the meet-
ing of the State Medical Society which will be held
October 3-6, 1921. L. M. Kauffman, M.D., Chambers-
burg, R. R. No. 8, was nominated for election by the
State Society as censor for the sixth censorial district.
Joseph Emiis, M.D., Waynesboro, read a rather com-
prehensive paper on "The Cause of Old Age." John
W. Croft, M.D., Waynesboro, discussed sleeping sick-
ness as it is looked upon to-day. He described clin-
ically two cases in his practice and one other case
which he had seen. The subject was generally dis-
cussed. There was no definite conclusion of special
value as to the nature of treatment, although the sug-
gestion of inserting some drainage was favorably
considered. Charles F. Palmer, M.D., Chambersburg,
told of having made some opening in the frontal bone
of the skull in a case that recovered, apparently from
the drainage thus secured.
John J. Copfmann, Reporter.
MERCER— JULY
Dr. W. W. Richardson, assisted by Dr. In^raharo
and Dr. F. C. Potter, was host to the members of the
Mercer Coiwty Medical Society at his Sanitarium at
Mercer on Thursday, July 14. A delicious and boun-
teous luncheon was served at one o'clock in the beau-
tiful grove of the Sanitarium.
There were thirty-five members present and the fol-
lowing guests : Dr. Lloyd Thompson, of Hot Springs,
Arkansas, a former Mercer boy; J. D. Whiteman,
D.D.S., and Dr. C. L- Howe, of Mercer, and Miss
Margaret Cumming, superintendent of Buhl Hospital,
Sharon.
A short business meeting followed, with Dr. Fer-
ringer, first vice-president, in the chair, President
O'Brien being absent. Dr. F. C. Potter, assistant
medical director of the sanitarium, was elected a
member, and one application for membership was
read. Dr. Potter read an excellent paper on the
"Physiology and Pathology of the Cerebro-Spinal
Fluid." The paper was ably discussed by Drs. Fer-
ringer, Richardson, Spearman and Lloyd Thompson.
A rising vote of thanks was given Dr. Richardson
and his staff for the excellent entertainment and to
Dr. Potter for his instructive paper.
Adjourned to meet in September, meeting place to
be decided upon by the secretary.
M. Edith McBkide, Reporter.
MONTOUR— JULY
The regular meeting of the society was held at the
Courthouse, Danville, July 13th in connection with
"Cancer Day" for Danville and vicinity, under the
auspices of the Committee on Cancer of the Medical
Society of the State of Pennsylvania. Dr. R. A.
Keilty, president of the local society, presided, and
the meeting was called to order at 2 p. m., with 75
physicians present from Williamsport, Milton. Wat-
sontown, Lewisburg, Simbury, Middleburg, Millers-
bitfg, Shamokin Dam, McClure, Aaronsburg, Elys-
burg, Spring Mills, Coalsdale, Lauretton, Hemdon,
Shamokin, Mt. Carmel, Shenandoah, Bloomsburg.
Berwick, Washingtonville, Jerseytown, Pottsgrove and
Danville.
Dr. J. M. Wainwright, Scranton, chairman of the
Committee on Cancer of the State Society, was the
first speaker, and outlined the work of the committee
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September, 1921
COUNTY SOCIETY REPORTS
911
and told something of what they had been and were
doing along educational lines through the profession
and the public. ' Dr. Henry D. Jump, Hiiladelphia,
President of the State Society, being present, was next
called upon for a few remarks and was warmly re-
ceived. He earnestly commended the work of Dr.
Wainwright and his committee. He said the State
Society, largely through this committee, had been
carrying on active educational work for the past six
or more years, and that not a little progress had been
made; but more is needed, the public especially needs
to be informed. So long as cancer cases are per-
mitted to submit themselves to osteopaths, chiroprac-
tors, the use of corrosive pastes and plasters, Lydia
Pinkham's Compounds, and all sorts of irregular ex-
pedients, which do no good but cause fatal delay, there
is need for education on the subject of cancer; and
it is the duty of the physician to blaze the way. He
emphasized the fact that regarding cancer several
points should be noted: (a) after 40 years of age one
out of ten deaths are due to cancer, and (b) there is
still need that physicians be urged to give attention to
every suspicious sjrmptom in order that there may be
an early recognition of the disease. He declared that
physicians tend to minimize the condition; too apt to
be hopeful that it is not cancer.
The principal speaker of the occasion was Dr. J. C.
Bloodgood, of John Hopkins University, Baltimore,
one of the most distinguished specialists on the sub-
ject in the country. He gave a most interesting and
helpful demonstration and clinic, elucidating the sub-
ject with quite a number of lantern slides and illus-
trated charts. He presented, with some detail, the
various classes of cancer, as of the tongue, lips, skin
(including moles), breast, bone cancer, etc., giving
some of their causes, outlining points in their early
recognition and treatment. He said the most of these
are preventable conditions and that we need to get
this information to the public. He used cancer of the
tongue as an example. This occurs mostly in men
who smoke; they are apt to use a rough pipe stem,
or they may have rough and unclean teeth. This gives
rise to the needed irritation. The cure lies in "stop
smoking," remove the snags of teeth and clean up the
good ones. He said, look with suspicion upon every
little sore or lump, especially if it cannot be cured in
three weeks; cut it out or, if possible, remove the
cause.
Dr. H. L. Foss, surgeon in chief of the Geisinger
Memorial Hospital, Danville, presented the closing
paper, "The Cancer Problem at the Geisinger Hos-
pital." He said, since the hospital opened five and'
one-half years ago, 263 cases with cancer had been
admitted for treatment; that nearly always these pa-
tients came late in the course of the disease (they
nearly always do), and that they will continue to until
the campaign of education among the laity and the
profession, of which this meeting is a part, begins to
make itself felt. In the late war 55,000 of our men
were killed, while in the same two years 180,000 peo-
ple died of cancer in the United States. Dr. Foss then
presented an abstract of the histories of ten cases,
taken at random from the records of the hospital.
Most of these had taken the attitude of "watchful
waiting," either through the advice of physician or
friends, or through their own desire to wait. These
cases, except one, were over 40 years of age, and
from eight months to three years had been allowed
to elapse, since the first symptoms of the disease, be-
fore admission to the hospital. Most of the cases re-
cited were hopelessly inoperable when admitted to the
hospital, yet doubtless most of them could have been
cured in the early stages.
Ignorance of the facts concerning this terrible dis-
ease is at the foundation of this delay. With the can-
cer patient there is the mistaken idea that the disease
is incurable or that, like syphilis, it is a disgrace. He
fears an operation and is beset with thoughts of the
hopelessness of the result. He too often delays while
he makes an investigation of some advertised nostrum,
or the claims of some so-called "cancer specialist."
There is ample excuse for all this; it is ignorance.
But when the patient at last consults his physician
why should there be, in so many instances, added and
often fatal delay? Here again the factor is ignorance
but in this instance there can be no excuse. If the
patient refuses to accept the advice of his physician
for immediate surgical excision it is another matter;
but if he fail to receive prompt and adequate treat-
ment through the negligence of his physician, then
upon the physician rests a grave responsibility.
At ages over 40 years, one woman in eight and one
man in fourteen dies of cancer. With these facts be-
fore us, the cancer patient who consults his or her
physician consults a man who does not know his busi-
ness if he treats a suspicious symptom without first
making a careful examination; or if, in the presence
of characteristic signs, he adopts a policy of watchful
waiting; or if he treats a suspicious lesion with
medicines, or corrosive pastes or caustics; or if he
treats a case of piles without making a rectal exami-
nation (60% of all cancers of the rectum are first
treated as piles) ; or if he temporizes with patented
nostrums advertised as cancer cures; or if he per-
mits optimism to replace a careful examination; or
if he permits laziness to delay a thorough investiga-
tion of such warning signs as a growing lump in a
female breast, an abnormal discharge from the uterus
of a woman past the menopause, or persistent indi-
gestion especially in a patient past 45 years of age, or
the chronic ulcer within the mouth or upon the face
or lip.
Of cancer cases who have been admitted to the
Geisinger Hospital during the past five years, not 5%
came within three months of the beginning of the
trouble. Nearly all had received some sort of treat-
ment, ranging from the application of caustics to pow-
wowing. Many had employed various forms of self
medication, but a large number had been treated by
their physicians. The success of the conquest of can-
cer rests largely in the hands of the patient, but he
must be ediKated; and next to the patient, it rests
in the hands of his trusted friend, the physician.
After some general discussion of the points brought
out, the meeting adjourned to the Geisinger Hospital,
where a demonstration of the treatment of cancer
with radium was given by Dr. E. H. Adams, a mem-
ber of the staff of the hospital.
J. H. Sandel, Reporter.
PHILADELPHIA— MAY
Regular stated meeting, May 25, 1921. The presi-
dent. Dr. George Morris Piersol, in the chair. After
the usual routine business had been transacted the
evening was devoted to a symposium on The Rat
Situation.
The Rat Menace of the United States: Dr. S. B.
Grubbs, Surgeon, U. S. Public Health Service, read
a paper in which he said that there is undoubtedly a
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THE PENNSYLVANIA MEDICAL JOURNAL September, 1921
rat menace; a menace to life and a menace to busi-
ness from bubonic plague which has been spreading
over the world during the past twenty-five years.
There is, on the other hand, an economic loss from
rats that is going on each day and night. For our
purposes it is sufAcient to recognize that we have to
deal with the gray, or burrowing rat and the black,
or climbing rat. All rats possess an intelligence that
is almost uncanny, certain highly developed special
senses and a strength and persistence that overcomes
many difficulties. Generally speaking, both kinds of
rats are scattered all over the civilized globe and are
intimately associated with man and feed upon every-
thing that he produces as food for himself and his
domestic animals. The gray, or Norway rat is the
pirate rat of the story books. While not nimble, he
has managed to board ships and to travel to all ports.
He kills for the love of killing as well as for food ;
what he wants he takes; he fears no animal his size.
He is short of tail, broad of jaw and back, heavy and
muscular, good at digging but p«or at running or
climbing — let others nm or climb when he walks forth.
He lives where he chooses which is in burrows or
near the ground, in or under a protecting structure.
Under the term black rat are included the alexandrius
and rattus. This one is more slender, graceful and
agile. His tail is long. He can run well and climb
wonderfully but, being no match for the gray rat,
thrives in the walls and roofs of houses and such
places as his enemy cannot go.
All rats are prolific breeders. Beginning at two
months, females will produce as many as eight to ten
litters a year, each consisting of eight to twelve young.
Fortunately rat infant mortality is large and a de-
creased food supply will reduce both the number of
litters and the number of young in each. Restricting
the nesting places also decreases the number of litters
but has slight effect upon the number in each. In ad-
dition, restricted nesting places mean restricted pro-
tection so that in the struggle for existence the young
and weak ones are driven out or killed by the stronger
ones. It is upon the restriction of rat food and of rat
nesting that all our efficient and economical measures
must be based.
Rats have diseases some of which may be trans-
mitted to man. Rat leprosy, infective jaundice and
rat bite fever may be largely of academic interest but
bubonic plague is an everyday danger and an economic
loss. With the beginning of this century plague in-
vaded the western hemisphere, appearing in San Fran-
cisco in 1900 and in Ensenada and Mazatlan, Mexico,
in 1902. Coming from the other direction in 1912 it
reached Porto Rico, probably from the Canary Is-
lands, and shortly after it appeared in Havana and
New Orleans. During 1920 plague was found in Pen-
sacola, Florida, and in Galveston and Beaumont. Texas.
In February of this year it occurred in Porto Rico
once more. In those places that are solidly and per-
manently constructed, such as many European ports
or where the disease is fought by a vigorous anti-rat
campaign, as in the United States, it may be eradi-
cated but, where buildings are. rat harbors and efforts
are divided between rat control and prevention of hu-
man cases, the disease usually becomes endemic.
We believe the chief value of rat catching is to lo-
cate rat infection in advance of human cases and so
we examine every rat we can get, and also insist on
permanent rat-proofing not only of infected but of all
buildings. Plague is a hard disease to exclude and
difficult to eradicate when once admitted. The expe-
rience in New Orleans where human plague reap-
peared after eighteen months without finding any rat
infection — April, 1917, to October, 1919— during which
time 50,000 rats were examined, must make us timid
about declaring the infection definitely eradicated and
should cause us to advocate that in places once in-
fected, rat control and surveys in some form should
continue indefinitely.
Dropping for a moment this public health aspect of
the rat question, let us consider the harm that the
healthy rat does. A large amount of damage is done
by rats seeking food or gnawing apparently for the
mere fun of it. Everyone who stores merchandise,
except under exceptional circumstances, will find rat
losses of some kind if he will investigate. Captains
and managers of vessels who are alert to save, usuallr
know that rats play havoc with certain cargoes and
are, therefore, glad to have their ships fumigated al-
though this may cost them $100 in addition to several
hours' delay. All they ask is that the fumigation shall
get the rats and stop claims against them for rat dam-
age to cargo in transit. The greatest loss is from the
consumption and waste of food products. The best
general estimate that we have now is that there is one
rat for every city dweller and ten for everyone living
in the country and that the food of each rat costs ap-
proximately half a cent a day, or $1.83 per year. Pri-
mary rat-proofing, that is, made as a part of the orig-
inal construction adds but slightly to the expense. If
this is neglected, however, so that it becomes neces-
sary to alter buildings already up, the expense is con-
siderable. We know from experience that quarantine
alone cannot be entirely relied upon. We need to
stress the advantage of rat-proofing in advance of in-
fection. It would be good business for every port and
ii; fact for every inland city to require new construc-
tion of the rat-proof. Such requirements would grad-
ually convert our rat-ridden seaports into places where
rats could easily be controlled, where rat losses would
be small, where plague would have a small chance of
getting started, and where if it did, it could rapidly
be exterminated.
The Rat in Relation to Philadelphia's Food Supply.
Dr. Henry D. Martien, Bureau of Meat Inspection, of
Philadelphia, read this paper in which he said that in
the recent rat campaign special investigations of condi-
tions, laying stress upon places where foodstuffs were
stored or handled, were conducted. This class of
buildings included food warehouses, animal abattoirs,
chicken-keeping and slaughtering establishments, mar-
kets, meat markets, fish and oyster houses, grocery
stores, bakeries, restaurants and fertilizing plants.
These places afford the rat a most bountiful ration to
feed upon and further provide most favorable condi-
tions under which they breed. Dirty, careless mer-
chants, buildings with defective walls or foundations,
broken wooden floors, unscreened ventilators, doors,
windows, and transoms left open during the night
doors and windows in poor repair, defective side-
walk, privy wells, defective- plumbing and storing of
boxes, barrels and papers in cellars and vacant rooms
are some of the conditions which are encountered in
his routine inspection work. It was these conditions
that he strove to correct. Another most important
feature of the rat control work in regard to food sup-
ply was the surrounding environment such as stables,
poorly built buildings, carelessness in handling foods
and the disposal of waste material. The chicken-keep-
ing and killing establishments were a very common
place of rat infestation, as it was almost always the rule
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September, 1921
COUNTY SOCIETY REPORTS
913
that rats and chickens went together. The rat-proof-
ing of a chicken establishment was a difficult problem
for the following reasons : The price of poultry and
the margin of profit make the owners of these places
most reluctant in making necessary improvements to
keep out the rat. Dr. Martien said he was not advo-
cating high prices, but if the shopkeeper put his build-
ing in proper sanitary condition and kept it so he must
work on a greater margin of profit.
The abattoir was possibly the worst infected place
that presented itself to-day on account of the vast
amount of material that was at hand to feed upon and
also on account of presenting most favorable breeding
places. The pens in which the live stock are kept af-
ford most favorable breeding places as well as a shel-
ter; stables which are in almost all cases located near
these abattoirs, provide favorable breeding places.
Some of the means employed in Philadelphia's de-
ratization work were briefly: Anti-rat propaganda
scattered by means of anti-rat editorials and publica-
tion in the daily newspapers, pamphlets and bulletins
scattered by the Department of Public Health and the
"U. S. Public Health Service. An educational cam-
paign must be conducted depicting the proper methods
of rat-proofing. Encourage the erection of buildings
with rat-proof foundations. Correct the building laws
for new buildings and repair work. Replace wooden
floors with cement, patch defective concrete floors with
cement; seal defective openings around pipes and rat
holes with cement; screen all windows, ventilators,
doors, windows, transoms and skylights. In short
build out the rat. In rat-proofing a building the fol-
lowing conditions must be considered: Ground area,
walls, ceilings, garret, roof, dead space in general, ven-
tilators, abandoned sewers, doors, windows, outside
piping, water and sewer piping, down spouts, wiring
and air and light shafts. A very small detail might
be overlooked whereby a rat-proof structure may be-
come badly infested. In the educational work several
classes and conditions are met with : First, the man
who was progressive in business and was eager to
comply with the city's request; ten per cent of the
merchants could be placed in that class. Second, a
group who were willing to comply but on account of
ignorance were continually a health menace. A large
majority of the people with whom he came in contact
would fall in this class. Third, those who are in busi-
ness for gain only and care not for any law.
In conclusion he pointed to some of the results at-
tained in Philadelphia's rat work. To-day they had
under control the rat situation in the wholesale fish
market and one might say the market was clean. In
our cold storage plants the rat was finding a hard
time to exist and the same statement applied to the
abattoirs. The educational campaign had been most
successful as a large majority of the food handlers
had been convinced that the rat was a health menace,
a pest, and a destroyer of property not only by eating
food products but also by setting fire to property.
Bubonic Plague : The Rat Situation in Philadelphia.
Dr. C. Y. White, Director of the Laboratory of Hy-
giene of Philadelphia, read this paper in which he
stated that he had been in three campaigns in Phila-
delphia, one starting in the latter part of 'i2-'i3, then
in '14 and in the last fall, 1920. The earlier campaigns
were undertaken for the purpose of determining
whether bubonic plague was present in Philadelphia
or not. They made a strenuous effort to capture as
many rats as possible. In the last campaign while
they tried to get rats, the chief message was through
an educational campaign. To help this educational
proposition along the department prepared a great
number of circulars. These pamphlets were placed
chiefly in business houses and in places where they
tried to educate those who came in direct contact with
the rat. It is pretty well accepted at present that
plague is carried from place to place, or port to port,
or locality to locality by the rat, but the actual infec-
tion to the human being is due to the rat flea. In the
plague situation in the South it was demonstrated
very well, or at least surmised, that the flea had a
great deal to do with this dissemination. Dr. White
said the department had examined about 12,000 rats.
They found 22 leprosy rats in the three campaigns.
Dr. White said he felt that in Philadelphia in order
to keep up the rat campaign it should be made a part
of the function of the Public Health Department. He
thought Dr. Grubbs would agree with him that it was
impossible to expect the community to rid a place the
size of Philadelphia of rats. As fast as you kill them
off probably so fast they will breed, but a community
the size of Philadelphia should know the condition of
its rat population and that could be done by surveys,
probably not quite as extensive nor quite as large as
the United States Public Health Survey suggests;
They suggest about 10% survey, which would mean in
Philadelphia about 200,000 rats. The cost of the rat
survey in the South has been from $1.00 to $1.30 per
rat. In the rat campaign in Philadelphia last fall,
while it was not as extensive as the Southern rat cam-
paign, they were able to catch a rat and dissect it for
about 30 cents. So they felt that if they were to have
connected with the department here a small rat corps,
consisting of probably 3 or 4 rat catchers and an in-
spector, that they could accomplish much in one year
as to the rat population; then if they found an in-
fested rat, devoting the employment of the larger
corps to clean up. We should strive to give our Pub-
lic Health Service at Washington a bigger appropria-
tion so that they can come back and handle the situa-
tion outside of the United States. He thought recently
some of the funds were rather cut short by the pres-
ent congress. The keystone to the whole subject of
the plague situation is to keep out the rat rather than
to try to get it out after it comes in. .
Dr. Joseph McCracken, of Canton, China, said that
he would like to say a little bit about what they had
found in the Orient. He was fortunate enough to be
in Canton, where this plague was supposed to have
begun and, sitting on the wall of the'city of Canton,
he counted the number of coffins during plague. In
one hour he counted over 200 coffins going out of that
one gate to be buried in the hills back of the city.
When you consider a place with a population about
the size of Philadelphia, all within not more than two
miles' square area, where the roofs were so close you
could almost step from one house to the other, and
realize that there was absolutely nothing done in that
whole city for the sake of health (not anything what-
ever by the government and very little by any indi-
vidual), that there was practically no sewer system in
that city and that the place was riddled with rats as
well as with the bubonic plague, it almost made you
wish you had a diver's suit to go down and walk on
the streets. Yet, after living in Canton six or seven
years, he knew of only one foreigner who died of
plague. That foreigner was kind enough to pick up a
bubonic case and the patient vomited almost into the
man's face and he died of plague a few days later.
Most of the talk was about bubonic plague and_^hat| ^
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914
THE PENNSYLVANIA MEDICAL JOURNAL Skptembkr, 1921
was the general kind that they had in the South. He
knew of very few cases in the southern part of China
which was pneumonic; it was bubonic. He was of
the opinion that there were two separate diseases. It
has generally been their idea that the plague was car-
ried by the rat and the pneumonic possibly by some
other animal similar to but not a rat. In northern
China a recent statement by Dr. Wu, in charge of the
plague in North Man6hurian Mission, and Dr. Young,
a practitioner in Pekin, asserts that the first cases
are bubonic and then develop the pneumonic form.
That was certainly not brought out in the epidemic
which existed in China a few years ago. It was an
epidemic of pneumonic and while the bubonic
mortality is very much less than that of the
pneumonic where it is absolutely fatal, so fatal
was it that Dr. McCracken remembered when they
had an epidemic in Northern China some of the
Southern nurses volunteered to go up and help in the
plague and ii went up. After 9 had died with pneu
monia one of those left came home with high fever
and headache and thought his time had certainly come.
. As he lived in a hotel, he told the Chinese boy what to
do with his trunk and fur overcoat and then he took
a big dose of medicine and thought it would be the
last of him. When he woke up the next morning
feeling much better, he looked for his trunk and fur
overcoat but found they were minus. The boy had
skipped. In Chinese houses where you have very little
authority over the people, it is almost impossible to
carry on anything like a thorough campaign.
Dr. Seneca D. Egbert, of Philadelphia, said that he
felt the point that was made in regard to the develop-
ment of the idea of cleanliness in many of our stores
and other establishments in the city was most impor-
tant. The survey he made a year and a half ago had
impressed upon him that many, many places where
food was handled and dispensed were beyond the pale
of cleanliness. The people who managed them did not
know what cleanliness meant. There was a tremen-
dous amoimt of campaigning that we all might do. We
could help our patients to feel that they must -carry on
this campaign of education. In other words we could
insist upon cleanly food coming from cleanly places
and refusing to deal with places that are not cleanly.
John J. Repp, Reporter.
POTTER-TIOGA— JULY
POSTGRADUATE PROGRAM
The joint meeting of the Potter and Tioga County
Medical Societies which was held at Westfield, Fri-
day, July IS. was a pronounced success if we are to
judge by the expression of approval made by the men
present. The program was carried out in every detail
and every man on the program, except Dr. Donaldson,
of Williamsport, was present and performed his part.
On account of the bad roads we did not arrive at
Westfield untill 11 o'clock and the meeting started at
II : 15 and continued until 5:30, with the exception of
one hour for dinner. There were forty-one physicians,
two laymen and seven wives of physicians present at
the meeting. Every paper presented was pronounced
first class and all the subjects were discussed by one
or more of the men present. An excellent dinner was
served at the hospital, those present being the guests
of the two societies.
The men of the two societies gave every indication
of being well pleased with the meeting and invited us
to come again. The program follows:
POSTGRADUATE PROGRAM
The Medical Society of the State of Peimsylvania's
joint meeting of the Tioga and Potter County So-
cieties, Westfield, Tioga County, Pa., Friday, July 15,
1921.
10:20 A. M. (Eastern Standard Time)
Chairman, Dr. W. S. Brenholtz, Trustee, M.S.S.P.
"Pleural Effusion and Early Tuberculosis," Dr. C.
W. Youngman, Williamsport. Discussion opened by
Dr. W. F. Kunkle, Williamsport.
"Pneumonia in Children," Dr. R. K. Rewalt, Wil-
liamsport. Discussion opened by Dr. V. P. Chaapel,
Williamsport.
"Cancer," Dr. Donald Guthrie, Sayre. Discussion
opened by Dr. A. F. Hardt, Williamsport.
"The Fallacies of Wassermann Tests," Dr. Ford E.
Weddigen, Williamsport. Discussion by Dr. L. E.
Wurster, Williamsport.
"Industrial Accidents," Dr. J. B. Nutt, Williamsport.
Discussion opened by Dr. C. W. Youngman, Williams-
port.
12: 30 — Dinner
i: 30 P. M.
Chairman, Dr. Donald Guthrie, Trustee, M.S.S.P.
"Cooperation to Secure Needed Medical Legisla-
tion," Eh-. W. S. Brenholtz, Williamsport.
"Simple Methods in Diagnosing Abnormal Cardiac
Thymus," Dr. L. B. Wurster, Williamsport. Discus-
sion opened by Dr. R. K. Rewalt, Williamsport
"Thyroid Disease with Special Reference to the
Toxic Forms of Goitre," Dr. Harold L. Foss, Danville.
Discussion by Dr. H. L. Donaldson, Williamsport.
"Obstetrics and the General Practitioner," Dr. V. P.
Chaapel, Williamsport. Discussion by Dr. J. B. Nutt
Williamsport.
"Acute Abdominal Conditions," Dr. .A. F. Hardt
Williamsport. Discussion by Dr. Harold L. Foss,
Danville.
SNYDER, MIFFLIN, JUNIATA AND PERRY
—AUGUST
INTERCOUNTY AH-DAY CLINIC AT I.EWISTOWN
On Tuesday, August i6th, the physicians of Snyder,
Mifflin, Juniata and Perry Counties were accorded an
unusual opportunity for pleasure and profit. The de-
tails for the meeting were arranged by Dr. C. R. Phil-
lips, of Harrisburg. Dr. H. C. Frontz, of Hunting-
don, District Councilor, presided. Forty-five physi-
cians were in attendance.
The meeting opened with an interesting talk by Dr.
Frederick L. Van Sickle, on Medical Legislation — Past
and Prospective. The remainder of the program was
as follows: Infant Feeding, Dr. H. R. Douglass; Dia-
betes, Dr. J. W. Ellenberger; Pleural Effusions, Dr.
C. R. Phillips; Post- War Conditions in Poland, Dr.
G. R. Moffitt ; Acute Abdominal Conditions, Dr. G. B.
Stuli ; Cancer, Dr. Harvey F. Smith.
Dr. Elizabeth Allison, of the Mifflin County Society,
spoke on medical aspects of the work of the Young
Women's Christian Association.
The latest and best thought on all the subjects cov-
ered by the program was excellently presented. And
each of the speakers had the happy faculty of making
his subject interesting as well as instructive.
A pleasant feature of the meeting was the noonday
hmcheon which was privately served in the new Y. M.
C. A. building in Lewistown. This gave opportunity
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September, 1921
COUNTY SOCIETY REPORTS
915
for the renewal of old friendships and the beginning
of new ones.
May we hope that this meeting will be the forerun-
ner of others like it? J. A. C. Clarkson, Secy.
STATE NEWS ITEMS
ENGAGEMENTS AND MARRIAGES
Announcement is made of the marriage of Miss
Anne N. Regar and Dr. Rufus E. LeFever, of Reading.
The marriage has been announced of Dr. John
Vincent McAninch, of Brownsville, and Miss Jane
Davis, Registered Nurse, of Ligonier, on July 30, 1921.
Announcement is made of the engagement of Miss
Elsie Dupuy Graham Hirst, daughter of Dr. and Mrs.
Barton Cooke Hirst, of Philadelphia, and Bertram
Lippincott, son of Mr. and Mrs. J. Bertram Lippincott,
of Bethayres.
Dr. C. C. Glass, of Meyersdale, and Miss Hazel
McGilvery, of Pittsburgh, were married at Meyers-
dale, June 28th, by Rev. J. J. Brady, of Sts. Philip's
and James' Church. Mrs. Glass is a graduate nurse of
the West Penn Hospital Training School. They are
now domiciled at 235 Main St., Meyersdale.
deaths
Dr. S. p. Lonostreet, school director, ex-coroner of
Lackawanna County and former director of public
health in Scranton, died August i6th, at his home in
that city, after a three-day illness of heart trouble,
aged 59. He leaves a widow and four children.
It is with deepest regret that we announce the
death, on July 26th, of Dr. Mary McCay, mother of
Dr. Robert B. McCay, of Stmbury. Dr. Mary, as she
was affectionately known, was born January 16, 1857,
and had the honor of being a charter member of
Northumberland County Medical Society, holding her
membership continuously until her death.
Dr. Charles Heister Smith, former county com-
missioner, practicing physician in Linglestown for 46
years, and active in community affairs, died August
30th, from the effects of an attack of apoplexy.
Dr. Smith was born August 9, 1851. He was a
graduate of the medical school of the University of
Pennsylvania, class of 1872, and began to practice in
Linglestown immediately after graduation until 1918,
when he was compelled to retire because of ill health.
Dr. John C. Feltv, Gettysburg, died August 6th, of
nephritis. Dr. ' Felty was bom March 25, 1849, and
was graduated from the Medical Department of the
University of Pennsylvania March 3, 1873. For about
twenty-five years, up to 1915, he was on the staff of
the New Jersey Insane Asylum at Trenton. He had
previously been in general practice in Adams County,
Pa., and returned there after his retirement from the
hospital staff. He was a member of the Presbyterian
Church, serving on the board of trustees for a num-
ber of years, and of the Masonic order.
Dr. Charles F. Altmiller, of Bloomsburg, died at
the home of his father in Hazleton, August 2, 1921,
after an illness of a year which followed an attack of
influenza. Dr. Altmiller was born at Hazleton July 4,
1877, was graduated from the Medico-Chirurgical Col-
lege of Philadelphia, May 25, 1901, became a member
of the Columbia County Medical Society July 18, 1905,
served one year as president of the society and was a
member of the House of Delegates at the Bedford
Springs Session of the State Society.
Dr. Hiram M. Hiller, formerly of Chester, late of
Bcllefonte, died August 7th, following a stroke, aged
54. Dr. Hiller was prominent as a physician, surgeon
and explorer of lands in the far East — Japan, China,
the Malay States, Borneo and Sumatra. He_ was
graduated from the University of Pennsylvania in
1891, was a member of the Royal Geographical So-
ciety, Soci^te Geographique de Paris, Academy of
Natural Sciences of Philadelphia; was identified with
all the branches of- Masonry, attached to the staff of
Chester Hospital, the Glen Mills School and a member
of the Chester, Penn and Rittenhouse Clubs.
vacation notes
• Dr. Alfred E. Fretz, Sellersville, spent the month
of August among the Poconoes.
Dr. and Mrs. L. Webster Fox, of Philadelphia,
spent the summer traveling in Honolulu, and the West.
Dr. Maude Conyers ExlEY, of Harrisburg, has re-
turned from a two months' tour of Europe.
Dr. and Mrs. W. Reynolds Wilson, Philadelphia,
spent some time during the summer at St. Andrew's,
New Brunswick.
Dr. and Mrs. Horatio C. Wood, Jr., and family, of
Philadelphia, occupied the Lowry, Jr., camp at Pocono
Lake Preserve during the summer season.
Dr. and Mrs. Clifford B. Lull, of Philadelphia,
spent several days during August with their friend.
Dr. Joseph T. Murphy, of Pottsville.
Dr. and Mrs. Williams Biddle Cadwalader and
daughter, of Philadelphia, will return home on Sep-
tember 24th from an extended fishing trip in Canada.
Dr. and Mrs. J. L. Brubaker, together with Mr.
and Mrs. George Loudon, of Juniata, made a six
weeks' automobile tour of the New England States
during the summer.
Dr. E. T. Prizer and daughter, of Lancaster, spent
a month during July and August enjoying the beauties
of California, the wonders of the Northern Rockies
and the splendor of Canada.
During the summer Dr. and Mrs. William J. \yil-
kinson, of Sellersville, enjoyed an extended vacation,
living in a house boat hear Atlantic City, as a result
of which the doctor is reported in much better health.
One of the most attractive' of the campis in the
Adirondacks is that at Paul Smith's belonging to Dr.
and Mrs. George Fales Baker, of Philadelphia, where
many of their friends have been entertained during
the summer. " ■
items
Dr. William Martin, Atlantic City, N. J., ad-
dressed the Bucks County Medical Society at Sellers-
ville, August loth, on "Some Facts About Hyperten-
sion and Its Treatment." He detailed his observations
during ten years of work along the line of electro-
therapeutics.
The Third Annual Meeting of the Pennsylvania
State Chamber of Commerce will be held at the Penn-
Harris Hotel, Harrisburg, October loth and nth.
Acceptances have been received from national and
state celebrities to address the membership on leading
topics, details of which will be announced in due time.
The Department of Public Welfare, which was
created by the last legislature, combining the several
Departments of the Public Charities, is to be presided
over by Dr. John M. Baldy, of Devon, formerly presi-
dent of the Bureau of Medical Education and Licen-
sure, with the title of Commissioner of Public Wel-
fare. The many friends of Dr. Baldy in the profes-
sion of the state are delighted with the appointment,
and the Journal joins in congratulations, believing
Dr. Baldy to be the right man for this position.
"The position of President of the Bureau of Medical
Education and Licensure, made vacant by the resigna-
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THE PENNSYLVANIA MEDICAL JOURNAL September, 1921
tion of Dr. John M. Baldy, has been filled by the ap-
pointment of Dr. Irvin D. Metzgar, of Pittsburgh, a
member of the Bureau. Up to the present the vacancy
in the Bureau has not been filled.
GENERAL NEWS ITEMS
The Fifth Ankuai, Roul Cau, of the Red Cross
will be held November nth to 24th, 1921.
Manupactureks op pharmaceuticals and medi-
cines in Indianapolis are planning to take a large part
in the Indianapolis Industrial Exposition, to be held
October loth to 15th, at the Indiana State Fair
Grounds under the auspices of the Indianapolis Cham-
ber of Commerce.
The Board of Trustees of the Johns Hopkins Hos-
pital has recently issued the following dictum : The
maximum fee that any surgeon ought to charge for an
operation, no matter how wealthy the patient may be,
is $1,000. The maximum charge that any physician
ought to make for attending patients in a hospital is
$35.00 a week.
The New Jersey Senate Bill 149, endorsed by the
State Medical Society, which sets the educational
standard of a four-year high school and four-year col-
lege course for chiropractors, abolishes the state
chiropractic board, and places chiropractors under the
jurisdiction of the State Board of Medical Examiners,
has been signed by Governor Edwards.
Plans for the organization of a School of Public
Health in Harvard University, with the aid of an ini-
tial gift of $1,785,000 by the Rockefeller Foundation,
have been announced by the University and the officers
of the Foundation. This school will provide oppor-
tunities for research, will unify courses for public
health officers already developed at the University and
will offer new or extended teaching facilities in public
health administration, vital statistics, immunology,
bacteriology, medical zoology, physiological hygiene
and communicable diseases.
The Second International Congress op Eugenics
will be held at the American Museum of Natural His-
tory, New York, September 22-28. The- provisional
program announces addresses by the following emi-
nent eugenists: Dr. Lucien Cuenot, Nancy, France;
Dr. Herman Lundborg, Uppsala, Sweden; Dr. M. V.
de Lapouge, Poitiers, France; Major Leonard Dar-
win, London, England, and others. In connection with
this Congress an Eugenics Exhibition, consisting of
charts, maps, pictures, models, scientific apparatus, etc.,
will be held in the Forestry Hall of the Museum.
BOOKS RECEIVED
Operative Surgerv, by J. Shelton Horsley, M.D.,
F.A.C.S., Attending Surgeon, St. Elizabeth's Hospital,
Richmond, Va. Cloth, 721 pages, with 613 original
illustrations by Miss Helen Lorraine. St. Louis: C.
V. Mosby Company, 1921. Price $10.00.
Organic Dependence and Disease: Their Origin
AND Significance, by John M. Clarke, D.Sc, Colgate,
Chicago, Princeton; LL.D., Amherst, Johns Hopkins;
member of the National Academy of Sciences; New
York State Paleontologist. Cloth, 113 pages, illus-
trated. New Haven: Yale University Press; Lon-
don: Humphrey Milford, Oxford University Press,
1921.
General Pathology, An Introduction to the Study
of Medicine, being a discussion of the development
and nature of processes of diseases, by Horst Oertel,
Strathcona Professor of Pathology and Director of
the Pathological Museum and Laboratories of McGill
University and of the Royal Victoria Hospital, Mon-
treal, Canada. Cloth, 357 pages. New York: Paul
B. Hoeber, Publisher, 1921. Price $5.00.
The Assessment of Physical Fitness, by Correla-
tion of Vital Capacity and Certain Measurements of
the Body, by Georges Dreyer. C.B.C., M.A, M.D.,
Fellow of Lincoln College, Professor of Pathology in
the University of Oxford, Corresponding Member of
the Royal Danish Academy of Letters and Sciences;
in collaboration with George Fulford Hanson, Late
Lieutenant U. S. A. Medical Corps, Air Service; with
a Foreword by Charles H. Mayo, M.D., Rochester,
Minn. Cloth, 127 pages. New York : Paul B. Hoeber.
Publisher, 1921. Price $3.50.
General Medicine, Volume I, Edited by Frank Bill-
ings, M.S., M.D., Head of the Medical Department
and Dean of the Faculty of Rush Medical College.
Chicago ; and Burrell O. Raulston, A.B., M.D., Assist-
ant Attending Physician and Resident Pathologist
Presbyterian Hospital, Chicago. This is the first vol-
ume of The Practical Medicine Series, comprising
eight volumes on the year's progress in medicine and
surgery, imder the general direction of Charles L. Mix,
A.M., M.D., Professor of Physical Diagnosis in the
Northwestern University Medical School. Series 1921.
Cloth, 630 pages. Chicago : The Year Book Publish-
ers. Price $2.50.
The Perfect Gentle Knight, by Hester Donaldson
Jenkins, Ph.D., with an introduction by Charles M.
DeForest, Modem Health Crusader Executive. Illus-
trated with original drawings and with reproductions
from old engravings. Cloth, 59 pages. Yonkers-on-
Hudson, N. Y. World Book Company. Price 32c
postpaid.
BOOK REVIEW
A TEXTBOOK OF PATHOLOGY. By William G.
MacCallum, M.D., Professor of Pathology and
Bacteriology, Johns Hopkins University. Second
Edition. Thoroughly revised. Octavo volume of
1,15s pages with 575 original illustrations. Phila-
delphia and London: W. B. Saunders Company,
1920. Cloth, $10.00 net.
In reviewing this book, we have read it word for
word, and from cover to cover, with great pleasure
and profit.
In some subtle manner the text betrays an author of
great personal charm with whom the reader becomes
more and more intimate as he proceeds from page to
page with increasing interest and attention. The
medical author who is bold enough to make use of
the first person singular commonly imparts egotism,
dogmatism, ppmposity or some other disagreeable
quality to his writing, but here it is different, and the
occasional appearance of the capital I seems to be the
secret of a delightful intimacy that grows up between
author and reader.
Without ostentation on the part of the writer his
reader gradually comes to realize that he is listening
to the words of one of wide experience in many coun-
tries, who has traveled around the world, and kept bis
eyes open wherever he went. Can this be better shown
than in such sentences as these?
"Notes made in Manila at a time when I had an op-
portunity to make a large number of autopsies in cases
of cholera during an epidemic of considerable se-
verity."
"C. J. Martin has shown me the plugs of plague
bacilli which form in the proventriculus of the flea."
"In one case which I studied in Professor Mar-
chand's laboratory, the man had been accidentally in-
Digitized by
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September, 1921
BOOK REVIEW
917
fected by thrusting the needle of a syringe full of a
culture of bacillus mallei into his thumb."
"Since writing this chapter the first time, I have
had the opportunity of visiting many leper colonies in
the South Sea Islands, the East Indies, the West In-
dies and in South America, and have had occasion to
perform some autopsies in advanced cases."
In our minds it is a question whether "Textbook" is •
a well chosen title. In his preface the author himself
says that the book "is in no sense a book of reference."
We heartily agree with him. It is a book to read,
and what is more, a book to read through. It must be
so read to be appreciated as it well merits. It is also
a question whether it is adapted to the requirements
of students. To us it seems rather better adapted to
practitioners who have already some familiarity with
the matter and problems considered.
The novel method of presenting the subject from
the standpoint of etiology, with which the author ex-
perimented in the first edition, and which he has con-
tinued in the second, makes it difficult for students to
use. In most medical schools it is customary to pre-
sent pathology in the conventional and time-honored
divisions of general pathology and special pathology
which are here ignored. If the new method of pres-
entation were universally approved and adopted, the
book would find greater usefulness as a text, but
where it is not, the student becomes lost in his endeav-
ors to follow his lecture courses. Where in this book
will he find all of the diseases of the liver brought
together and compared? How shall he get his special
pathology ?
But the subjects dealt with are treated in an ex-
tremely interesting and fairly thorough fashion.
Above all the treatment is rational. The author tells
what others have thought or think, then draws his
own conclusion in a simple and convincing manner.
For example, in discussing "Perithelial tumors," he
says, "I have searched in vain for perithelium or even
for any clear description of it, and do not believe such
cells exist." How often he says "To me it seems" or
"I am of the opinion." He is rarely dogmatic upon
any point, but has an open mind, and leaves his reader
with one equally open.
We wish that we had time to point out the various
matters in which we agree with him, as in the inade-
quacy of the evidence that the bacillus influenzae is the
cause of influenza, and the other things that we appre-
ciate, as we do what he says about "Nephritis," "Catch-
ing cold," and many things in the chapter on tumors.
The work is beautifully illustrated with, original
photographs and drawings from the microscope, many
of which are in colors, and all of which may be said
to represent the highest perfection of the art of medi-
cal illustration. There are 575 of these, of which only
40 have to be credited to other authors. The number
of illustrations is the same as in the first edition. The
text of the first edition contained 1,048 pages, the new
edition has 1,118. The 70 additional do not account
for the great increase in the size of the volume, which
seems rather to depend upon the weight of the paper
used. This increase in the size and weight of the book
is unfortunate as it makes the book entirely too large
to be comfortably used. It cannot be held in the jiands,
and when in the lap is too far away from the eyes to
enable the smaller type used to be conveniently read.
The quality of paper necessary to bring out the illus-
trations makes it difficult to read with the book resting
upon a table on account of the disagreeable reflections
from the shining surface of the paper.
We feel that we must congratulate the author upon
the very small number of obvious errors that the book
contains. It must have been given most careful proof
reading. On page 404, 3d line from the bottom, the
word "microscopically" is wrongly spelled. On page
40s it seems to us that the word "not" has been omitted
near the end of the fourth line. Several times, on
pages 398, 408, 730 and 740 the word "variegated" is
used where varied is evidently meant. On page 869,
the meaning of an entire paragraph is made vague, if
not incomprehensible, through the use of the word
"injected" at the end of the tenth line. We suppose
"formed in the blood" was intended. On page 1081,
7th line from the bottom, instead of ectodermal, or
ectodermic, the word "ectodermian" appears. We can-
not find that there is such a word. It has struck us
that the little paragraph upon "Partial Gigantism"
(congenital hypertrophy?) on page 942 is very pecu-
liarly placed; in fact it seems lost. But these are
such trifles in a whole so excellent that we are almost
ashamed to mention them. Indeed we feel that their
very small number is one of the best recommendations
that the book could possibly have. J. McF.
THE SURGICAL CLINICS OF CHICAGO. Vol-
ume IV, Number 6 (December, 1920). Fifty-seven
illustrations and' complete index to Volume IV.
Philadelphia and London: W. B. Saunders Com-
pany, 1920.
This the final number for 1920 completes four years
of publication of the Surgical Clinics of Chicago. It
will be remembered by many that these interesting
records of Chicago surgery were an outgrowth of the
serial printings of the clinical lectures of John B.
Murphy. After the death of that well known teacher,
the publishers changed the title of the journal, thus
giving the profession opportunity to read the instruc-
tive words of a large number of surgeons practicing
in the hospitals of the city of Chicago. It is an-
nounced that a further step will be taken by the Saun-
ders Co. by which the Surgical Clinics will be widened
in scope and become the Surgical Clinics of North
America.
Dr. Kellogg Speed describes a very interesting
transplantation of tendons to cure otherwise incurable
wrist drop due to musculo-spinal paralysis. Dr. A.B.
Kanavel supplies a paper of exceeding value, showing
methods of reconstructing hands disabled by prior
suppurative inflammation involving tendons. His re-
ports upon the use of fat grafts and flaps, freeing
tendons, nerve suture, and arthroplasty, associated •
with heat, splints and mobilization reveal an advance
in the treatment of crippled hands that will surprise
many surgical readers. The results obtained in recent
years in this branch of plastic surgery are among the
unexpected wonders of surgical craftsmanship. Dr.
A. H. Montgomery contributes a very valuable lecture
on pathologic fractures due to fibro-cystic osteitis.
The three lectures just mentioned are of special in-
terest, because they discuss topics of gn^owing impor-
tance in modem surgery. The operations described
were unknown, or almost unknown, to surgery pre-
vious to 1900. J. B. R.
THE MEDICAL CLINICS OF NORTH AMER-
ICA. March, 1921. New York Number. Vol. IV,
No. S. Philadelphia and London: W. B. Saunders
Company.
This volume of the Clinics contains discussions of
various subjects as follows : Jaundice from Arsphe-
namin, by Dr. Longcope; the Significance of Some
Gastro-Intestinal Symptoms, by Dr. Holland; the
Management of Functional Digestive Disorders, by
Dr. Kantor; Serositis, by Dr. Lamb; Scarlet Fever,
by Dr. Bullowa; Leukemia, by Dr. Rosenthal; Blood
Transfusion, by Dr. Ottenberg; the Heart in Tuber-
culosis, by Dr. Boas; the Functional Activity of the
Heart, by Dr. Hart; Disease of the Coronary Ar-
teries, by Dr. Pardee; Convalescence from Lobar
Pneumonia, by Dr. Brooks; Dyspnea and Hyperpnea,
by Dr. Barr; Orthostatic Albuminuria, by Dr. Bass;
Glycosuria, by Dr. Geyelin ; Hyperthyroidism, by Drs.
Sanger and Bauman; Basal Metabolism, by Drs.
Mosenthal and Marks and by Dr. McCann; Endo-
crines, by Dr. Blumgarten; Reversive Secondary Sex
Phenomena, by Dr. Draper. A. A. E.
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OFFICIAL TRANSACTIONS
The Medical Society of the State of Pennsylvania
Organized 1848 Incorporated, December 20, 1890
Officers and Members of the Sixty-three Component County Societies
/
MEMBERS OF THE HOUSE OF
DELEGATES
COMMITTEE ON CREDENTIALS
Dr. William S. Wray, Chairman, Philadelphia.
Dr. Harry A. Spangler, Carlisle.
Dr. M. Edith MacBride, Sharon.
REFERENCE COMMITTEE ON REPORTS OP OFFICERS AND
STANDING COMMITTEES
Dr. George G. Harman, Chairman, Huntingdon.
Dr. John A. Darrow, Erie.
Dr. Franklin B. Witmer, Lebanon.
REFERENCE COMMITTEE ON SCIENTIFIC BUSINESS
Dr. Walter S. Stewart, Chairman, Wilkes-Barre.
Dr. Robert A. Keilty, Danville.
Dr. Claude W. McKee, Greensburg.
REFERENCE COMMITTEE ON NEW BUSINESS
Dr. Paul J. Pontius, Chairman, Philadelphia.
Dr. Samuel W. Miller, Lancaster.
Dr. J. Newton Himsberger, Norristown.
(The offset names are the alternates, and where
street address only is given, the name of the city fol-
lows the name of the county.) ,
ADAMS COUNTY
George H. Seaks, New Oxford, Pres.
Henry Stewart, Gettysburg, Secy.
Edgar A. Miller, East Berlin.
William E. Wolff, Arendtsville.
ALLEGHENY COUNTY (PITTSBURGH)
Carey J. Vaux, 526 Larimer Avenue, Pres.
William H. Mayer, Jenkins Arcade, Secy.
John W. Worrell, iio S. Fairmount Avenue.
Charles H. Aufhammer, 5004 Jenkins Arcade.
Newman H. Bennett, 736 Brownsville Road.
Edward B. Heckel, 719 Jenkins Building.
Frederick C. Billings, 626 Union Arcade.
Frank R. Braden, 1616 State Street, Coraopolis.
George C. Johnston, 8088 Jenkins Arcade.
Alvin Edmonds Bulger, 836 Braddock Avenue,
Braddock.
Robert C. Clarke, Wallace Building.
George W. McNeil, 231 Frankstown Avenue.
Amos W. Colcord, Clairton.
Myrtle R. Feltwell, 553 Centennial Ave., Sewickley.
William H. Mayer, Jenkins Arcade.
James L. Foster, Freeport Road, Hoboken.
Austin C. Frank, 138 Brownsville Road.
L Hope Alexander, 725 Jenkins Building.
John F. Golden, W. Liberty Avenue, Dormont.
John S. Kelso, 740 California Avenue, Avalon.
Henry P. Ashe, 1304 Colwell Street.
Thomas T. Kirk, 4916 Liberty Avenue.
C. Bradford McAboy, 1301 E. E. Trust Building.
Joseph G. Steedle, Chartiers Avenue, McKees Rocks.
Samuel F. McComb, Tarentum.
William P. McCorkle, 569 Sherwood Ave., Sheridan.
John G. Burke, 8122 Jenkins Arcade.
Olive B. Steinmetz, Eighth and Ann Streets Home-
stead.
Marcus Spiro, loi Taggart Street, N. S.
John M. Thorne, 7036 Jenkins Arcade.
Lloyd L. Thompson, 305 E. Eighth St., Homestead.
Frederick Wohlwend, Tarentum.
John A. Hawkins, Jenkins Arcade.
William M. Woodward, 607 Fifth Ave., McKeesport.
Miles E. Stover, 516 Allegheny Avenue.
Richard J. Behan, Jenkins Arcade.
William G. Shallcross, Highland Building.
Charles B. Maits, 6692 Kinsman Road.
ARMSTRONG COUNTY
George S. Morrow, Dayton, Pres.
Jay B. F. Wyant, Kittanning, Secy.
Frederick C. Monks, Kittanning.
John M. Cooley, Kittanning.
Charles A. Rogers, Freeport.
BEAVER COUNTY
Harry W. Bemhardy, Rochester, Pres.
Boyd B. Snodgrass, Rochester, Secy.
Jefferson H. Wilson, Beaver.
Guy S. Shugert, Rochester.
Robert M. Patterson, Beaver Falls.
BEDFORD COUNTY
Frank S. Campbell, Hopewell, Pres.
Norman A. Timmins, Bedford, Secy.
William C. Miller, State Department of Health, Har-
risburg.
Walter F. Enfield, Bedford.
BERKS COUNTY (READING)
Abner H. Bauscher, 336 N. Fifth Street, Pres.
John E. Livingood, 249 N. Fifth Street, Secy.
H. Philemon Brunner, 122 Oley Street.
John S. Borneman, Boyerstown.
Heister Bucher, 142 S. Fifth Street.
Frank P. Lytic, Birdsboro.
John M. Bertolet, 1333 Perkiomen Avenue.
Israel Cleaver, 233 S. Fifth Street.
BLAIR COUNTY (aLTOONa)
Albert S. Oburn, 701 Seventh Avenue, Pres.
Charles F. McBumey, 604 Ninth Street, Secy.
Richard S. Magee, 1320 Ninth Street.
William L. Lowrie, Tyrone.
Joseph D. Findley, 1123 Thirteenth Avenue.
BRADFORD COUNTY
Philip H. Schwartz, Towanda, Pres.
Cyrus Lee Stevens, Athens, Secy.
Cyrus Lee Stevens, Athens.
Arthur L. Parks, Rome.
Charles L. Kenyon, Monroeton.
BUCKS COUNTY
Frank Lehman, Bristol, Pres.
Anthony F. Myers. Blooming Glen, Secy.
J. Fred Wagner, Bristol.
Henry L. Bassett, Bristol.
William G. Moyer, Quakertown.
BUTLER COUNTY (bUTLER)
Alfred H. Ziegler, 112 Washington Street, Pres.
L. Leo Doane, Reiter Building, Secy.
Alfred H. Ziegler, 112 Washington Street.
James E. Quigley, Butler.
Clinton M. Young, Queen Junction.
CAMBRIA COUNTY (jOHNSTOWN)
Olin G. A. Barker, 804 Johnstowm Trust Bldg., Pres.
J. Walter Bancroft, 410 Lincoln Street, Secy.
Frank U. Ferguson, Gallitzin.
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September, 1921
OFFICIAL TRANSACTIONS
919
Benjamin F. Bowers, St. Benedict.
William F. Mayer, 228 Market Street.
Clarence B. Millhoflf, 627 Franklin Street.
Edward Pardee, South Fork.
William E. Grove, 181 Fairfield Avenue.
CARBON COUNTY
John K. Henry, Mauch Chunk, Pres.
Jacob A. Trexler, Lehighton, Secy.
Ira E. Freyman, Weatherly.
John E. Wasser, East Mauch Chunk.
Stanley F. Druckenmiller, Lansford.
CENTER COUNTY
Joseph P. Ritenour, State College, Pres.
Melvin Locke, Bellefonte, Secy.
David Dale, Bellefonte.
Marvin W. Reed, Bellefonte.
CHESTER COUNTY
Willis N. Smith, Pheenixville, Pres.
Joseph Scattergood, West Chester, Secy.
Laban T. Bremerman, Downingtown.
William W. Betts, Chadds Ford.
U. Grant Gifford, Kennett Square.
CtARION COUNTY
James M. Hess, Tylersburg, Pres.
Charles C. Ross, Clarion, Secy.
George B. Woods, Curllsville.
John B. Miller, Sligo.
John T. Rimer, Clarion.
CI,EARFIELD COUNTY
Luther W. Quinn, Dubois, Pres.
John M. Quigley, Clearfield, Secy.
John C. Sullivan, Dubois.
Ward O. Wilson, Clearfield.
Lever F. Stewart, Clearfield.
CLINTON COUNTY
Edwin C. Blackburn, Lock Haven, Pres.
Robert B. Watson, Lock Haven, Secy.
David W. Thomas, Lock Haven.
John B. Critchfield, Lock Haven.
Saylor J. McGhee, Lock Haven.
COLUMBIA COUNTY
Charles B. Yost, Bloomsburg, Pres.
Luther B. Kline, Catawissa, Secy.
Clark S. Long, Benton.
Donald B. McHenry, Orangeville.
Frank R. Clark, Berwick.
CRAWFORD COUNTY
R. Bruce Gamble, Meadville, Prfes.
Cornelius C. Laffer, Meadville, Secy.
Oliver H. Jackson, Meadville.
Glennis E. Humphrey, Cambridge Springs.
Samuel J. Dickey, Conneautville.
CUMBERLAND COUNTY
Newton W. Hershner, Mechanicsburg, Pres.
Calvin R. Rickenbaugh, Carlisle, Secy.
Harry A. Spangler, Carlisle.
Samuel E. Mowery, Mechanicsburg.
Selden S. Cowell, Huntsdale.
DAUPHIN COUNTY (HARRISBURG)
Clarence R. Phillips, 1646 N. Third Street, Pres.
Andrew J. Greist, Steelton, Secy.
Earle R. Whipple, Steelton.
Herbert F. Gross, 1501 N. Second Street.
Jesse L. Lenker, 232 State Street.
J. Wesley Ellenberger, 922 N. Third Street.
John R. Plank, Steelton.
Harry B. Walter, 1317 N. Third Street.
DELAWARE COUNTY (cHESTER)
George H. Cross, 525 Welsh Street, Pres.
Walter E. Egbert, 601 E. Thirteenth Street, Secy.
C. Irvin Stiteler, Fifth and Welsh Streets.
J. Clinton Starbuck, Media.
Frederick H. Evans, Chester.
ELK COUNTY
James G. Flynn, Ridgway, Pres.
Andrew L. Benson, Ridgway, Secy.
Andrew L. Benson, Ridgway,
Samuel G. Logan, Ridgway.
John W. Warnick, Johnsonburg.
ERIE COUNTY (ERIE)
John A. Darrow, io6 W. Ninth St., Pres.
Roy S. Minerd, 128 W. Eighth St., Secy.
Fred Fisher, 343 E. Sixth Street.
Fred E. Ross, 132 W. Ninth Street.
Joseph A. Stackhouse, Ii6 W. Eighth Street.
Chester H. McCallum, 219 W. Eighth Street.
Lemuel A. Lasher, 216 W. Twenty-Fourth Street.
Roy S. Minerd, 128 W. Eighth Street.
PAYETTE COUNTY
Elliott B. Edie, 308 First National Bank Building,
Connellsville, Pres.
Robert E. Heath, Fairchance, Secy.
David E. Lowe, Uniontown.
Albert E. Coughenour, Point Marion.
John L. Messmore, Masontown.
Harry Clyde Hoffman, Connellsville.
Arthur E. Crow, Uniontown.
D. Hibbs Sangston, McClellandtown.
FRANKLIN COUNTY
W. Edgar Holland, Fayetteville, Pres.
John J. Coffman, Scotland, Secy.
Frank N. Emmert, Chambersburg.
Samuel D. ShuU, Chambersburg.
Thomas D. White, Orrstown.
GREENE COUNTY
Rufus E. Brock, Waynesburg, Pres.
Harry C. Scott, Waynesburg, Secy.
Frank S. Ullom, Waynesburg.
Rufus E. Brock, Waynesburg.
Thomas N. Millikin, Waynesburg.
HUNTINGDON COUNTY
Harry C. Wilson, Warriors Mark, Pres.
John M. Beck, Alexandria, Secy.
George G. Harmon, Huntingdon.
Cloy G. Brumbaugh, Huntingdon.
Marshall B. Morgan, Huntingdon.
INDIANA COUNTY
Harry B. Neal, Indiana, Pres. _
James M. Torrance, Jr., Indiana, Secy.
William E. Dodson, Indiana.
William B. Ansley, Saltsburg.
Malcolm L. Raymond, Waterman.
JEFFERSON COUNTY
Samuel M. Davenport, Dubois, Pres.
Norman C. Mills, Eleanor, Secy.
Francis D. Pringle, Punxsutawney.
John H. Murray, Punxsutawney.
Norman C. Mills, Eleanor.
JUNIATA COUNTY
John W. Deckard, Richfield, Pres.
Brady F. Loing, Mifflin, Secy.
Amos W. Shelly, Port Royal.
Joseph S. Brown, Okeson.
Isaac G. Headings, McAlisterville.
LACKAWANNA COUNTY (sCRANTON)
Daniel E. Berney, Connell Building, Pres.
James D. Lewis, 204 W. Market Street, Secy.
Frederick J. Bishop, Connell Building.
James E. O'Toole, 124 S. Seventh Avenue.
Joseph C. Reifsnyder, Connell Building.
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THE PENNSYLVANIA MEDICAL JOURNAL September. 1921
James P. H. Ruddy, Dime Bank Building.
George A. Clark, Connell Building.
John W. Grant, Boulevard Avenue, Dickson City.
LANCASTER COUNTY (LANCASTER)
Edgar J .Stein, 225 N. Duke Street, Pres.
Horace C. Kinzer, 128 N. Duke Street, Secy.
J. Paul Roebuck, 233 N. Duke Street.
Walter D. Blankenship, 144 E. Chestnut Street.
Samuel H. Heller, 10 N. Mulberry Street.
Samuel W. Miller, 217 E. King Street.
Clarence R. Farmer, 573 W. Lemon Street. ■
Jacob D. Hershey, Manheim.
LAWRENCE COUNTY (NEW CASTLE)
Charles M. Iseman, EHwood City, Pres.
William A. Womer, no N. Mill St., Secy.
John Foster, 36 Mercer Street.
Don C. Lindley, New Castle.
Samuel W. Perry, 225 E. Long Avenue.
LEBANON COUNTY
Franklin B. Witmer, Lebanon, Pres.
John E. Marshall, Lebanon, Secy.
J. DeWitt Kerr, Lebanon.
Seth A. Light, Lebanon.
Curtis L. Zimmerman, Lebanon.
LEHIGH COUNTY (alLENTOWN)
R. Cornelius Peters, 402 N. Eighth Street, Pres.
J. Treichler Butz, City Hall, Secy.
Frederick R. Bausch, 109 N. Second Street.
William F. Herbst. 28 N. Fifth Street.
George H. Boyer, 528 N. Sixth Street.
LUZERNE COUNTY (wILKES-BARRE)
Lewis Edwards, 790 Market Street, Kingston, Pres.
Elmer L. Meyers, 239 S. Franklin St., Secy.
Walter S. Stewart, 98 S. Franklin Street
Elmer L. Meyers, 239 S. Franklin Street.
Charles Long. 33 S. Washington Street. .
Harry LeRoy Whitney, Plymouth.
Gerdon E. Baker, Forty Fort.
William J. Davis, 225 S. Barney Street.
Samuel M. Wolfe, 218 S. Franklin Street.
William Clifton Smith, Plymouth.
Peter P. Mayock, 68 S. Main Street.
LYCOMING COUNTY (wILLIAMSPORT)
Robert K. Rewalt, First National Bank Bldg., Pres.
Walter S. Brenholtz, 151 E. Third Street, Secy.
Walter S. Brenholtz, 151 E. Third Street.
Victor P. Chaapel, 2017 W. Fourth Street, Newberry
Sation.
Wesley F. Kunkle, 519 Seventh Avenue.
J. Louis Mansuy, Ralston.
John P. Harley, 27 W. Fourth Street.
Joseph W. Albright, Muncy.
MC kean county
Benjamin F. White, Jr., Bradford, Pres.
F. Wade Paton. Bradford. Secy.
Henry James Nichols, Bradford.
Louis D. Joseph, Bradford.
F. Wade Paton, Bradford.
mercer county
August M. O'Brien, State Street, Sharon, Pres.
M. Edith MacBride. Sharon, Secy.
Jkf. Edith MacBride, Sharon.
Paul T. Hope, Mercer.
Willard B. Campbell, Grove City.
MIFFLIN COUNTY
James W. Mitchell, Lewistown, Pres.
James A. C. Clarkson, Lewistown, Secy.
Samuel M. Swigart, Lewistown.
Oscar M. Weaver, Lewistown.
MONROE COUNTY
Charles S. Logan, Stroudsburg, Pres.
William R. Levering, Stroudsburg, Secy.
Charles S. Logan, Stroudsburg.
Walter L. Ajngle, E. Stroudsburg.
William R. Levering, Stroudsburg.
MONTGOMERY COUNTY
Charles F. Doran, Phoenixville, Pres.
Edgar S. Buyers, Norristown, Secy. '
J. Newton Hunsberger, Norristown.
Warren Z. Anders, Collegeville.
George T. Lukens, Conshohocken.
Herbert A. Bostock, Norristown.
J. Elmer Gotwals, Phoenixville.
Frank C. Parker, Norristown.
MONTOUR COUNTY
Robert A. Keilty, Danville, Pres.
John H. Sandel, Danville, Secy.
Horace V. Pike, State Hospital, Danville.
Frank D. Glenn, State Hospital, Danville.
Reid Nebinger, Geisinger Hospital, Danville.
NORTHAMPTON COUNTY (bETHLEUEM)
Milton W. Phillips, Chapman Quarries, Pres.
Paul H. Walter, 60 E. Broad Street, Secy.
Francis J. Dever, 60 E. Broad Street.
Paul H. Kleinhans, Bethlehem.
Herbert J. Schmoyer, Bethlehem.
Victor S. Messinger, Easton.
Tyrus E. Swann, Easton.
W. Gilbert Tillman, 1803 Washington Stret, Easton.
NORTHUMBERLAND COUNTY (SUNBURy)
George A. Deitrick, 30 N. Third Street, Pres.
Charles A. Swenk, First National Bank Bldg., Secy.
Horatio W. Gass, 910 Market Street.
Henry T. Simmonds, 48 N. Market St., Shamokin.
PERRY COUNTY
Harvey M. Woods, Blain, Pres.
Maurice L Stein, New Bloomfield, Secy.
Lenus Carl, Newport.
PHILADELPHIA COUNTY (PHILADELPHIA)
George Morris Piersol, 1913 Spruce Street, Pres.
J. Morton Boice, 4020 Spruce Street, Secy.
John Welsh Croskey, 1909 Chestnut Street.
Mary Buchanan, 2106 Chestnut Street.
D. Randall MacCarroll, 1906 Chestnut Street.
Thomas R. Currie, 512 Lehigh Avenue.
William B. Scull, 3024 Richmond Street
Charles N. Sturtevant 4321 Frankford Avenue.
J. Allen Jackson, Danville (Montour Co.).
R. Powers Wilkinson, 1613 S. Broad Street.
Nathaniel S. Yawger, 21 17 Chestnut Street.
George A. Knowles, 4812 Baltimore Avenue.
Tello J. d'Apery, 767 N. Fortieth Street
Edward A. Shiunway, 2046 Chestnut Street.
Wilmer Krusen, 127 N. Twentieth Street
Charles S. Barnes, 2035 Chestnut Street.
Theodore Le Boutillier, 2008 Walnut Street
Arthur C. Morgan, 2028 Chestnut Street
George D. Fussell, 421 Lyceum Avenue.
Howard D. Geisler, 132 W. Walnut Lane.
William S. Newcomet, Rush Hospital.
Lida Stewart Cogill, 1831 Chestnut Street
Francis Ashley Faught, 5006 Spruce Street.
Paul J. Pontius, 1831 Chestnut Street.
Ralph Getelman, 201 1 Chestnut Street
Arthur Wrigley, 1019 Pine Street,
William S. Wray, 2007 Chestnut Street.
Edwin S. Cooke, 1831 Chestnut Street
Elmer H. Funk, 1318 Spruce Street
J. Norman Henry, 1906 Spruce Street
Henry B. Kobler, 653 N. Sixty-Third Street
McCluney Radcliffe, 1906 Chestnut Street
William N. Bradley, 1725 Pine Street.
I. Rendall Strawbridge, 1418 N. Fifteenth Street
William S. Higbee, 1703 S. Broad Street.
George C. Yeager, 1419 E. Susquehanna Avenue.
John Kolmer, University of Pennsylvania.
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OFFICIAL TRANSACTIONS
921
Irving W. Hollingshead, 123 S. Eighteenth Street
William C. Ely, 3912 Chestnut Street.
John F. Sinclair, 4103 Walnut Street.
Myer Solis-Cohen, 21 13 Chestnut Street.
Charles A. E. Codman, Spruce and Forty-Second Sts.
John A. McGIinn, 113 S. Twentieth Street.
Irwin S. MeyerhoflF, 1727 N. Sixteenth Street.
John M. Baldy, Lincoln Building.
J. Morton Boice, 4020 Spruce Street
Henry Page, 315 S. Sixteenth Street.
Samuel C. Falls, 743 S. Sixty-Third Street. •
William B. Scull, 3024 Richmond Street
R. Powers Wilkinson, 1613 S. Broad Street
Moses Behrend, 1427 N. Broad Street
Charles S. Potts, 2018 Chestnut Street.
J. Torrence Rugh, Medical Arts Building.
Addinell Hewson, 2120 Spruce Street.
Edward B. Krumbhaar, Philadelphia General Hos-
pital.
Seth Brumm, Stock Exchange Building.
Edward J. Moore, 1619 Arch Street.
Frank White, Medical Arts Building.
Edwin P. Longaker, 1402 N. Sixteenth Street
Frances C. Van Gasken, 115 S. Twenty-Second Street.
Mary T. Miller, 313 N, Twenty-Third Street.
W. Hersey Thomas, Medical Arts Building.
J. Torrance Rugh, Medical Arts Building.
POTTER COUNTY
Elwin H. Ashcraft, Coudersport, Pres.
F. Gumey Reese, Coudersport, Secy.
James T. Hurd, Galeton.
Nathan W. Church, Ulysses.
SCHUYLKILL COUNTY
Christian Gruhler, Shenandoah, Pres.
George O. O. Santee, Cressona, Secy.
George R. S. Corson, Pottsville.
Arthur B. Fleming, Tamaqua.
George H. Moore, Schuylkill Haven.
David Taggart, Frackville.
Charles D. Miller, Pottsville.
John G. Striegel, Pottsville.
SNYDER COUNTY
Charles N. Brosius, Shamokin Dam, Pres.
Percy E. Whiffen, McClure, Secy.
G. Edgar Hassinger, Middleburg.
John O. Wagner, Beaver Springs.
SOMERSET COUNTY
Charles B. Koms, Sipesville, Pres.
H. Clay McKinley, Meyersdale, Secy.
Bruce Lichty, Meyersdale.
Milton U. Mclntyre, Boswell.
Charles P. Large, Meyersdale.
SULLIVAN COUNTY
George C. Swope, Mildred, Pres.
Carl M. Bradford, Forksville, Secy.
Philip G. Biddle, Dushore.
Justin L. Christian, Lopez.
Martin E. Herrman, Dushore.
SUSQUEHANNA COUNTY
Arthur J. Denman, Susquehanna, Pres.
Edward R. Gardner, Montrose, Secy.
Horace D. Washburn, Susquehanna.
Dever J. Peck, Susquehanna.
Abram E. Snyder, New Milford.
TIOGA COUNTY
Lloyd G. Cole, Blossburg, Pres.
Solomon P. Hakes, Tioga, Secy.
Farnham H. Shaw, Wellsboro.
Nathan W. Mastin, Wellsboro.
John H. Doane, Mansfield.
UNION COUNTY
Amos V. Persing, Allenwood, Pres.
Charles A. Gundy, Lewisburg, Secy.
Oliver W. H. Glover, Laurelton.
Albert H. Hill, Mifflinburg.
Amos V. Persing, Allenwood.
VENANGO COUNTY
Ford M. Summerville, Oil City, Pres.
John F. Davis, Oil City, Secy.
Frederick W. Brown, Franklin.
John L. Hadley, Oil City.
Fayette C. Eshleman, Franklin.
WARREN COUNTY
Roy L. Young, Warren, Pres.
Elwin S. Briggs, Warren, Secy.
Michael V. Ball, 214 Penna. Avenue, W., Warren.
Robert B. Mervine, Sheffield.
Irving G. Hyer, Clarendon.
WASHINGTON COUNTY
Charles L. Harsha, Canonsburg, Pres.
Charles C. Cracraft, Claysville, Secy.
William Douglass Martin, Dunn's Station.
John B. McMurray, Washington.
Homer P. Prowiti Washington.
Cephas T. Dodd, Washingtton.
Charles B. Wood, Monongahela.
LeRoy W. Braden, Ten Mile.
WAYNE COUNTY
Alexander M. Cook, S. Canaan, Pres.
Edward O. Bang, S. Canaan, Secy.
Edward O. Bang, S. Canaan.
Sarah A. Bang, S- Canaan.
Alexander M. Cook, S. Canaan.
WESTMORELAND COUNTY
D. Ray Murdock, Greensburg, Pres.
Myers W. Horner, Mount Pleasant, Secy.
Claude W. McKee, Greensburg.
Clyde R. McKinniss, Torrance P. O.
D. Allison Walker, Southwest.
Harry W. Tittle, New Florence.
William H. Taylor, Irwiri.
Edgar B. Sloterbeck, Monessen.
WYOMING COUNTY
Van C. Decker, Nicholson, Pres.
Herbert L. McKown, Tunkhannock, Secy.
Thompson M. Baird, 23 W. Forty-Third Street, New
York, N. Y.
William W. Lazarus, Tunkhannock.
YORK COUNTY
Louis S. Weaver, 3 E. Market Street, York, Pres.
Gibson Smith, 220 S. George Street, York, Secy.
Horace M. Alleman, Hanover.
Nathan C. Wallace, Dover.
G. Emanuel Spotz, York.
Lawton M. Hartman, York.
James C. May, York.
Martha L. Bailey, Dillsburg.
REPORTS OF OFFICERS AND
COMMITTEES
Report of the Secretary
To the President and House of Delegates:
Per Capita Receipts, August 27, 1920, to August 27,
1921 :
Assessment 157 mem-
bers $785.00
Assessment 7,231
members (inc. 20
half-year new mem-
bers ) 36,105 .00
$36,890.00
For 1920.
For 1921.
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THE PENNSYLVANIA MEDICAL JOURNAL September, 1921
Allotments :
Medical defense . . .
Medical benevolence
$6,061.50*
1,106.70
$7,168.20
$29,721.80
♦Includes $528 paid to Philadelphia County.
MEMBERSHIP
The total paid membership August 27, 1920, was
7,043; the total paid membership August 27, 1921, was
7,231, with the following component society distribu-
tion for 1920 and 1921 respectively : Adams County —
24,24; Allegheny — 1118,1167; Armstrong— 61,60;
Beaver— 54,60; Bedford— 21,17; Berks— 125,132 ; Blair
—88,86; Bradford— 51,52; Bucks— 84,83; Butler—
49,48; Cambria — 125,120; Carbon — 30,29; Center —
30,28; Chester — 75,75; Clarion— 36,31 ; Clearfield —
62,63; Clinton — 27,26; Columbia — ^48,46; Crawford —
55,54; Cumberland— 4141 ; I>auphin — 145,150; Dela-
ware—96,87; Elk — 27,27; Erie— 113,124; Fayette —
120,115; Franklin — 59,54; Greene — 22,26; Huntingdon
— 37,38; Indiana — 63-60; Jefferson — ^49,46; Juniata —
1 1,13 ; Lackawanna — 176,205 ; Lancaster — 126,128 ;
Lawrence— 56,59; Lebanon— 36,33 ; Lehigh— 83,99 ; Lu-
zerne— 229,231 ; Lycoming — 103,105 ; McKean — 44,44 ;
Mercer — 71,75; Mifflin — 27,26; Monroe — 14,13; Mont-
gomery— 137,150; Montour — 20,22; Northampton —
130,130; Northumberland — 64,59; Perry — 19,17; Phila-
delphia—1965,2040; Potter— 16,14; Schuylkill— 117,102;
Snyder — 14,12; Somerset — 45,45; Sullivan — 8,8; Sus-
quehanna— ^22,20; Tioga — 33,33; Union — 18,19; Venan-
go— 62,58; Warren — 49,48; Washington — 124,125;
Wayne — 29,27; Westmoreland — 148,150; Wyoming —
13,13; York— 118,123.
During the year death removed ninety-three of our
members.
The above figures demonstrate an encouraging
growth, but they are far removed from the possible
total of eight thousand we had hoped to achieve by
this time.
MEDICAL DEFENSE
Applications for defense against suits for alleged
malpractice since September i, 1920, total eight, num-
bering from Case No. 139 to Case 146.
Case No. 139. Application dated November 15, 1920.
Claimant alleges poor result following Pott's fracture.
No action since summons was served November, 1920.
Case No. 140. Application dated September 14, 1920.
Alleged permanent injury to neck subsequent to treat-
ment for adenitis. Summons not yet served.
Case No. 141. Application dated December 17, 1920.
Alleged rectovaginal fistula subsequent to perineor-
rhaphy. Appearance entered in court. Case not yet
called.
Case No. 142. Application dated February i, 1921.
Alleged neglect in treatment of Pott's fracture. Ap-
pearance entered in court. Case not yet called.
Case No. 143. _ Application dated February 3, 1921.
Alleged neglect in treatment of fracture of tibia and
fibula. Summons not yet served.
Case No. 144. Application dated March 11, 1921.
Alleged that death was caused by overdose of anti-
toxin in treatment -of neglected case of diphtheria.
Appearance entered into court. Case not yet called.
Case No. 145. Application dated May 15, 1921. Al-
leged improper treatment of fractured femur. The
applicant was called once in consultation and is co-
defendant with a physician not a member of this so-
ciety at the time of the alleged malpractice, and the
hospital in which the claimant was treated. Summons
served May 7, 1921. Case not yet called.
Case No. 146. Application dated June 12, 1921. Al-
leged improper treatment in case of fracture at elbow
joint. Summons not yet served.
The following cases have been disposed of or have
been up in court during the past year :
Case No. 133. Application approved November 22,
1919. Appeared on daily trial list and nonsuit entered,
October 8, 1920.
Case No. 135. Application approved January 24,
1920. September 22, 1920, jury rendered verdict for
the defendant.
Case No. 136. Application approved May 17, 1920.
Applicant having administered anesthetic for a tooth
extraction refused later to treat the claimant This
case was settled by the defendant out of court, against
the advice and without the consent of the District
Councilor.
An agitation has recently arisen in one or two state
medical societies advocating the assumption by the
society of insurance against possible financial loss by
judgment rendered in suits for alleged malpractice.
Maintaining an open mind, we are at present of the
opinion that it is not the function of our Society to
assume the responsibility or control of this phase of
liability insurance. Our success in defending our well
selected cases to date would apparently indicate that
necessary payments of judgment would be few and far
between. In spite of this favorable experience we be-
lieve, however, that such protection is best handled by
experienced liability insurance companies. The great-
est menace to our present plan is the general casualty
company, which makes a side issue of physicians' and
surgeons' liability insurance. Such _ companies are
prone to seek early settlement of their cases without
due consideration of the unfavorable influence of such
action upon the medical profession at large. We be-
lieve that certain companies specializing in this type
of insurance are able to offer such insurance to our
members at a reasonable annual premium and are very
much less likely to insist on compromises without full
consideration of the defendant physician and the med-
ical profession. The experience of our Society during
the past year has been particularly good. We have
actually expended but $150.00 in defense of our mem-
bers, in contrast with $4,209.10 the previous year.
Postgraduate Program
Meetings have been conducted with unflagging in-
terest and success at four widely separated points in
the state during the months of July and August. The
meeting at Westfield (Tioga County) was attended by
forty-five physicians from four adjoining counties;
the meeting at Somerset (Somerset County) was at-
tended by ninety-two physicians from eight neighbor-
ing counties; the meeting at Lewistown (Mifflin Coun-
ty) was attended by forty-five physicians from five
counties; the meeting at Carbondale (Lackawanna
County) coming on August 31st is at a date too late
to be included in this report.
All of these meetings have had morning and after-
noon sessions. The essayists have endeavored to fol-
low teaching methods, stressing and repeating certain
fundamental points at the risk of being considered
peculiar in style of presentation. The subjects for
presentation have been practically the same at all
meetings, and the appreciation expressed by those in
attendance, as well as by those appearing on the pro-
gram, should be highly encouraging to future post<
graduate program committees.
The expense to the Society incidental to these meet-
ings has averaged considerably less than $1.00 per
member in attendance, a small sum, we believe, in
comparison to the amount of good accomplished.
The Society is greatly indebted to those of its mem-
bers who took part in the program and who in every
instance gave up a day's time, and in many instances
undertook a more or less arduous journey. It is to be
hoped that this small beginning will receive encour-
agement and develop into a postgraduate program that
will in a few years not only include the rural and
mountainous counties, where the condition of the
roads plays an all-important part, but that every coun-
ty in turn may become a postgraduate center for one
day at least for the physicians of its neighboring
counties.
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September, 1921
OFFICIAL TRANSACTIONS
923
MISCELLANEOUS
Throughout the late Legislative session, and in prep-
aration for the activities of public health legislation
committees, we were more than ever impressed by the
willing response of members to the suggestion of so-
ciety officers and committeemen. In fact, from all
parts of the state contributions to the legislative pro-
gram were directly proportionate to the efforts of
officers and committeemen in their presentation of the
appeal.
The good results attained through the efiforts of the
component societies, guided by our representation in
the Medical Legislative Conference, served not only
to weld closer the entire Pennsylvania medical profes-
sion, but also demonstrated the fact that medical men
and women are more interested in general movements
to which they are personal contributors of funds and
influence.
We sincerely trust that the present satisfying state
of interest in public health legislation will not be per-
mitted to flag for want of stimulation by those re-
sponsible for maintaining the same.
Increase of membership and response to obligations
in each of the component societies has been, during the
past year, as always, proportionate to the energy dis-
played by the secretary and other officers.
The members of your Board of Trustees having,
during the past year, inaugurated the plan of quarterly
meetings, have been faithful in attendance and diligent
m duties assigned.
The attendance at the two meetings of the Commit-
tee on Scientific Work was one hundred per cent.
In closing we wish to express our appreciation of the
cooperation received from the officers of this society
and its component societies, and to urge upon all such
officers an increase of interest in the future develop-
ment of our organization.
Respectfully submitted,
Walter F. Donaldson, Secretary.
Report of the Executive Secretary to the Board of
Trustees
The second annual report of the Executive Secre-
tary, embracing the year's work, is herewith submitted
for your consideration :
Nearly all the field work of organization, as related
to the component county medical societies, has been
conducted from the office. Few visitations have been
made, owing to the fact that no apparent need was
manifested by requests from councilors of the dis-
tricts and that there was more urgent reason for the
completion of the work in the office in carrying on the
several duties under this office title. To this there
are two exceptions. A meeting of the Snyder, Juniata,
Perry and Mifflin County Societies was held in Lewis-
town on August i6th, at which time a full day of post-
graduate work was presented under the direction of
and by some members of Dauphin County Society.
A fuller report of the meeting will be found elsewhere
in this Journal. The second exception was the meet-
ing of the Fourth Censorial District held at the Co-
lonial Country Club at Harrisburg, August 25th, at
which the work of the State Society, its relation to
the members and to medical legislation and organiza-
tion were emphasized.
Much correspondence has been carried on with the
officers of the county societies and individual members,
which correspondence we believe has been of benefit
in the endeavor to make this office the clearing house
for the members of the state society.
The legislative activities throughout the 1921 session
of the Assembly offered us plenty of work, of a nature
both clerical and advisory to the Medical Legislative
Conference. Through the bulletin published under
the authority of the conference we endeavored to keep
the officers and members of _ the county societies in
touch with the standing of bills in passage and with
such advice and requests as would make it possible
for the Conference to succeed in the interest of or-
ganized medicine. The report of the Conference,
Uirough its president. Dr. George A. Knowles, is suffi-
cient and illuminating evidence of that work. The
Conference has again been successful in preventing un-
wise and unnecessary legislation and has aided in the
passing of such bills as will be a benefit to the people
of the State as well as to the profession.
It is necessary, however, to point out that the
methods adopted in the past cannot succeed much
longer, as it will be necessary for the profession to
realize that we can no longer ask favors without ren-
dering, prior to their biannual session, some service to
those who make the laws in the State. We cannot be
assured of our friends returning from session to ses-
sion and standing staunch in opposition to the most
influential political pressure, when measures might be
presented which we should oppose and have in the
past opposed. Individually and collectively the profes-
sion should realize that we have a duty at the polls,
the doing of which will place us in the position to re-
quest favors that at present we are sure under such
circumstances could be denied us with good grace.
There must be a reasonable give if we desire to take
favors.
The county societies have been furnished with the
plan of procedure for the prosecution of illegal practi-
tioners, and this office has endeavored to furnish such
aid as has been requested on the part of component
county societies. But little has come to the office which
would require personal visitation to aid in the prosecu-
tion of such cases in the State. The Department of
Health and the Bureau of Medical Education and Li-
censure have been more active in this work than here-
tofore, making the work of this office, up to the pres-
ent, lighter than we had anticipated. Notice has been
served, however, that the Department of Health will
not be able to carry on an active campaign of prosecu-
tion without additional assistance from the State So-
ciety or the Medical Legislative Conference, due to the
fact that appropriations made at the last session of the
Legislature are not sufficient to cover the entire year
in an aggressive manner. The House of Delegates
should take this into consideration and advise the
•Board as to what their wishes will be for the next
fiscal year.
In reviewing the work of the past year we realize
that the work which the Executive Secretary may
carry on during the ensuing year should offer an op-
, portunity, if the Board so desires, of acquainting the
county societies with the need not only of postgraduate
work but also of increasing the membership of the
county societies and of aiding them to become thor-
oughly conversant with the business and economic
side of the State Society work.
As the work of the executive secretary embraces
that of the editor, the following report is submitted:
report of the Editor
The first number of Volume XXIV of the Pennsyl-
vania Medical Journal was issued from the office in
Harrisburg, October, 1920, since which time the entire
work of the Journal has been conducted by the Editor,
under the direction of the Publication Committee.
We have endeavored to interest the colleges of the
State, the academies of medicine and other societies
in submitting abstracts to the Journal for publication,
believing that the profession should receive as fully
as possible the details of the work done by members
of our profession in the State. The county society
reporters have been constantly urged to submit reports
of their transactions, and it is believed that the volume
of the Journal which closes with this number will
show an increased interest through these reports from
the county societies. The editorial pages have con-
tained matter of value to the profession and we trust
that the past may be only a beginning of progressive
journalism for each succeeding year. Inasmuch as the
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924.
THE PENNSYLVANIA MEDICAL JOURNAL SePTEMBEIt, I92I
Pennsylvania Medical Journal is now in the posses-
sion of the State Society, it stands to reason that each
member has an equal interest and right to see this, his
Journal, become one of the best state society publica-
tions in the United States. This can be brought about
only by making the Journal the outlet for all suitable
material that may be produced within the State, there-
by enhancing its value to the profession as well as
creating a mutual interest and relationship with au-
thors and contributors.
In order to make the Journal profitable fiiiancjally,
and otherwise, it is necessary to increase the number
of advertising pages. In this, also, every member of
the society should assume an interest and aid the
editor and publication committee in securing and hold-
ing eligible advertisers for the Journal. Passive in-
terest or indifference is the surest way to make the
Journal a financial burden.
Following is a statement of receipts and remittances
for the Journal from July 19, 1920, to August 23,
1921:
Receipts
Advertising $5,457.80
Subscriptions IS7-S5
Journals sold 25.86
Authors' payments for cuts 132.04
Miscellaneous 96.99
Total $5,870 24
Remittances
Remitted to Treasurer $5,819.80
Credit allowed on Expense Accounts 3.35
Stamps 18.98
Miscellaneous (Refunds, etc.) 28.11
Total $5,870.24
Petty Cash Account
1921
Nov. 2. Received of Secretary $300.00
Aug. 19. Received of Secretary 300.00
Total $600.00
Nov. 2 to Aug. 23. Disbursed $321 .69
Aug. 23. Balance on hand 278.31
Total $600.00
No financial report of the Manager of Sessions and
Exhibits can be submitted at this time but, briefly, we
can assure the Board of Trustees that the exhibit in
Philadelphia will be as fine as that conducted by any
society outside of the American Medical Association.
All arrangements for the session have been completed
and we are assured of a successful commercial exhibit
and urge the Board to request every visiting member
to inspect it thoroughly.
In concluding this report, the Executive Secretary
desires to express to the Board the pleasure which has
accompanied the work of the past year, and this has
been rendered exceedingly encouraging by the active
assistance and cooperation offered by every member
of the Board of Trustees.
Respectfully submitted,
Frederick L. Van Sickle,
Executive Secretary.
REPORT OF THE TREASURER, DR. J. B. LOWMAN
i9» RECEIPTS
Sept. I, to casb, balance on hand $18,477.25
Oct. I, to cash received for account of Manager of
Sessions and Exhibits - 195 . 00
Oct I, to cash received for account of Editor of
Journal 244-30
Nov. I, to cash received for account of Manager of
Sessions and Exhibits 1,952.50
Nov. I to casb received for account of Editor of
Journal 369 . 46
Nov. 20, to cash received from Dr. W. F. Donaldson
— Membership dues 220.00
Nov. 20, to cash received from Dr. W. F. Donaldson
— Sale of Buttons 229 . 1 5
Not. 20, to cash received for account of Editor of
Journal 33>-24
Dec. 14, to cash received from Dr. W. F. Donaldson
— Membership dues , 695.00
Dec. 14, to cash received for account of Editor of
Journal 99-43
Dec. 27, to cash received from Dr. W. F. Donaldson
— Membership dues 910.00
Dec. 27, to cash received for account of Editor of
Journal 393.8o
1921
Jan. 7, to cash received from Dr. W. F. Donaldson
— Membership dues 670 . 00
Jan. 7, to cash received for account of Editor of
Journal 33* ■ So
Jan. 15, to cash received for account of Editor of
Journal 327 . 34
Jan. 22, to cash received from Dr. W. F. Donaldson
— Membership dues 2,730.00
Feb. 3, to cash received from Dr. W. F. Donaldson
— Membership dlies 2,995.00
Feb. 10, to cash received for account of Editor of
Journal 185.81
Feb. 19, to cash received from Dr. W. F. Donaldson
— Membership dues 3,000.00
Mar. 2, to cash received for account of Editor of
Journal 3S0.5»
Mar. 5, to cash received from Dr. W. F. Donaldson
— Membership dues 2,545 • 00
Mar. 16, to cash received for account of Editor of
Journal 37>-7i
Mar. 21, to cash received from Dr. W. F. Donaldson
— Membership dues 3,725.00
Mar. 29, to cash received for account of Editor of
Journal 216.39
Apr. 1 1, to cash received from Dr. W. F. Donaldson
— Membership dues 4,230 . 00
Apr. 16, to cash received for account of Editor of
Journal 186.73
Apr. 26, to cash received from Dr. W. P. Donaldson
— Membership dues 13,340.00
Majr 3, to cash received from Dr. W. F. Donaldson
— Membership dues 650.00
May 3, to cash received for account of Editor of
Journal 393- 7*
May 23, to cash received from Dr. W. F. Donaldson
— Membership dues 350.00
May 23, to cash received for account of Editor of
Journal 40 1 . 76
June 25, to cash received from Dr. W. F. Donaldson
— Membership dues 340.00
June 25, to cash received for account of Editor of
Journal > 110.00
July 5, to cash received for account of Editor of
Journal 328.64
July 12, to cash received from Dr. W. F. Donaldson
— Membership dues 195.00
Aug. 3, to cash received for account of Editor of
Jownal 477-49
Aug. 19, to cash received from Dr. W. F. Donaldson
— Membership dues 217.50
Aug. 19, to cash received for account of Editor of
Journal 217-85
Aug. 26, to cash received from Dr. W. F. Donaldson
— Membership dues 77-50
Aug. 26, to casb received for account of Editor — . 368.83
Aug. 31, to cash received for uncancelled check No.
122, issued 1919-1920 5-00
Aug. 31, to cash received from Medical Benevo-
lence Fund in payment of Orders No. 85
and No. 1 74, drawn from the General Fund . . 492 . 75
Aug. 31, to cash received from Medical Defense
Fund in payment of Order No. 18, drawn
.from the General Fund 15a. 00
Total receipts. General Fund $64.099 . 1 7
EXPENDITURES
Order
No. 1920
1. Oct. 8, by cash, Wm. Penn Hotel, expenses
Pittsburgh Session $1,400.00
2. Oct. 29, by cash, Wm. Penn Hotel, expenses
Pittsburgh Session 115.00
3. Oct. 29, by cash. Miller Bros. & Co., rent,
Harrisburg Office 60.00
4. Oct. 29, by cash, A. G. Trimble, Buttons,
Pennants 336.28
5. Oct. 29, by cash, Royal Typewriter Co., Type-
writer, Editor's Office 115.00
6. Oct. 29, by cash, Louis Weber & Son, Gavels
(2) 60.00
7. Oct. 29, by cash, American Surety Co., Treas-
urer's Bond 37-50
8. Oct.- 29, by cash, Cotteral-Ebner Co.. Equip-
ment, Editor's Office 56. 1 o
9. Oct. 29, by cash, H. M. Black, Equipment,
Editor s Office 22. 40
10. Oct. 29, by cash, J. B. F. Wyant, account of
Trustees and Councilors 46.50
11. Oct. 29, by cash, Mary S. Blair, Stenographer,
Manager of Sessions and Exhibits 100.00
Digitized by
(^oogle
September, 1921
OFFICIAL TRANSACTIONS
925
Order
No.
13. Oct. 39, by cash, James L. Daugherty, Orches-
tra, Pittsburgh Session $85.00
13. Oct. 39, by casE, Frederick L. Van Sickle,
Petty cash account. Manager Sessions and
Exhibits 300.00
14. Oct. 39, by cash, E. Roessler, Supplies, Sec-
retary's Office >4. OS
I J. Oct. 39, by cash, Martha S. Long, expenses.
Registration Office 20.00
16. Oct. 39, by cash. Publishing House, U. E.
Church, balance due on September Journal 303.30
17. Oct. 29, by cash, George E. Fern, setting up
Commercial Exhibits, Pittsburgh Session 500.00
18. Oct. 39, by cash, Burleigh & Challener, Medi-
cal Defense Case 150.00
19. Oct. 39, by cash, Walter F. Donaldson, expense
account Secretary 131.67
20. Oct. 39, by cash, Frederick L. Van Sickle, sal-
ary as Executive Secretary and Manager 375.00
21. Oct. 39, by cash, Frederick L. Van Sickle,
Stenographer's services and supplies 103.68
32. Oct. 29, by cash, Mary S. Boyer, Stenog-
rapher to Editor 65 . 38
23. Oct. 39, by cash. Publishing House, U. E.
Church, account of Journal 89. 31
34. Oct. 29, by cash. Publishing House, U. E.
Church, copies of ^'Official Transactions".. 22.50
25. Oct. 29, by cash, C. B. Longenecker, expense
account as Asst. Secretary, Pittsburgh. .. . 58.59
26, Oct. 39, by cash. Fairchild Bros. & Poster,
refund. Commercial Exhibit 40.00
37. Oct. 29, by cash. The Abbott Laboratories,
refund. Commercial Exhibit 50.00
38. Oct. 39, by cash, Margaret Harrington,
Stenographer to Secretary 70.00
39. Oct. 30, by cash, William Whitford, report-
ing and expenses, Pittsburgh 318.18
30. Oct. 30, by cish, C. K. Melhom, Moving Pic-
ture Machine and operator, Pittsburgh
Session 115.00
31. Oct. 30, by cash, Frederick R. Green, expenses
Pittsburgh 5'. 41
33. Nov. 4, by cash, Jenkins Arcade Co., rent.
Secretary's Office 30.00
33. Not. 4, by cash. Miller Bros, & Co., rent.
Editor's Office 60.00
34. Nov. 18, by cash, J. H. Johnson, Triplicate
receipts tia.oo
35. Nov. 18, by cash, F. E. Dillon, reporting
Pittsburgh 157.87
36. Nov. 18, by cash, Cotterel-Ebner Co., equip-
ment. Editor's Office 77.60
37. Nov. 18, by cash. Evangelical Press, October
Journal 1,073.26
38. Nov. 18, by cash. Evangelical Press, programs
1930 Session 173.85
39. Nov. 18, by cash, Frederick L. Van Sickle
account Executive Secretary and Manager
Sessions 264 . 64
40. Dec. I, by cash. Evangelical Press, expense
account. Editor 32 . 05
4t. Dec. I, by cash, M. C. Repp, reporting Pitts-
burgh Session 150.00
42. Dec. I, by cash, William H. Park, expenses,
Pittsburgh Session 37 . 50
43. Dec. I, hjr cash, Frederick L. Van Sickle,
Typewriter, Editor 100.00
43 1-2. Dec. 6, by cash, Henry D. Jump, Presiden-
tial Visits 56. 59
44. Dec. 6, by cash, John F. Culp, expense. Scien-
tific Program Committee 35 .00
45. Dec. 6, by cash, A.C. Wood, expense Com-
mittee Scientific Work 45. o;
46. Dec. 6, by cash, Mary S. Blair, Stenographer
to Editor 1 25 . 00
47. Dec. 6, by^ cash, Rae Frieberger, Stenographer
to Eaitor 100.00
48. Dec. 6, by cash, Frederick L. Van Sickle, sal-
ary as Executive Secretary and Manager 375.00
49. Dec. 6, by cash, Jenkins Arcade Co., rent.
Secretary's Office 30 . 00
50. Dec. 6, by cash, • Miller Bros. & Co., rent
Editor's Office 60.00
51. Dec. 6, by cash, Margaret Harrington, Stenog-
rapher, Secretarv 77 . 00
53. Dec. 7, by cash. Evangelical Press, Journal,
November 1,498.73
53. Dec. 7, by cash. Evangelical Press, expense
account. Editor 8. 50
54. Dec. II. by cash, Harry Bastow, reporting,
Pittsburgh Session 80. 10
55. Dec. II, by cash. The John Gwyer Press,
Printing and stationery 86.00
56. Dec. II, by cash, Walter F. Donaldson, sal-
ary as Secretary 375-00
57. Dec, II, by cash, J. B. Lowman, salary as
Treasurer , , 50 . 00
58. Dec. II, by cash, J. B. Lowman, Building and
Loan Investment 300 . 00
59. Dec. II, by cash, Ida L. Little, Stenographer
to Secretary -. 85.00
60. Dec. II. by cash. Walter F. Donaldson, expense
Secretary's Office 40.53
Order
No.
61. Dec. 30, by ciisb. Evangelical Press, Journal,
December
62. Dec. 20, by cash, Mildred Bird, expense, Pitts-
burgh Session
63. Dec. 20, by cash. The Misses Beatty, expense,
Pittsburgh Session
64. Dec. 20, by cash, B. J. Myers, Quarterly sal-
ary as Legal Councilor
65. Dec. 20, by cash. Evangelical Press, Printing
and envelopes : . . .
66. Dec. 37, by cash, Frederick L. Van Sickle,
salary as Executive Secretary and Manager
67. Dec. 37, by cash, Mary S. Blair, Stenographer
to Executive Secretary
68. Dec. 27, by cash, Rae Freiberger, Stenographer
to Executive Secretary
69. Dec. 27, by cash, Jenkins Arcade Company,
rent. Secretary's Office
70. Dec. 27, by cash. Miller Bros. & Co., rent.
Executive Secretary's Office
71. Dec. 27, by cash, Margaret Harrington, Stenog-
rapher to Secretary
1921
72. Jan. 7, by cash, E. S. Joseph, Insurance, equip-
ment or Executive Secretary's Office
73. Jan. 7, by cash, J. B. F. Wyant, expenses as
Trustee
74. Jan. 7, by cash, Moses Behrend, reproducing
drawings, Pittsburgh Session
75- Jan. 7, by cash, W. S. Brenholtz, expenses
as Trustee
76. Jan. 19, by cash. Evangelical Press, Journal for
January
77. Jan. 19, by cash, Mary S. Blair, Stenographer
to Executive Secretary
78. Jan. 19, by cash, Mae Weider, Stenographer to
Executive Secretary
79. Jan. 19, by cash, Frederick L. Van Sickle, sal-
ary as Executive Secretary and Manager..
80. Jan. 19, by cash. Miller Bros. & Co., rent.
Executive Secretary's Office
81. Jan. 19, by cash, Jenkins Arcade Company, rent
Secretary's Office ■
83. Jan. 19, by cash, Margaret Harrington, Stenog-
rapher to Secretary
83. Jan. 19, by cash, John Gwyer Press, Printing
and stationery
84. Jan. 19, by cash, J. B. Lowman, Building and
Loan Investment
85. Jan. 19, by cash, E. B. Heckel, Interest on
Medical Benevolence Fund
86. Jan. 27, by cash, Mae Weider, Stenographer,
Executive Secretary
87. Jan. 37, by cash, Frederick L. Van Sickle, for
Stenographic services
88. Feb. 19, by cash, Evangelical Press, Journal
for January, in full of account '
89. Feb. 19, by cash, C. R. Rickenbaugh, refund
per capita assessment
90. Feb. 19, by cash Penna. State Chamber of
Commerce, Membership dues
91. Feb. 19, by cash, J. B. Lowman, Building and
Loan Investment
93. Feb. 19, by cash, John Gwyer Press, Printing
Com. on Scientific Program
93- Feb. 19, by cash, Henry D. Jump, expense.
Presidential Visits
94. Feb. 19, by cash, H. W. Mitchell, expenses.
Trustee
95. Feb. 19, by cash, Mary S. Blair, Stenographer
Executive Secretary
96. Feb. 19, by cash, Mae A. Weider, Stenographer
Executive Secretary
97. Feb. 19, by cash. Miller Bros. & Company,
rent. Executive Secretary's Office
98. Feb. 19, by cash, Frederick L. Van Sickle,
salary as Executive Secretary and Manager
99. Feb. 19, by cash, E. Roesler, Office supplies.
Secretary
100. Feb. 19, by cash, Margaret Harrington, Stenog-
rapher to Secretary
loi. Feb. 19, by cash, Jenkins Arcade Company,
rent. Secretary's Office
I03. Feb. 38, by cash. Burns & Company, Equip-
ment, Executive Secretary's Office
103. Feb. 28, by cash, Henry D. Jump, expenses.
President
104. Feb. 38, by cash, Thomas G. Simonton, ex-
penses. Scientific Program Committee
105. Feb. 38, by cash, Frederick L. Van Sickle,
Traveling expenses. Executive Secretary. .
106. Feb. 28, by cash, C. L. Stevens, rebate from
Co-op. Medical Advertising Bureau
107. March 3, by cash, H. T. Price, expense. Scien-
tific Program Committee
108. Mar. 3, by cash, Edward A. Shumway, refund
for 81 members of Phila. Co. Society
109. Mar. 3, by cash, J. B. Lowman, salary as
Treasurer
no. Mar. 3, by cash, Walter F. Donaldson, salary,
as Secretary
HI. Mar. 3, by cash, Ida L. Little, Stenographer
to , Secretary
$1,485.11
75 00
54-50
75.00
9.30
375-00
125.00
100.00
30.00
60.00
77.00
9.24
28.09
38.00
35.70
1.331 -3'
135.00
50.00
375.00
60.00
30.00
77.00
42.00
100.00
239-95
10.00
40.00
308.56
5.00
25.00
100.00
22.00
7-58
59-24
135.00
100.00
60.00
375.00
3-15
77-00
30.00
•97-75
1 1 - 3i
37-74
9.10
113.68
28.72
20.35
50.00
375.00
75- 00
Digitized by
Cnoogle
926
THE PENNSYLVANIA MEDICAL JOURNAL September, 1921
Order
No.
113. Mar. 5, by cash. Adding Machine Exchange,
Adding Machine, Executive Secretary.... $98.00
113. Mar. 21, Dy cash. Evangelical Press, Journal
February 1,583.54
114. Mar. 31, by cash, J. B. Lowman, Building &
Loan Investment 100 . 00
115. Mar. 33, by cash, Frederick L. Van Sickle, sal-
ary as Executive Secretary 37S . 00
116. Mar. 33, by cash, Mary S. Blair, Stenographer
to .Executive Secretary 135.00
117. Mar. 33, by cash, Mae Weider, Stenographer
to Executive Secretary 100.00
118. Mar. 33, by cash. Miller Bros. & Co., rent
Executive Secretary's office 70.00
119. Mar. 33, by cash, Jenkins Arcade Company,
rent. Secretary's office 30.00
120. Mar. 33, by cash, Margaret Harrington,
Stenographer to Secretary 77.00
131. Mar. 33, Dy cash, American Surety Company,
Premium on bond of Secretary 13.50
133. Mar. 33, by cash, American Surety Company,
Premium on bond of Executive Secretary 6.35
133. Apr. II, by cash, B. J. Myers, salary as Legal
Counsel 75-00
134. Apr. II, by cash. Evangelical Press, Journal
for March 1.586.93
135. Apr. 15, by cash, Frederick L. Van Sickle,
salary as Executive Secretary and Manager 375.00
136. Apr. 15, b^ cash, Mary S. Blair, Stenographer,
Executive Secretary 135.00
137. Apr. IS, by cash, Mae Weider, Stenographer,
Executive Secretary 100.00
laS. Apr. 15, by cash. Miller Bros. & Company,
rent. Executive Secretary's Office 70.00
139. Apr. IS, by cash, J. B. Lowman, Building and
Loan Investment 100.00
130. Apr. 15, by cash, Jenkins Arcade Company,
rent. Secretary's office 30.00
131. Apr. 15, by cash, Margaret Harrington, Stenog-
rapher to Secretary 80.00
133. Apr. 15, by cash, W. F. Donaldson, Postage,
stationery and supplies 49 . 53
133. May '14, by cash, Evangelical Press, Journal
for April i ,478 . 78
134. May 14, by cash, H. G. Schlciter, expenses
Scientific Program Committee 36.34
135. May 14, by cash, J. B. F. Wyant, expenses.
Board of Trustees 55-90
136. May 14, by cash, J. M. Wainwright, expense.
Com. on Public Health and Education.... 10.05
137. May 14, by cash, Hamies & Salsbury, Work-
men s Compensation Insurance 10.00
138. May 14, by cash, American Medical Associa-
tion, A. M. A. Directory, Secretary.... 12.00
139. May 14, by cash, Jenkins Arcade Company,
rent. Secretary's office 30.00
140. May 14, by cash. Miller Bros. & Co., rent.
Executive Secretary's office 70.00
141. May 14, by cash, Frederick L. Van Sickle,
salary as Executive Secretary and Manager J75.00
143. May 14, by cash, Mary S. Blair, Stenographer,
Executive Secretary 135.00
143. May 14, by cash, J. B. Lowman, Building and
Loan Investment 100.00
144.' May 14, by cash, J. B. Lowman, salary as
Treasurer 50.00
145. May 14, by cash, W. F. Donaldson, salary as
Secretary 37S.OO
146- May 14, by cash, Margaret Harrington, Stenog-
rapher to Secretary 80.00
147. May 14, by cash, Ida L. Little, Stenographer
to Secretary 75 . 00
148. May 33, by cash, H. W. Mitchell, expenses
as Trustee 39.53
149. June 4, by cash, H. T. Price, expenses. Scien-
tific Program Committee 27.55
150 June 4, bjr cash, Thos. G. Simonton, expenses.
Scientific Program Committee 37 .43
151. June 4, by cash, H. G. Schleiter, expenses,
Scientific Program Committee 37.43
152. June 4, by cash, Frederick L. Van Sickle,
Stenographic services 48.00
153. June 4, by cash, Margaret M. Miller, Steno-
graphic services 53 .00
154. June 35, by cash. Evangelical Press, Journal
for May 1,477.24
155. June 2S, by cash, B. J. Myers, salary as
Legal Counsel 75. 00
156. June 25, by cash, Frederick L. Van Sickle,
salary as Executive Secretary and Manager 375-00
157. June 25, by cash, Mary S. Blair, Stenographer
to Executive Secretary 125.00
158. June 25, by cash, Margaret M. Miller, Stenog-
rapher to Executive Secretary 100.00
159- June 25, by cash. Miller Bros. & Company,
rent. Executive Secretary's office 70.00
160. June 25, by cash, Jenkins Arcade Company,
rent, Secretary's office 30.00
161. June 25, by cash, Margaret Harrington, Stenog-
rapher to Secretary 80.00
162. June 2$, by cash, J. B. Lowman, Building and
Loan Investment 100.00
Order
No.
163. June 25, by cash, B. J. Myers, collection of
account for Medical Journal $9.50
164. July 15, by cash, E. J. G. Beardsley, expenses
Scientific Program Committee 19-64
165. July 15, by cash, Frederick L. Van Sickle,
salary as Executive Secretary and Manager 375. o«
166. July 15. by cash, Mary S. Blair, Stenographer
to Executive Secretary 135.00
167. July IS, by cash, Margaret M. Miller, Stenog-
rapher to Executive Secretary 100.00
168. July 15, by cash, Miller Bros. & Co., rent.
Executive Secretary's office 70 . 00
169. July IS, bv cash, Jenkins Arcade Company,
rent, Secretaiy's office 30.00
170. July IS, by cash, Margaret Harrington, Stenog-
rapher to Secretary • 80.00
171. July IS, by cash, J. B. Lowman, Bmlding and
Loan Investment 100.00
173. July IS, by cash, E. H. Ashcraft, refund of
dues ; 5.00
173. July 21, by cash, Evangelical Press, Journal
for June i^75-«7
174- July 26, by cash, E. B. Heckel, Interest on
Benevolence Fund ■-•• 252.80
175. July 36, by cash, Edward A. Shumway, refund
on dues paid for Pbila. Co. Society for
Defense Allotment 507.75
176. Aug. 17, by cash. Evangelical Press, Stationery,
Executive SecreUry 3S-io
177. Aug. 17, by cash, Walter F. Donaldson, ex-
penses. Scientific Program CommJ"ee .... 65.28
178. Aug. 17, by cash, Walter S. Brenholu, ex-
penses, Scientific Program Committee.... 58.50
179. Aug. 17, by cash, Walter S. Brenholtx, ex-
penses. Trustee and Councilor i3-<>9
180. Aug. 17, by cash, Frederick L. Van Sickle,
expenses. Executive Secretary's office 300.00
181. Aug. 17, by cash, Walter F. Donaldson, ex-
penses. Committee on Scientific Work.... 5^-4*
182. Aug. 17, by cash, Frederick L. Van Sickle,
salary as Executive Secretary and Manager 375.00
183. Aug. 17, by cash, Mary S. Blair, Stenographer,
Executive Secretary 135.00
184. Aug. 17, by cash, Margaret M. Miller, Stenog-
rapher, Executive Secretary -... 100.00
185. Aug. 19, by cash. Miller Bros. & Co., rent.
Executive Secretary's office 70.00
186. Aug. 19, by cash, Jenkins Arcade Company,
rent. Secretary's office 30.00
187. Aug. 19, by cash, Margaret Harrington, Stenog-
rapher, Secretary 80.00
188. Aug. 19, by cash, J. B. Lowman, Building and
Loan Investment *. . . . 100.00
189. Aug. 19, by cash, I. J. Meyer, expenses.
Trustee and Councilor 95.6o
190. Aug. 31, by cash. Evangelical Press, Journal
for July 1,709.94
191. Aug. 31, by cash, Frederick L. Van Sickle,
salary as Executive Secretary and Manager 375 -00
193. Aug. 31, by cash, Mary S. Blair, Stenographer
to Executive Secretary 135.00
193. Aug. 31, by cash, Margaret M. Miller, Stenog-
rapher to Executive Secretary 100.00
194. Aug. 31, by cash. Evangelical Press, Journal
for August 1,464.35
195. Aug. 31, by cash. Evangelical Press, Journal
for September, estimated cost i ,450 .00
196. Aug. 31, by cash, Margaret Harrington,
Stenographer to Secretary 80.00
197. Aug. 31, by cash, Walter F. Donaldson, salary
as Secretary 375 . 00
198. Aug. 31, by cash, Ida L. Little, Stenographer
to Secretary 75. 00
199. Aug. 31, by cash, J. B. Lowman, salary as
Treasurer 50.00
300. Aug. 31, by cash, B. J. Myers, salary as
Legal Counsel 75 - 00
301. Aug. 31, by cash, J. B. Lowman, Building and
Loan Investment 100.00
303. Aug. 31, by cash, Walter F. Donaldson, ex-
pense account, Secretary 43 • So
203. Aug. 31, by cash, Henry D. Jvmp, expense
account, President i.ss
204. Aug. 31, by cash. Evangelical Press, reprints
of membership list 16.10
305. Aug. 31, by cash, J. B. Lowman, for Medical
Defense Fund for investment 5,533.50
306. Aug. 31, by cash, J. B. Lowman, for Medical
Benevolence EHind for investment 1,106.70
Total expenditures. General Fund.... $45>855-43
CLASSIFIED STATEMENT OF RECEIPTS
Sept. I, 1930 to Sept. I, 1921
CBNCIUU. rvND
Cash on hand September 1, 1920 $18,477.35
Received from Dr. W. F. Donaldson,
for membership per capita tax, 1930 $785.00
Received from Dr. W. F. Donaldson,
for membership per capita tax, 1931 36,105.00
Received from Dr. W. F. Donaldson
for sale of Buttons 329.15
Digitized by VjOOQIC
September, 1921
OFFICIAL TRANSACTIONS
927
Received from Dr. F. L. Van Sickle,
for account of Sessions and Exhibits $3,147.50
Received from Dr. F. L. Van Sickle,
for account of Editor, for Adver-
tising and subscriptions 5,707 . 53
Received from uncancelled check No.
132, issued 1919-20 5.00
Received from Medical Benevolence Fund
in payment of orders issued against
said Fund 492.75
Received from Medical Defense Fund
in payment of orders issued against
Fund 150.00
$4S.62i .92
Total $64,099.17
USDICAI, BCNCVOLENCB PUND
Cash on hand September i, 1920 $1,742.65
Received from interest on investment.. $436.00
Received from interest on deposit 56.75
Received from allotments from member-
ship per capita tax, 1020 23.55
Received from allotments from member-
ship per capita tax, 1921 1,083.15
$1,599-45
Total $3,342.10
MEDICAL DEFBHSE FUND
Cash on hand September i, 1920 $6,481.94
Received from interest on investment.. $262.50
Received from interest on deposit 226.92
Received from allotments from member-
ship per capita tax, 1920 "7' 75
Received from allotments from member-
ship per capita tax, 1921 5,415.75
$6,022.92
Total $12,504.86
ENDOWMENT FUND
Cash on hand September >, 1920 $637.75
Received from interest on investment.. $212.50
Received from interest on deposit 23.11
235.61
Total $873-36
SUMMARY
General Fund $64,099 . 1 7
Medical Benevolence Fund 3,342.10
Medical Defense Fund 12,504.86
Endowment Fund .- . . . 873 . 36
Total Receipts $80,819.49
CLASSIFIED STATEMENT OF EXPENDITURES
Sept. I, 1920 to Sept. I, 1921
CENSBAL FUND
Medical Defense Fund for investment.'. $5,533.50
Medical Defense Fund, on account 150.00
Medical Benevolence Fund for investment 1,106.70
Medical Benevolence Fund, on account.. 492.75
Endowment Fund, investment 1,200.00
Journal for year 18,215.23
Salaries:
Executive Secretary and Editor 4,500.00
Secretary 1,500.00
Treasurer 200.00
Legal Counselor $300.00
Stenographers — Secretary's office 1,245 .oo
Exec. Secretary and Editor's office.. 2,743.06
Expense, Gavels for President 60.00
Expense, Premiums on bonds of Treas-
urer, Secretary and Executive
Secretary 56 . 25
Expense, Pittsburgh meeting 3,652. 74
Expense, Printing, stationery and post-
age 394-53
Expense, Annual Dues, Chamber of Com-
merce 25 .00
Expense, Compensation Insurance lo.oo
Expense, Refunds on Commercial Ex-
hibits 90.00
Expense, Refunds on per capita assess-
ments 538. 00
Expense, Rebate for Co-op. Medical Ad-
vertising Bureau 1 1 3 . 68
Expense, Collection of account for Medi-
cal Journal 9.50
Expenses of Secretary's office, for rent
equipment, supplies, etc 661.89
Expenses of Executive Secretary and
Editor's office, for rent, equipment,
supplies, etc 2,162.38
Expenses of President, for visits, etc. 76.94
Expenses of Committees, Councilors and
Trustees 759.68
Expenses of Assistant Secretary 58 . 59
Total $45,855-42
SPECIAL FUNDS
(No investments made during past year)
Total disbursements $45,855 . 42
STATEMENT OF CASH BALANCES AND
INVESTMENTS
Sept. I, 1920
CASH
General Fund $18,243.75
Medical Benevolence Fund 2,849.35
Medical Defense Fund 12,354 . 86
Endowment Fund 873 . 36
$34,3*1 - 3*
MEDICAL BENEVOLENCE FUND
Wilkes-Barrc City Improvement Bond,
No. 94, Series i, Par Value $1,000.00,
y/i per cent $1,000.00
Liberty Bonds 9,200.00
$10,200.00
MEDICAL DEFENSE FUND
Wilkes-Barre City Improvement Bonds,
Nos. 96, 97 and 98, Series i. Par
Value $1,000.00, 454 per cent $3,000.00
Liberty Bonds 3,000.00
— — $6,000.00
ENDOWMENT FUND
100 Shares Peoples' Building and Loan
Association — 57 installments paid.... 5,700.00
Liberty Bonds 5,000.00
$10,700.00
Total cash balances and investments Sept. i,
>92o $61,221.32
SUMMARY STATEMENT OF CASH BALANCES. RECEIPTS AND EXPENDITURES
September i, 1920 to September i, 1921
Cash balance, Sept. i, 192 : $27,339.59
Receipts:
Membership per capita tax 36,890.00
Allotments from membership per capita tax 6,640.20
Account of Manager of Sessions and Exhibits 2,147.50
Account of Editor, for Advertising and Subscriptions.... 5,707.52
Sale of Buttons 229.15
Uncancelled check, issued 1919-1920 5.00
Interest on investmenta and deposits 1,217.78
Total receipts, Sept. 1, 1920 to Sept. i, 1921 52,837.15
Total receipts, including balances Sept. i, 1920 80,176.74
Transfer of Funds
Total balances and receipts 80,176.74
Expenditures, Sept. i, 1920 to Sept. i, 1921 45.855.42
Balances, Sept. 1, 1921 34,321.32
* Transferred From
*• Transferred To
Total General Medical Medical Endowment
Fund Benevolence Defense Fund
Fund Fund
$18,477.25 $1,742.65 $6,481.94 637.75
36,890
,00
2,147
•SO
5.?07
.52
229.
15
5-
00
44.979-17
63,456.42
"«42.75
64,099.17
45.855-42
"8,243.75
1,106.70
492.75
1.599.45
3.342.10
•492.75
a.849.35
5.533 -SO
489.42
6.022.92
12.504.86
•150.00
12,354.86
2,849.35 12,354.86
235.61
235.61
873 -3«
873.36
873-36
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THE PENNSYLVANIA MEDICAL JOURNAL September, 1921
Repokt of the Chairman of the Board of Trustees
To the President and House of Delegates:
The Board of Trustees reorganized Thursday after-
noon, October 7, 1920, by electing the undersigned
chairman and Dr. Donald Guthrie, clerk. The new
trustees, Drs. Jay B. F. Wyant (reelected), and Harry
W. Albertson (reelected) and Dr. Walter S. Bren-
holtz, of Williamsport, elected to fill the unexpired
term of the late Dr. G. Franklin Bell, were present.
Plans were discussed and evolved for providing
funds for the Medical Legislative Conference of the
State of Pennsylvania. A minimum of $1.00 from
each member of the State Society was suggested. We
are glad to say that this request met with a generous
response, the members of many component societies
giving considerable more than the minimum. It is to
be hoped that such contributions will be made yearly,
thus supplying the Legislative Committee with ample
funds for its work.
After fixing the financial budget for the various ac-
tivities of the Society for the year, the Board of Trus-
tees adjourned and did not meet again until the regu-
lar quarterly meeting which was held December 13,
1920, in the offices of the Executive Secretary, 212 N.
Third St., Harrisburg, Pa. Such meetings were held
also on February 2d and May 2. At different times
during these meetings your Board was in closest pos-
sible contact with the activities of the various officers
of the Society, the Public Health Legislation Commit-
tee, the Medical Legislative Conference and the Scien-
tific Work Committee. We feel confident that our
Society could not have received more faithful service
than it has during the past year at the hands of its
various officers, committeemen and members of its
Board of Trustees. Certain amendments to the Con-
stitution and By-Laws affecting the office of Execu-
tive Secretary were recommended (see page 836, Au-
gust, 1921, Journal). Much time and effort was de-
voted to the discussion of the best possible means of
correcting the glaring illegal practices of hundreds of
unlicensed and licensed drugless therapists through-
out the state. At the present time, however, this un-
fortunate phase of the practice of the healing art is in
a more or less chaotic state, due very largely to the
fact that regulatory and disciplinary laws upon the
statute books of our state do not carry with them pro-
vision for the necessary funds to prosecute those who
infringe upon the Medical Practice Acts. This con-
dition is aggravated at present by attempts to shift or
divide the responsibility between the Public Health
Department, the Bureau of Medical Education and
Licensure and the newly created Department of Public
Welfare. These unfortunate circumstances, plus the
high cost of traveling have interfered very materially
with the fulfillment of two very important functions
of the Executive Secretary's office.
The Board of Trustees, having adopted recommen-
dations regarding postgraduate work among compo-
nent societies, referred same to the 1921 Committee on
Scientific Work. We feel that such suggestions offer
a fine opportunity for additional service by the State
Society to our members residing in certain of our
rural and mountainous counties, where it is almost
impossible to hold meetings during winter and spring
months. Reports from four such meetings held this
summer at Somerset, Westfield, Lewistown and Car-
bondale evidence enthusiastic receptions by the physi-
cians in attendance.
Our personal experience with censorial meetings
has been so gratifying that we urge yearly meetings.
The number and quality of these meetings depend
largely on the leadership of the District Councilor and
we are informed by officers of the Society that the
esprit de corps of component societies is always best
in the district whose councilor is active.
During the year provision was made, adopting rec-
ommedations of our Committee on Finance, to employ
an expert accountant to make an inventory and estab-
lish an accounting and checking system to apply to the
offices of the Secretary, Treasurer and Executive Sec-
retary, with instructions to each of these officers to
file a statement of receipts and expenditures with our
Finance Committee ten days prior to the regular quar-
terly meetings of the Board of Trustees.
The financial cost of the proper administration of
our Society with its more than seven thousand mem-
bers has almost doubled since 1918. Our gain in mem-
bership in comparison has been but slight. Our 1921
income from per capita tax will apparently be insuffi-
cient to pay the current year's administrative expenses.
Increase of our present income is possible only
through (a) increase of membership, (b) increase of
Journal advertising, (c) increase from yearly scien-
tific exhibits, or by increasing the per capita tax. If
every member of our Society will do his full duty to-
ward items a, b and c, the last suggestion need never
be adopted.
We urge the individual members of the 1921 House
of Delegates, as they return to their countj- societies,
to become active missionaries throughout the coming
year in increasing membership, loyalty, attendance
upon scientific meetings, interest in health legislation
' and in medical economics.
J. B. F. Wyant, Chairman.
Reports of Individual Councilors
dr. FRANKC. HAMMOND, PHILADELPHIA, COUNCILOR FOR
THE FIRST COUNCILOR DISTRICT
To the President and House of Delegates:
The condition of the First District has been uni-
formly satisfactory during the past year. At this
date .(August l, 1921), the Philadelphia County Med-
ical Society is composed of 2,072 active members and
five honorary members. Of this number, five are life
members. Up to April i, 1921, dues were paid by 2,013
members, whose state assessments were sent to the
State Secretary. To the present time, dues have been
paid by 2,040 members, which, of course, represents
the number of active members in good standing.
There are thirty-two delinquent members under sus-
pension and who are threatened with being dropped
from the roll on September 30th, if their dues are not
paid. These members have received four notices of
nonpayment from the secretary and one notice from
the membership committee. Of these delinquent mem-
bers, seventeen reside in Philadelphia County. Up to
the present time, during the year 1921, sixty-one new
members were elected, fifty-five of whom have quali-
fied. Since January i, 1921, fifteen members have died.
Sixteen members, who were leaving the city or going
out of practice, have resigned since January i, 1921.
three of whom paid dues for the year. Ten members
were transferred to other societies during the year, of
whom eight have paid dues.
The Committee on Medical Defense, during the
year, has had only four applications for defense,
three of which are, undoubtedly, blackmail. One case
came to trial, which was won without the case going
to the jury. Another case was settled by the insur-
ance company, against the advice of the committee.
It is very unfortunate to have an insurance company
settle a case, because whether or not the physician is
guilty, the fact that settlement is made is generally
accepted as sufficient evidence that the physician was
guilty. There are instances where the insurance com-
pany will settle a case without conference with the
physician ; in other words, if the insurance company
can make a settlement which would be less than what
it would cost to defend the case in court should it
come to trial, the company invariably shows a ten-
dency to make such settlement. Physicians should be
upon their guard in this matter, as it is a very vital
factor in their community. .
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September, 1921
OFFICIAL TRANSACTIONS
929
DR. HARRY W. AI.BERTSON, SCRANTON, C0UNC1IX)R I'OR THE
SECOND DISTRICT
To the President and House of Delegates:
As Cotincilor of the Second District I beg to make
the following report for the year just ending:
There are no pending suits for malpractice, and no
applications for defense have been received by me dur-
ing the year.
The societies that I have visited, and the reports of
those where it has been impossible to make an official
visit, show a healthy state of growth and organized
activity. The attendance at all meetings is uniformly
good and the programs are of high order.
The contribution of $i.oo per capita to the legisla-
tive fund by the _ members of the various societies
comprising this district was largely carried out, and
during the sessions of the legislature, active interest
was manifest by all the societies, and a willingness to
assist in arousing interest in our behalf among the
members of the House and Senate was to my mind the
best proof that the medical men of this district are
alive and awake to their interests.
We are looking forward with pleasure to an all day
postgraduate program meeting that has been arranged
for August 31st at Carbondale.
DR. IRA G. SHOEMAKER, READING, COUNCILOR FOR THE
THIRD DISTRICT
To the President and House of Delegates:
The Councilor of the Third District has been in
touch with each society and is pleased to report con-
ditions favorable in practically the entire field. There
has been a reported increase in the membership of
each county, with the exception of Delaware and
Schuylkill, which show losses. In the case of Dela-
ware, this is probably due to a number of the men
holding membership in adjacent societies because of
inconvenience in attending meetings in their own
county. In both of the latter societies, several of the
members have failed to pay their annual assessments,
in consequence of which they stand suspended.
Following a custom, since our election to the office
of Councilor, two visits have been made annually to
each society; this has been done this year, with the
exception of two societies which we hope to visit
before October.
Each society was asked to contribute two dollars
($2.00) per member for the use of the Medical Legis-
lative Conference. This was done in all but Mont-
gomery County, which paid five dollars ($5.00). The
total amount contributed approximated thirteen hun-
dred dollars, ($1,300.00), for which we feel considera-
ble pride.
Since the meeting of the Board of Trustees in May,
when we were apprised of the fact that there might
be no medical representation in the Legislature of
1923, we are urging upon the societies in our district
the necessity for political activity along two lines:
first, the assurance from the present legislators or
their probable successors, that they would support only
such legislation as would be for the good of the Com-
monwealth and upholding the high standard of the
healing art ; second, in the event of not being able to
secure this assurance, some members of the profession
must consent to enter the field and secure the nomina-
tion and election if possible, in order that our rights
may be safe-guarded.
There have been no requests for assistance in al-
leged malpractice suits. Two members from Berks
County received letters from attorneys in which they
were asked to call and make settlement for alleged
faulty technique in treatment, against which we ad-
vised. The letters were ignored, we have heard noth-
ing since, and believe no further action will be taken.
DR. THEODORE B. APPEL, LANCASTER, COUNCILOR FOR THE
FOURTH DISTRICT
To the President and House of Delegates:
The report of the Fourth District for last year has
been one of steady progress in the seven societies rep-
resented in the Fourth District All are in a healthy
condition and doing good work. The programs, as a
rule, are well conceived and carried out. York County
particularly deserves credit for laying out a program
III advance for the entire year, and there have been
few occasions when it has been interfered with. In
Adams County the erection of a new hospital has
given the society a home, and the members of the so-
ciety practicall}r form the staff. In E>auphin and Lan-
caster the meetings are held in the Academy of Medi-
cine at Harrisburg and the Medical Club at Lancaster,
respectively, where well equipped libraries are in
operation. Lebanon meets in rooms at the Court
House, York and Cumberland at one of the hotels,
and Franklin changes its meeting place to different
localities to accommodate its members. From the
reports received from the secretaries, the number of
practitioners not members, who would be considered
as eligible, is extremely small. The field is very well
covered. But little trouble is experienced in any of
the counties reported on the subject of illegal practi-
tioners.
A suit has been brought against a member of the
Lancaster County Society for alleged malpractice (case
No. 143). The case involves a bad result in a frac-
tured leg, and a charge of negligence has been made.
An investigation indicates that the charge has no
foundation and apparently belongs to the category
which savors strongly of blackmail. The trial (if case
comes to trial) will come up in the fall.
DR. HOWARD C. FRONTZ, HUNTINGDON, COUNCILOR FOR THE
FIFTH DISTRICT
To the President and House of Delegates:
Presented herewith is my report as Councilor of the
Fifth District for the year:
The component county societies of the district have
been holding meetings regularly, except Perry County
Society, which is one of the oldest county societies.
This society held a meeting May 25, 1921, at which
time officers were elected and the ten members present
decided to renew their efforts to keep it in a healthy
condition.
A postgraduate meeting for MifHin, Juniata, Perry
and Snyder Counties was held at Lewistown, August
16, 1921. Six physicians from Harrisburg presented
medical and surgical subjects of practical interest to
the practitioner and Dr. Van Sickle, Executive Secre-
tary, spoke relative to the work of the State Society.
The addresses were well received and discussed. .\
luncheon was served and general good fellowship pre-
vailed. About forty-five doctors were present. The
idea of taking postgraduate instruction to the doctor
is a good one, and this work should be continued
throughout the state, especially in the rural counties.
Xo censorial meetings were held during the year.
The suit. No. 135, against one of Huntingdon County's
doctors came to trial in Huntingdon County Court in
September, 1920. It resulted in the court directing
the jury to render a verdict for the defendant. .\
damage suit against a Huntingdon County doctor was
brought August 17, 1921. Application for defense will
be made in a few days.
DR. IRWIN J. MOVER, PITTSBURGH, COUNCILOR FOR THE
SIXTH DISTRICT
To the President and House of Delegates:
The Councilor of the Sixth District respectfully asks
permission to submit the following report :
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930
THE PENNSYLVANIA MEDICAL JOURNAL SEPTEMBeR, 1921
The Westmoreland County Society was visited at
Greensburg, March i, 1921. There was a small attend-
ance but interest was very good. On June 2, 1921, the
Fayette County Society met at Uniontown. A good
number were in attendance and the meeting was in-
teresting. No discussion was requested and the pro-
gram of scientific papers was not interrupted.
The Washington County Society was visited at
Washington, June 14, 1921. Much interest was taken
in both the general council topics and in the regular
program. On the evening of June 14, 1921, the Greene
County Society was visited at Waynesburg. The en-
tire meeting was given over 'to councilor talk and a
very general discussion.
June 21, 1921, the Alleg:heny County Society was vis-
ited officially and a definite place was given for coun-
cilor report after the regular scientific program was
presented. The meeting was well attended. A very
interesting and well attended Postgraduate Conference
was held at Somerset on July 19, 1921. The program
and general plan was well worked out by Secretary
Donaldson, assisted by the local committee. Topics
introduced especially have been :
1. The importance of increased membership.
2. Meetings to which the public should be invited.
3. Necessity of active interest in the legislative af-
fairs pertaining to the public welfare.
Some thoughts that have arisen —
1. How to make the Councilor Meetings most inter-
esting to each society.
2. What subjects should be presented.
3. How best to determine the needs and progress of
each County Society.
Three applications, Nos. 139, 140 and 146, have been
accepted for Medical Defense from Allegheny County.
DR. HARRY W. MITCHELL, WARREN, COUNCILOR FOR THE
SEVENTH DISTRICT
To the President and House of Delegates:
Frequent visits to the societies have been made dur-
ing the past year, and matters of special interest have
been brought to the attention of the various secretaries
by correspondence.
The society meetings in the Seventh Councilor Dis-
trict are usually well attended, and active interest is
being demonstrated in the meetings and general med-
ical matters.
Suit for alleged malpractice was brought against a
physician in the district, which is now pending. The
physician in question was called to attend a child who
had been ill for three days, suffering from laryngeal
diphtheria. Antitoxin was administered immediately,
and the patient died after showing teniporary im-
provement following the first administration of anti-
toxin. Suit was brought on the ground that the use
of this agent was responsible for the death of the
child. It is, perhaps, needless to report that this un-
just accusation will be met by adequate defense. Sev-
eral cases against alleged illegal practitioners are
pending in the district. The State Department of
Health and the local medical society are cooperating
in the prosecution of these cases, which are of much
importance, not only locally, but to the general medical
interests of the state. The trials have been postponed
until the fall term of court.
DR. DONALD GUTHRIE, SAYRE, COUNCILOR FOR THE EIGHTH
DISTRICT
To the President and House of Delegates:
The condition of the societies in the Eighth District
has been unusually good for the past year. There has
been one threat to sue for alleged malpractice, but as
this was several months ago and as nothing definite
has been heard since, it is my opinion that there will
be no suit.
The councilor has been able to visit all the societies
except McKean. This society has been written to,
however, several times and from reports everything
is satisfactory in that county.
I have corresponded several times with the secre-
tary of the Potter County Society. The men are en-
thusiastic and I look forward to some active work in
this society during the coming year.
I have tried to start a campaign for new members,
and hope during the next year to report a general in-
crease of membership in this district.
DR. J. B. F. WYANT, KITTANNINC. COUNCILOR FOR THE
NINTH DISTRICT
To the President and House of Delegates:
The Councilor for the Ninth District takes pleas-
ure in saying that the societies of the district are all
good working societies. Official visits were made to
Butler, Venango and Armstrong Counties. Dates were
arranged for visiting the other counties of the district,
but circumstances developed at the last moment that
disarranged my plans.
Butler County meets monthly and was visited at the
regular meeting June 14, 1921. There was a good at-
tendance and much interest displayed. It has forty-
nine members in good standing and quite a number of
physicians not members and has one suit for alleged
malpractice pending, No. 141.
A visit was made to Venango County on July 19,
1 921. It was her annual outing day and was well at-
tended. Physicians and their families assembled in
Monarch Park. The day was beautiful, the banquet
was the best of the season, the program was excellent
Dr. John W. Boyce, of Pittsburgh, gave an illustrated
lecture on the "Heart." While the members were en-
joying the scientific program, their ladies were socially
engaged. Venango County has one alleged malprac-
tice suit scheduled for trial. No. 145. Venango County
has fifty-nine members and a few nonmembers.
Armstrong County has sixty members, a 100 per cent
numerical medical society, and meets monthly.
Clarion Medical Society has thirty-one members,
(few nonmembers), and meets quarterly.
Indiana Medical Society has sixty-three members,
(few nonmembers) and mets the second Tuesday of
each month.
Jefferson County Society, which has a membership
of forty-six, with a few not yet in, meets monthly.
These societies are all planning for 100 per cent nu-
merically. In fact there is a general wave all over the
State, a sort of epidemic for new members. Let us
hope that every eligible physician in Pennsylvania will
be a member in good standing in one of our cont-
ponent societies before we meet again.
DR. WALTER S. BRENHOLTZ, WILLIAMSPORT, COUNOLOR FOI
THE TENTH DISTRICT
To the President and House of Delegates:
As Councilor for the Tenth District I present my
first report of the condition and activities of the so-
cieties of this district for the year just drawing to a
close.
We have visited all the societies of this district dur-
ing the past year, except that of Union County, and in
all our visits we found the meetings very well attended,
the members very active and very interesting profitable
programs. We were treated royally on all our visits
and found the members more than willing to cooperate
in all measures we presented to them that were for
the good of the profession. There has been a steady
and healthy growth in membership in all the various
societies of the tenth district. There remain very few
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September, 1921
OFFICIAL TRANSACTIONS
931
eligible physicians who are not members of a county
society.
Regular monthly meetings are held by all the so-
cieties of the district except that of Union County So-
ciety, which holds meeting every three months. Sev-
eral attempts have been made to visit the Union Coun-
ty Society, but as the membership in that society is
small, they very seldom have a meeting and their secre-
tary fails to notify us of a meeting.
Seven of the eight societies of the tenth district
voted unanimously, upon our request, to assess every
member three dollars for the use of the Medical Leg-
islative Conference in its work to prevent the enact-
ment of legislation by the last Legislature that would
be obnoxious to the medical profession and not in the
best interests of the people of this Commonwealth.
This action on the part of the members of the various
societies of the tenth district convinces us that the
medical profession is more united than ever in the sup-
port of all measures and efforts being put forth in the
interest of legislation that is of vital importance to all
practitioners of medicine and to the advancement of
medical science.
We have honestly endeavored to render every as-
sistance possible, to further the cause of a better or-
ganized medical profession and we sincerely hope that
the day is very near when every legal practitioner of
medicine will be convinced that he needs the organiza-
tion more than it needs him.
It is indeed a pleasure to be able to say that not one
of our members has been threatened with suit for al-
leged malpractice.
Motto of the Tenth Councilor District : "Peace and
Good Will."
Report of Committee on Public Health Legislation.
To the President -and House of Delegates:
The Committee on Public Health Legislation, ap-
pointed by President Jump, organized and united with
the Committee on Public Health Legislation of the
Homeopathic and Eclectic Medical Societies, forming
the Medical Legislative Conference of Pennsylvania.
All matters pertaining to medical legislation were
cared for by the Conference, and the Committee of the
Medical Society of the State of Pennsylvania func-
tionated through this source.
A detailed report of the work and results obtained
by the Conference was published in the Journal of
June, 1921, and the members of the society are re-
ferred to this issue of the Journal for information.
Respectfully submitted,
Edgar M. Green,
Joseph G. Steedle,
L. Webster Fox,
S. J. Miller,
F. L. Van Sickle,
G. A. KnowlEs, Chairman.
Report of the Committee on Health and Pubuc
Instruction
To the President and House of Delegates:
Your Committee on Health and Public Instruction
begs leave to submit the following report of its ac-
tivities for the past year :
At a meeting held early in the year, it was decided
to urge upon each county society that they arrange
for one meeting during the year when subjects pertain-
ing to public health should be discussed. As a result
of this appeal, ten societies are reported as having held
such meetings.
The following action was taken on a communication
from the Pennsylvania Pharmaceutical Association,
which was referred to this Committee for action, viz :
That a Committee of three members of the State So-
ciety be appointed to meet with a similar committee of
the Pharmaceutical Association, for the purpose of
effecting a closer cooperation between the medical pro-
fession and pharmacists, having in view the curtail-
ment of the prescribing over the counter by phar-
macists, and the dispensmg of drugs by the physician,
and the discouragement of self-drugging by the pa-
tient.
Your committee further recommends that the med-
ical schools of this State be urged to instruct students
in the laws pertaining to public health, and that the
Committee on Licensure examine candidates in these
laws.
It is the sense of this Committee that all members
of our society should cooperate with civic and other
organizations doing public health work in their re-
spective localities, so that Pennsylvania shall take its
proper rank in public health affairs.
Respectfully submitted,
C. Howard WitmER, Chairman.
Report of the Commission on Cancer
(Subsidiary to the Committee on Health and Public
Instruction.)
To the President and House of Delegates:
The Committee has maintained its usual activity
during the past year. A very successful "Cancer Day"
was held in South Bethlehem in June, at which the
Commission had the assistance of Dr. John G. Clark
and Dr. Henry K. Pancoast of Philadelphia, and Dr.
George E. Brewer of New York City. Very instruc-
tive clinics were given by these gentlemen and an in-
teresting and well attended public meeting was held
in the evening at the high school.
Another very successful "Cancer Day" was held in
Danville, at which Dr. J. C. Bloodgood and Dr. Henry
D. Jump were the principal speakers. There was a
very large and enthusiastic attendance of doctors from
Danville and from many towns situated quite a dis-
tance away. Both these meetings emphasized the
great value of "Cancer Days" in propaganda work.
Further "Cancer Days" are already planned for the
coming year.
There has been very active cooperation with the
Committee on Postgraduate Work. Dr. E. A. Weiss
gave a very valuable cancer talk at one of these com-
mittee meetings in Somerset, and Dr. Donald Guthrie
did the same at a large meeting at Westfield, Tioga
County. Further cooperation with this Committee is
already planned for the coming year. The Commis-
sion is also working with the national society in con-
nection with "Cancer Week" during the coming fall.
Respectfully submitted,
J. M. Wainwricht, Chairman.
Report of the Committee on Society Comity and
Policy
To the President and House of Delegates:
Your Committee on Society Comity and Policy has
not originated any work during the year, nor has any
thing been brought to its attention by other commit-
tees. The only matter that may be said to have been
directly or indirectly referred by the House of Dele-
gates to our committee was a certain responsibility in
the report of the special committee on hospitals for
rural communities, that committee having been in-
structed to "confer with the Committee on Society
Comity and Policy before making its report."
Respectfully sumbitted,
. C. L. Stevens, Chairman.
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THE PENNSYLVANIA MEDICAL JOURNAL Septembbr, 1921
Report of the Committee on Efficient Laws on
Insanity
(Subsidiary to the Committee on Public Health Legis-
lation.)
To the President and Home of Delegates:
The Committee made a careful study of all bills pro-
posed in the last Legislature affecting the interests of
the insane, and were active in presenting their views
before the various hearings, also keeping in close
touch with the agents of the Medical L^islative Con-
ference of Pennsylvania.
The Legislature increased the maintenance board
rate of indigent insane patients from. $5.00 to $6.00
weekly. This was an important piece of legislation,
and while efforts were made to secure a larger weekly
board rate, it is barely possible that on a falling
market, the hospitals may be able to run, during the
coming two years, without the necessity of incurring
deficits, which have been forced upon them for the
past four years, because of the failure of the previous
Legislatures to advance board rates beyond the figures
obtaining before the war.
The most important measure passed by the last Leg-
islature was the Public Welfare Act, which provides
for abolition of the Board of Public Charities and the
Committee on Lunacy and transferring the powers ex-
ercised by these bodies to a new commission, taking
office September i, 1921.
The Commission appointed two years ago by the
governor to revise and codify the laws on insanity,
made an elaborate study of the situation, holding many
hearings, and presented their findings in a report
which was emt>odied in a hill oresented to the Legisla-
ture for its consideration. This bill contained many
admirable provisions which would go far to improve
existing customs in the care of the insane. It, how-
ever, provided for a central supervision, which would
have been in conflict with the Public Welfare Bill.
The new Commission appointed under the provisions
of the Public Welfare Act, will have an opportunity of
considering the recommendations for improving the
methods of support, commitment, etc., now in practice.
The Commission's report may well serve as a guide to
future legislation and rulings of the new Supervisory
Commission.
The Committee desires to express its appreciation
of the excellent support given by the Medical Legisla-
tion Conference of Pennsylvania, not alone relating
to the subject of insanity, but in all medical legislation.
Respectfully submitted,
Harry W. Mitchell, Chairman.
Report of the Committee on the Defense of Medical
Research
(Subsidiary to the Committee on Public Health Legis-
lation.)
To the President and House of Delegates:
Xo business was brought before the committee on
the Defense of Medical Research during the past year.
James D. Heard, Chairman.
Report of Committee on Medical Benevolence.
To the President and House of Delegates:
The work of the Committee on Benevolence has
been continued as usual through the year. Although
early in the year through the Journal of our State
Society, attention was called to this feature of our
work, we have had no new claims for assistance.
During the year two of our beneficiaries died. It was
thought advisable to continue the relief to the family
of one of these.
We append herewith our financial report.
William T. Sharpless, Chairman.
Receipts
Balance in bank August 31, 1920 $i95-73
Cash received from Treasurer Lowman,
June 24, 1921 239-95
Cash received from Treasurer Lowman,
July 27, 1921 252.80
$688.48
Disbursentents
October 7, 1920 $50.00
October 7, 1920 50.00
January 22, 1921 60.00
January 22, 1921 60.00
April 8, 1921 60.00
April 8, 1921 60.00
July 27, 1921 60.00
July 27, 1921 60.00
$460.00
$228.48
Respectfully submitted,
Edward B. Heckel, Treasurer.
Report of the Committbb on Akchives.
To the President and House of Delegates of the Med-
ical Society of the State of Pennsylvania:
Bound volumes of the annual transactions of the
Medical Society of the State of Pennsylvania for the
years 1851 to 1896 are in the Society's library in the
.University of Pennsylvania, Philadelphia. A second
set from 1854 to 1896 is in the office of the Executive
Secretary, Harrisburg. A third set front 1854 to 1896
is in the hands of the former secretary, C. L. Stevens,
M.D., Athens, awaiting the disposition of the Com-
mittee.
There are two sets of bound volwnes of the Penn-
sylvania Medical Journal for the first thirteen years,
1897 to 1910 (Vol. XXVIII to Vol. XXXIX of Trans-
actions) belonging to the Society, one set in the So-
ciety's library in the University of Pennsylvania, and
one set in the hands of the Executive Secretary, Har-
risburg.
There are in the hands of the former secretary. Dr.
Stevens, from two to twenty unbound copies for each
month of Volumes I to VII of the Journal. During
the past year we have received from Dr. J. B. F.
Wyant, Kittanning, the necessary copies of the Jour-
nal, 1904 to 1918, providing one full set of the trans-
actions for the period mentioned, and have been prom-
ised duplicates to provide the second set We have
postponed the actual binding of same on account of
the present high prices demanded for such work. Our
Committee is in full accord with the sentiment of the
following resolution which was unanimously adopted
by the 1920 House of Delegates :
"Resolved, That the Committee on Archives of the
Medical Society of the State of Pennsylvania work in
conjunction with similar committees of the County
Societies, and the data obtained be published in the
Journal of the Medical Society of the State of Penn-
sylvania, in a series of articles, and subsequently be
reproduced in a single volume."
We urge that each component society secure, as far
as possible, a complete set of the Pennsylvania Meih
ical Journal, keeping same in an accessible place for
reference. Our committee refers the officers of the
component societies to the following generous offer :
The former editor. Dr. C. L. Stevens, Athens, has
unbound copies of the Pennsylvania Medical Jour-
nal for each month from June, 1897, to September.
1920, which he will be glad to present to any component
county society, if the society will promise to have same
permanently bound for its society library at once.
Walter F. Donaldson, Chairman,
Cyrus Lee Stevens.
Samuel P. Gerhako.
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INDEX TO VOLUME XXIV
Abdomen, Concerning acute trau-
matic surgery of, 303
Abdominal drainage, 129
Abstracts from Gazette des Hopi-
taux, 822
from Mental Hygiene, 823.
from state medical journals, 77,
I6S, 2in, 333, 508, S7I, 643
Acrodynia, 287
Address,
Chairman's (Section on Eye,
Ear, Nose and Throat Dis-
eases), 205
Chairman's (Section on Medi-
cine), 47
Chairman's (Section on Pediat-
rics), 285
Chairman's (Section on Sur-
gery), 125
of welcome, by Dr. John J.
Buchanan, President of Alle-
gheny County Society, 113
of welcome, by Mayor Edward
Vose Babcock, 112
President's, i
Advertising (Officers' Dept.), 432
Alexander, Emory G., M.D. : Ap-
pendicitis in children, 135
Amendments to by-laws (Officers'
Dept.), 836
American Medical Association,
192 1 meieting (Officers' Dept.),
517
The Boston session (Officers'
Dept), 717
Anatomy, The relationship of, to
surgery, 125
Anders, James M., M.D.: The
outlook of chronic nephritis,
142
Anemia, Pernicious, a study of
148 cases, 324
Anesthesia in lung surgery. The
problem of, 380
Annual meeting of county socie-
ties: Adams, 347; Armstrong,
348; Blair, 436; Bucks, 182;
Columbia, 276; Chester, 437;
Cumberland, 348 ; Dauphin,
348; Elk, 349; Franklin, 437 ;
Luzerne, 351 ; McKean, 351 ;
Mercer, 351 ; Northampton,
352; Susquehanna, 352; Union,
i8s; Warren, 353; Wayne,
353; Wyoming, 353
Preparations for, 514 (Ed.)
Annual reports (Officers' Dept),
899
Antenatal hygiene, Some practical
aspects of, 693
Antivivisection and the California
Crusade, 173 (Ed.)
Apoplexy, Some mistaken ideas
concerning, 867
Appendicitis in children, 135
When shall the surgeon operate
in cases of, 664 (Ed.)
Arguments against noise, 663
(Ed.) .
Arsphenamm, 425 (Ed.)
B
Babcock, W. Wayne, M.D.: End
results in 608 cases of peri-
pheral nerve injury, 533
Baker, S. Josephine, M.D. : Mini-
mum physical standards for
the child laborer, 580
Baker, Willis M., M.D. : The pre-
vention of syphilis and its
sanitary management, 564
Barany tests, 798
Bartlett, Clarence, M.D.: Medical
practice and medical educa-
tion in its relationship to com-
pulsory health insurance, 245
Basal metabolism an appreciation
and a warning, 589 (Ed.)
Bauer, Edward L., M.D.: The
eradication of diphtheria by
means of toxin-antitoxin fol-
lowing Schick testing, 471
Behan, Richard J., M.D.: Cecal
statis and its relationship to
appendicitis, 130
Behrend, Moses, M.D. : Repair
and anastomosis of the bile
passages for_ the relief of
chronic jaundice, 465
Benevolence (Officers' Dept.), 268
Bichloride poisoning. The treat-
ment of, 702
Blair, Wm. W., M.D.: School
myopia, 206
Block, Frank Benton, M.D.:
Treatment of punctured
wounds, 156
Blodgett, Stephen H., M.D.: Dia-
betes (pancreatic) caused by
infection of the tonsils, 407
Blood pressure; Altered, and its
relation to imbalance, 806
apparatus. Errors and over-
sights resulting from the use
of, SS
guides during anesthesia and
operation, 372
Bone necrosis with special refer-
ence to tubercular lesion, 614
Book reviews, 45, 102, 201, 282,
359, 445. 530, 608, 686, 780, 862,
916
Books received, 45, 102, 201, 282,
358, 445, 530, 608, 686, 780, 862,
916
Bower, John O., M.D. : End re-
sults in 608 cases of periph-
eral nerve injury, 533
Boyd, D, Hartin, M.D.: Report
of a case of infantilism with
rickets, 870
Bradley, Wm., M.D. ; Chairman's
address, 2^5
Bubonic plague, 786
Bureau of Medical Education and
Licensure: List of questions
submitted at the January,
1921, examinations, 331
Cadwalader, Williams B., M.D.:
The early appearance of the
symptoms of combined scle-
rosis of the spinal cord and
the subsequent development
of severe anemia, 692
Cesarean section, Normal deliv-
ery after, 265
Cameron, Wm. H., M.D. : The
public and the cancer problem,
323
Cancer, 171 (Ed.)
of the breast with a study of
the results obtained in 218
cases, 781
Cauliflower, of the cervix in a
woman of twenty, 250
problem. The public and, 323
Carr, James G., M.D.: Pernicious
anemia — a study of 148 cases,
324
Cappers-Fess bill, The, 510 (Ed.)
Cartin, Harry J., M.D.: Acro-
dynia, 287
Cecal stasis and its relation to ap-
pendicitis, 130
Chaffee, O. N., M.D.: The duty
of the pediatrician to the
mother of the newborn, 794
Chalfant Sidney A., M.D.: Ova-
rian pregnancy with report of
a case, 548
Chest surgery as met by physical
drainage, The problems of, 396
Child laborer. Minimum physical
standards for, 580
Clark, Wm. L., M.D.: New con-
ceptions relative to the treat-
ment of malignant diseases
with special reference to ra-
dium'in needles, 214
Cleft palate. Treatment of com-
plicated, 64
Clinic, The new rural, 19
Clinics, Diagnostic, 336 (Ed.)
Coates, George Morrison, M.D. :
A discussion of the blood clot
dressing for the simple mas-
toid operation, 477
Colwell, A. H., M.D.: Transient
auricular fibrillation, 59
Corson, Edward Foulke, M.D. :
Occupational outbreaks of the
skin including novocaine erup-
tions, 887
Compensation cases, Doctors' duty
in, 427
Comroe, Julius H., M.D.: The
ancient and the modem kid-
ney, 8
Conference of industrial physi-
cians and surgeons, 575, 647,
703
Connelley, Clifford B., M.D. : Ad-
dress of welcome, 575
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THE PENNSYLVANIA MEDICAL JOURNAL September, 1921
Constitution and by-laws, i{>20,
changes in (Officers' Dept.),
88
Contagious diseases ; Do the pres~
ent quarantine laws need re-
vision? 265 (Ed.)
Commercial Exhibit, A trip
through (Officers' Dept.), 900
County medical society, The, 715
(Ed.)
medical society publications, 339
(Ed.)
society reports, 33, 93, 181, 275,
347, 435, 522, 602, 673, 837, 907
Crow, Arthur E., M.D. : Abdomi-
nal drainage, 129
Curbstone discussions, 85 (Ed.)
Dacryocystitis, Intranasal opera-
tion for, 483
Danforth, Wm. C, M.D.: Nitrous
oxid-oxygen analgesia and
anesthesia in normal labor and
operative obstetrics, 383
Damall, Wra. Edgar, M.D. : Cauli-
flower cancer of the cervix in
a woman of twenty, 250
Deaver, H. C, M.D.: Pyloric ste-
nosis with a report of fifty
cases, 632
Decker, H. Ryerson, M.D.: Post-
operative complications of the
respiratory tract, 391
Delegates, Attention of, 896
Denman, Ira O., M.D. : Oral and
sinus surgery in the forward
inclined sitting posture, under
Nj O-O anesthesia, 388
Dermatological society, 818
Diabetes (Pancreatic) caused by
infection of the tonsils, 407
Dickinson, B.M., M.D. :_ A phase
of accessory sinus disease, 551
Dietetics, Simplicity of modem, 28
(Ed.)
Diphtheria, The eradication of,
by means of toxin-antitoxin
following Schick testing, 471
The practical value of the toxin-
antitoxin injections in the im-
munization against, and of the
Schick test as a means for
identifying those that are sus-
ceptible, 474
Donaldson, H. J., M.D.: A brief
of one thousand hysterecto-
mies, 236
Ear and nose surgery. The use of
paraflRn and wax in, 875
Educating the public (Officers'
Dept.), 593
Ellenberger, J. Wesley, M.D.:
The industrial physician, 151
Encephalitis, epidemic. The autop-
sy findings in, 458
Epidemic (lethargic), 4
Lethargic449
epidemic (lethartic). An analy-
sis of the mental symptoms
associated with, 453
Endocrines in gastric disease, 229
Entwisle, Robert M., M.D.: Rec-
tal drainage for pelvic ab-
scess, 128
Epilepsy a symptom of splanch-
noptosis, 322
Ersner, Matthew S.. M.D. : Mis-
use of vaccines, hay fever pol-
lens and proteids, 490
Eruptions, Occupational outbreaks
of the skin including novo-
caine, 887
Estes, Wm. L., Jr., M.D.: Early
diagnosis of perforated gav
trie or duodenal ulcer, 307
False pretenders (Officers' Dept.),
668
Fee splitters, Hospital closes
doors to, 21
Feeding during the first two
years, 555
Fetal mortality. Factors in, 699
Fibrillation, Auricular, 486
Transient auricular, 59
Finegan, Thomas E., Pd.D.: The
physician and the public
schools, 210
Fiske, Eben W., M.D.: Mechan-
ical influences in sciatica, 638
Foss, Harold L., M.D.: Gastro-
enterostomy — a consideration
of the occasional disappoint-
ments that follow, 309
Fractures of the femur. The use
of the Thomas splint in, 617
Francine, A. P., M.D.: The state
tuberculosis work, what is be-
ing done, and future plans, 41 1
Fussell, M. Howard, M.D. : Chair-
man's address, 47
Gall bladder, Spantaneous rup-
ture of, with a report of three
cases, 463
Gastric or duodenal ulcer, per-
forated, Early diagnosis of,
307
Gastric symptoms from a surgical
viewpoint, 316
Gastritis, chronic. Analysis of, 233
Gastroenterostomy, A considera-
tion of the occasional disap-
pointments that follow, 309
General news items, 41, 99, 199,
279, 357, 444. 607, 68s, 852, 916
Givens, Maurice H., Ph.D.: The
antiscorbutic vitamine, 629
Glaucoma, Consideration of some
of the problems of, 367
Glynn. Wm. H., M.D.: Factors in
fetal mortality, 699
Goddard, Herbert M., M.D. : Ton-
sils considered from the view-
point of the specialist and
general practitioner, 153
Graduate medical teaching, 338
(Ed.)
Graham, Edwin E., M.D.: Feed-
ing during the first two years,
555
Green, Frederick R., M.D. : Health
insurance — a challenge to
physicians, 224
Griscom, J. Milton, M.D.: The
relation of intranasal pressure
to heterophoria, 804
Group system of medicine. The
preparation for, 47
Guedel, Arthur E., M.D.: Third
stage of ether anesthesia, 375
Gwathmey, James T., M.D.: The
anesthesia problem in lung
surgery, 380
H
Hall, Herbert E., M.D.: Pediat-
rics in the small city, 796
Hammer, A. Wiese, M.D. : Gas-
tric symptoms from a surgical
viewpoint, 316
Hammond, Frank C, M.D. : Sum-
mary of the reasons why the
medical profession is opposed
to compulsory health insur-
ance, 248
Hammond, Levi Jay, M.D.: Con-
cerning acute traumatic sur-
gery of the abdomen. 303
Harris, C. M., M.D.: The pharyn-
geal tonsil — important consid-
erations in its treatment, ^4
Harrisburg Academy of Medicine,
330, 642, 820
Hartman, Frank G., M.D. : 893
Hay fever. Misuse of vaccines,
pollens and proteids, 490
Health center bill, 19
education for children (Officers'
Dept.), 178
insurance — ^a challenge to phy-
sicians, 224
Insurance Commission, Report
of (Officers' Dept.), 596
insurance, compulsory. Medical
practice and medical educa-
tion in its relationship to. 245
insurance, compulsory. Summary
of the reasons. why the medi-
cal profession is opposed to,
248 .
insurance propaganda still alive,
77
Heard, James D., M.D. : Tran-
sient auricular fibrillation, 59
Heart diagnosis. Practical points
in, 49
Heiii, Gordon E., M.D.: Errors
and oversights resulting from
the use of the blood pressure
apparatus, 55
Heredity as an element in bac-
terial diseases, 609
Heterophoria, The relation of
intranasal pressure to. 804
Holiday greetings, 174 (Ed.)
Hollingsworth, I. P. P., M.D.:
Inspection of milk production,
419
Hopeful sign, 664 (Ed.)
Hospital, the profession and the
laity, 492
Holzapple, George E., M.D. : Peri-
carditis, 540
House of Delegates, 1921 (Offi-
cers' Dept.), 668
of Delegates and the presidency
(Officers' Dept.), 90
of Delegates in annual session
in Pittsburgh, 1920, Resolu-
tions adopted by, 179
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September, 1921
INDEX
937
Hyperthyroidism, Some sugges-
tions for the treatment of, 544
Hypertrichiasis in childhood : The
so-called dog-faced boy, 401
Hysterectomies, A brief of one
thousand, 236
Hysterectomy, The value of, sub-
total, in the treatment of fibro-
myomata of the uterus, 238
I
Illegal practitioners, 266 (Ed.)
In memoriam :
Allis, Oscar H., M.D., 780
Bell, G. Franklin, M.D., 92
Bishop, Wm. Thomas, M.D., 273
Bullock, E. C, M.D., 346
Cope, Thomas, M.D., 274
Heilman, Samuel Philip, M.D.,
273
Klein, Warren P., M.D., 273
McAvoy, James B., M.D., 521
Mcllhaney, Wm. H., M.D., 836
Index to vol. xxiv, 933
Industrial physician, 151
Infant mortality, The obligation
of industry in relation to, 577
Infantalism in children, 810
Infantilism, Report of a case with
rickets, 870
Inspection of milk production, 419
Insurance methods. Some prob-
lems encountered in attempt-
ing to apply, to the sickness
hazard, 319
Ivy, Robert H., M.D., D.D.S.:
War surgery of the face and
jaws as applied to injuries and
deformities of civil life, 69
Jaundice, chronic. Repair and
anastomosis of the bile pas-
sages for the relief of, 465
Jefferson Medical College, 80, 251,
495
Jobson, George B., M.D. : Chair-,
man's address, 205
Johns Hopkins and fixed medical
fees. 893 (Ed.)
Jump, Henry D., M.D. : Presi-
dent's adress, i
K
Kane, Evan O'Neill, M.D.: Is
the practice of medicine worth
while, 531
Keilty, Robert A., M.D. : Heredity
as an element in bacterial dis-
eases 600
Kennedy,' J. W., M.D.: The hos-
pital, the profession and the
laity, 492
Kidney, The ancient and the mod-
ern, 8
Kidneys, The diagnosis of the
functional capacity of, in vari-
ous types and stages of ne-
phritis, 791
Knowles, Frank Crozier, M.D.,
Hypertrichiasis in childhood,
the so-called dog-faced boy,
401
Knowles, Frank Crozier, M.D. :
Occupational outbreaks of the
skin including novocaine erup-
tions, 887
Krauss, Frederick, M.D. : Mas-
toiditis in children, 147
Krumbhaar, Edward B., M.D. :
Bubonic plague, its prevalence
in the U. S. and how the dan-
ger should be met, 786
Landis, H. R. M., M.D.: End re-
sult of sanatorium treatment
for tuberculosis, 687
Leaders (Officers' Dept.), 668
Leebron, J. D., M.D. : Infantilism
in children, 810
Legislative directory (Officers'
Dept.), 270
program. Our, 703
session, 1921 (Officers' Dept.),
Lenticonus, 877
Limitations vs. lamentations (Of-
ficers' Dept.), 176
Linn, Jay G., M.D.: School my-
opia, 206
List of officers and members of
the sixty-three component
county societies, June 30, 1921,
719
of persons attending the eleventh
conference of industrial phy-
sicians and surgeons, 712
M
McCarthy, D. J., M.D.: Altered
blood pressure and its relation
to imbalance, 806
McCready, J. Homer, M,D. : In-
tranasal operation for dacry-
ocystitis, 483
McKnight, H. A., M.D.: The
diagnosis and treatment of
perforated ulcers of the stom-
ach and duodenum, 416
Mackenzie, George W., M.D. :
Lenticonus, 877
Maclachlan, W. W. G., M.D.: The
autopsy findings in epidemic
encephalitis, 458
Maier, F. Hurst, M.D. : The value
of subtotal hysterectomy in
the treatment of fibromyomata
of the uterus, 238
Major General Gorgas, 75
Malignant disease,' New concep-
tions relative to the treatment
of, with special reference to
radium in needles, 214
Marcy, C. Howard, M.D.: The
effect of the influenza epi-
demic on tuberculosis, 296
Mastoid operation, simple, A dis-
cussion of the blood clot
dressing for, 477
Mastoiditis in children, 147
March 31st (Officers' Dept.), 431
Medical and public health legisla-
tion (Officers' Dept.), 433, 519
Defense (Officers' Dept.), 31,
177, 517, 668, 834
defense in alleged malpractice
suits, 830 (Ed.)
educational requirements are
they best for present day con-
ditions, 588 (Ed.)
Medical examiners. The National
Board of, 896 (Ed.)
legislative conference of Pa.
(Officers' Dept.), 88, 91, 670
libraries, 512 (Ed.)
obliquities, 633 (Ed.)
papers .and how to write them,
S13 (Ed.)
Pennsylvanians pull together,
IS6
profession and the public, 339
(Ed.) .
Medical Society of the State of
Pennsylvania :
General Meeting, 11 1
House of delegates, 103
Minutes of the conference of
secretaries, 121
Section on eye, ear, nose and
throat diseases, 118
Section on medicine, 114
Section on pediatrics, 119
Section on surgery, 179
Medical society building, 428
(Ed.)
Medicine, is the practice of worth
while, 531
Medicolegal : 334
An innovation, 86
Vaccination, 666 (Ed.)
Meeting of the A. M. A., 1921
(Officers' Dept.), 593
Members of the House of Dele-
gates answering roll call, iii
Membership, 1921 (Officers'
Dept.), 268
list, 1921 (Officers' Dept.), 668
list of county medical societies,
715 (Ed.)
Mental diseases. General symp-
tomatology of, 241
Meredith. Evan W., M.D.: Spon-
taneous rupture of the gall
bladder with a report of three
cases, 463
Miller, Albert H., M.D.: Blood
pressure guides during anes-
thesia and operation, 372
Morgan, A. C, M.D.: The post-
influenzal chest, 299
Muscular advancement operation.
Some observations on, 626
Myopia, School, its prevention,
importance of early recogni-
tion and treatment, 206
N
National Department of Health,
The nation's greatest need, 2i
National Department of Public
Health, 510 (Ed.)
Neale, Henry M., M.D. : Psycho-
therapy of tuberculosis, 689
Nephritis, The outlook of chronic,
142
New Committees (Officers' Dept.),
431 ■
New Journal year, A foreword
for, 24 (Ed.)
News items. How do we obtain,
86 (Ed.)
New and nonofficial remedies, 22,
335, 6oi, 906
Nightingale, Florence, The cen-
tenary of, 13
Nineteen twenty-one dues, 177
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THE PENNSYLVANIA MEDICAL JOURNAL September. 1921
Nitrous oxid-oxygen analgesia
and anesthesia in normal la-
bor and operative obstetrics,
383
Nurse shortage, 170 (Ed.)
Obstetrics and the general prac-
titioner, 290
Official transactions, 853, 918
Oral and sinus surgery in the for-
ward, inclined sitting posture
under Nj O-O anesthesia, 388
Origin of the Pennsylvania Medi-
cal Journal, 560
Owen, Hubley R., M.D.: Some
observations on the treatment
of wounds, 705
Park, Wm. H., M.D.: The prac-
tical value of toxin-antitoxin
injections in immunization
against diphtheria, and of the
^hick test as a means for
identifying those that are sus-
ceptible, 474
Parturient woman and her child,
Some practical aspects of the
care of, 697
Patterson, Ross V., M.D.: Auric-
ular fibrillation, 486
Pediatrician, The duty of, to the
mother of the newborn, 794
Pediatrics in the small city, 796
Pennsylvania Medical Journal,
Origin of, 560
Pericarditis, 540
Peripheral nerve injury. End re-
sults in 608 cases of, 533
Pertussis, Vaccine treatment of,
404
Philadelphia hotels and garages,
861 , ^ .
Philadelphia Laryngological Soci-
ety, 162, 501
Physician and the public schools,
210
Physiatric Institute, The, 573
Pike, Horace V., M.D.: General
symptomatology of mental
diseases, 241
Piper, Edmund B., M.D.: Some
practical aspects of the care
of a . parturient woman and
her child, 697
Pittsburgh Academy of Medicme
abstracts, 159. 252, 327, 421,
496, 567. 813, 889
College of Physicians, 815
Session, Aftermath of (Officers
Dept.),90
Pneumoperitoneum, 265 (Ed.)
Posey, Wm. Campbell, M.D.:
Some observations on the
muscular advancement oper-
ation, 626 ,
Postgraduate program (Officers
Dept.), 834
Postinfluenzal chest, 299
Post mortems, 716 (Ed.)
Postoperative complications of the
respiratory tract, 391
Potter, Ellen C, M.D.: Obliga-
tion of industry in relation to
infant mortality, 577
Pregtnancy, Ovarian, with report
of a case, 548
Preliminary scientific program,
853
Presentation of gavel to retiring
president, 112
Presidents of the State Society,
List of, 780
Professor Keen on medical au-
thorship, 662 (Ed.)
Program, The (Officers' Dept.),
668
Progress (Officers' Dept.), 431
Propaganda for reform, 23, 169,
261, 448, 667, 714, 862, 906
Pyloric stenosis, with a report of
fifty cases, 632
Potts, Charles S., M.D.: Some
mistaken ideas concerning
apoplexy, 867
President-Elect Hartman, 893
(Ed.)
Rectal drainage for pelvic abscess,
128
Reciprocity of medical licensure,
894 (Ed.)
Reed, A. L., M.D.: Epilepsy a
symptom of splanchnoptosis,
322
Reed, Marvin, W., M.D. : Bone
necrosis with special refer-
ence to tubercular lesion, 614
Registration (Officers' Dept.), 88
Rehfuss, Martin E., M.D. : Analy-
sis of chronic gastritis, 233
Remedies applied from the out-
side as Important as those ap-
plied from the inside, 16
Replaced vertebrae (Officers'
Dept.), 593
Resolutions endorsed by House of
Delegates, October, 1920, 92
Responsibility (Officers' Dept.), 30
Results (Officers' Dept.), 594
Rewalt, Robert K., M.D.: Vac-
cine treatment of pertussis,
404.
Riddle, S. S., Industrial cripple,
The rehabilitation of, 647
Roberts, John B., M.D.: Treat-
ment of complicated cleft
palate, 64
Sayers, R. R., M.D.: Transporta-
tion of the injured, 657
Schnabel, Truman G., M.D.: The
endocrines in gastric disease,
229
Schumann, Edward A., M.D. :
Some practical aspects of
antenatal hygiene, 693
Sciatica, Mechanical influences in,
638
Scientific program — Philadelphia
Session, 895
Sclerosis of the spinal cord, the
early appearance of, and the
subsequent development of se-
vere anemia, 692
Sears, Wm. Hardin, M.D.: Prac-
tical use of the Barany tests
away from medical centers,
798
Secretaries, Attention of (Offi-
cers' Dept.), 268, 343
Good (Officers' Dept.), 518
Senate and House Committees on
public health and sanitation
of the Legislature for 1921
(Officers' Dept), 345
Seventieth annual session. Echoes
from (Officers' Dept), 31
Services rendered, For (Officers'
Dept.), 899
Session, 1921 (Officers' Dept.), 899
Shumway, Edward A., M.D.:
Traumatic paralysis of the
left superior oblique muscle,
relieved by tenotomy of the
right inferior rectus, 623
Sinus disease, accessory, A phase
of, 551
Sinus disease and ocular involve-
ment, 205
Sistrunk, W. E., M.D. : Cancer of
the breast with a study of the
results obtained in 218 cases,
781
Smith, S. Calvin, M.D.: Practical
points in heart diagnosis, 49
Snowden, Roy R., M.D.: The
diagnosis of the functional
capacity of the kidneys in the
various types and stages of
nephritis, 791
"Socrates Redux":
Cardinal's robe, A glimpse of,
897 (Ed.)
Hero business, The, 340 (Ed.)
Legalization of medical practice,
515 (Ed.) . ^^ ^
Medical book review. The, 200
(Ed.)
Medical ethics, 429 (Ed.)
Medical industrial efficiency, 664
(Ed.)
Modern Paganism, The, 831
(Ed.)
Peculiarities of medical journal-
ism, 174 (Ed.)
Should our journal exist, 80
(Ed.)
Stahlman, T. M., M.D.: The use
of paraffin and wax in ear and
nose surgery, 875
Stanton, E. MacD., M.D.: Some
problems encountered in at-
tempting to apply insurance
methods to the sickness haz-
ard, 319
State medicine, 662 (Ed.)
State news items, 39, 9*5, 196. 277.
353. 441. 527. 605, 682, 780, 851,
915
Stevens, Cyrus Lee, M.D.: 24
Origin of the Pennsylvania
Medical Journal, 560
Stewart. Lever P., M.D.: The
problems of chest surgery as
met by physiological drain-
age, 396
Stop! look! listen !, 262 (Ed.)
Swat the baby killers, 337 (Ed.)
Syphilis, The prevention of, and
its sanitary management 5^4
Syphilitic infection. In what cases
do paresis and tabes follow,
26
T
Tabes, Observations on the treat-
ment of, 863
Taylor, J. Madison, M.D.: Reme-
dies applied from the outside
Digitized by
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September, 1921
INDEX
939
as important as those applied
from the inside, i6
Taylor, Mervyn Ross, M.D. : Tu-
berculosis and its relation to
industrial medicine, 72
Tetanus and its antitoxin, 82 (Ed.)
Therapeutics, Modem, 413
Third stage ether anesthesia, 37s
Thomas, T. Turner, M.D. : Oiair-
man's address, 125
Title of M.D., What is the value
of, 177
Tonsil, The pharyngeal — impor-
tant considerations in its
treatment, 884
Tonsils considered from the view-
point of the specialist and
general practitioner, 153
Tradition vs. common sense, 424
(Ed.)
Transportation of the injured, 657
Traumatic paralysis of the left
superior oblique muscle, re-
lieved by tenotomy of the
right inferior rectus, 623
Trustees, Midyear meeting of
board of, 431
Tuberculosis and its relation to
industrial medicine, 72
In children, 285
End results of sanatorium treat-
ment for, 687
The effect of the influenza epi-
demic on, 296
Psychotherapy of, 689
The state work, what is being
done and future plans, 411
The new vaccine, 263 (Ed.)
U
Ulcers of the stomach, perforated,
The diagnosis and treatment
of, 416
University of Pennsylvania, 251,
325
of Pittsburgh, medical alumni,
641
Utley, Frederick B., M.D. : Some
suggestions for the treatment
of hyperthyroidism, 544
Van Sickle, Frederick L., M.D.:
Our legislative program, 703
Volstead Act rulings, 514 (Ed.)
Vaughan, Victor C, M.D. : Major
General Gorgas, 75
Vitamine, The antiscorbutic, 629
W
Walsh, Joseph, M.D.: The cen-
tenary of Florence Nightin-
gale, 13
War surgery of the face and jaws
as applied to injuries and de-
formities of civil life, 69
Washington Society of Clinical
Medicine, 821
Wholey, C. C. M.D.: An analy-
sis of the mental symptoms
associated with epidemic (le-
thargic) encephalitis, 453
Wilder, Wm. H., M.D.: Consid-
eration of some of the prob-
lems of glaucoma, 367 ,
Wills Hospital Ophthalmic So-
ciety, 569
Williams, J. Whitridge, M.D.:
Obstetrics and the general
practitioner, 290
Where do we go from here, 831
(Ed.)
Who points the way, 85 (Ed.)
Webb, D. A, M.D.: The use of
the Thomas splint in fractures
of the femur, 617
Weinberg, Max H., M.D.: Epi-
demic encephalitis, 4
Wood, Horatio C, Jr., M.D.:
Modem therapeutics, 413
Wounds, punctured. Treatment of,
156
Some observations on the treat-
ment of, 70s
Wright, George J., M.D.: Obser-
vations on the treatment of
tabes, 863
X
X-ray, Fitting shoes by, a danger,
172 (Ed.)
The pneumo-peritoneal method
of, 27 (Ed.)
Therapy, deep. The newer tech-
nique for, 336 (Ed.)
Work, The Buckey diaphragm
in, 84 (Ed.)
The new, in the treatment of
cancer, 424 (Ed.)
Yellow fever vaccine to make
travelers immune in southern
countries, 250
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